The Head and Neck
E. George Elias in CRC Handbook of Surgical Oncology, 2020
Mixed tumors (pleomorphic adenoma) are usually benign (less than 10% are malignant) and are mostly found in the superficial lobe of the parotid gland. Superficial parotidectomy with preservation of the facial nerve is the ideal surgical approach. Because of the anatomic relations of the parotid gland, the pharyngeal wall on the affected side must be inspected and palpated prior to surgery to rule out deep lobe involvement of the parotid. If mixed tumors are encountered at other salivary glands, excision of the affected gland or the area is sufficient. Occasionally, mixed tumors can develop in an accessory salivary gland, located near the posterior lower border of the parotid gland. They present as slow growing, freely mobile, and nontender nodules. They can be locally excised in toto without sacrificing the superficial lobe of the parotid, as long as they are separated from the parotid gland. Recurrent benign mixed tumor of the parotid is rare and, if it occurs, the surgical procedure should be tailored to the individual case. If a patient is seen after freshly excised or biopsied tumor, parotidectomy with excision of the skin at the biospy site is recommended. If the patient is seen after an old excision of such a tumor, it is preferred to wait and in case of recurrence, re-resection is in order.13 Radiation therapy is not to be used as the primary treatment in benign mixed tumors.
Medical Negligence in Otorhinolaryngology
John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie in Basic Sciences Endocrine Surgery Rhinology, 2018
If the histology of a tumour has not been revealed by a fine-needle aspiration cytology then the lump needs to be excised with a substantial cuff of tissue around it. This is because, should the tumour be malignant or a pleomorphic adenoma, then local recurrence is a real risk and will be difficult to defend. Occasionally a GP will remove a parotid lump, often expecting it to be a benign skin lesion such as a sebaceous cyst, and get a surprise when the histology of a pleomorphic adenoma comes back. If such a patient is referred, the hospital consultant has a choice as to what to recommend to the patient. The choices are radiotherapy, revision superficial parotidectomy or watch and wait. There is no right thing to do and each case has to be weighed up, taking into consideration the size of the specimen removed and the age of the patient. Should the tumour be a low-grade malignancy then total parotidectomy with facial nerve preservation is usually the treatment of choice but all such cases now should be managed through a multidisciplinary team (MDT).
The salivary glands
Neeraj Sethi, R. James A. England, Neil de Zoysa in Head, Neck and Thyroid Surgery, 2020
The key features for parotidectomy are: Complete excision with an adequate margin to avoid local recurrence.Type of resection (i.e. partial, superficial, total) depends on tumour size.Typically a modified Blair or rhytidectomy incision is used for lower or mid-gland regions of the parotid. The rhytidectomy incision can be extended in the hairline for further exposure.
Refinement of the surgical indication and increasing expertise are associated with a better quality of pathology specimen in pleomorphic adenomas
Published in Acta Oto-Laryngologica, 2021
Konstantinos Mantsopoulos, Ann-Kristin Iro, Matti Sievert, Sarina Katrin Müller, Abbas Agaimy, Michael Koch, Heinrich Iro
In our department, surgical modalities in the parotid gland are defined as follows: extracapsular dissection (ED) is the removal of the tumour with a cuff of parotid tissue without intending to expose the main trunk or branches of the facial nerve. The procedure is called a partial superficial parotidectomy (PSP) if the main nerve trunk is deliberately exposed before dissection and only parts of the superficial lobe are removed together with the tumour. Removal of the entire parotid gland lateral to the facial nerve (superficial lobe) is defined as a lateral parotidectomy (LP), while excision of all the glandular parenchyma (superficial and deep parotid lobe) with preservation of the facial nerve trunk and its branches is referred to as complete parotidectomy (CP) [12,13]. PSP, LP and CP are classified as ‘facial nerve dissecting’ surgical techniques. In pathology specimens, complete coverage of PA by healthy tissue was defined as coverage of PA through healthy tissue (salivary gland parenchyma, parotid fascia, connective or fat tissue, muscle fibres of the superficial musculoaponeurotic system, sternocleidomastoid or digastric muscle) all around its periphery (irrespective of width of clear margins), so that its capsule was not exposed at all (Figure 1). That means that a limited focal exposure of an anatomically intact capsule, which equals to a locally marginal ‘in sano’ excision of a PA, precludes 100% coverage of the lesion through healthy tissue.
Comparative outcomes of extracapsular dissection and superficial parotidectomy
Published in Acta Oto-Laryngologica, 2019
Kerem Ozturk, Arin Ozturk, Goksel Turhal, Isa Kaya, Serdar Akyildiz, Umit Uluoz
Surgical excision has been accepted as a primary option by clinicians in the treatment of the benign parotid lesions. Since about 80% of parotid tumours are benign, low recurrence rates and reduced morbidity are the main goals of surgical management. Superficial parotidectomy (SP) procedure, including the dissection and surgical identification of the facial nerve and removal of the superficial part of the gland, has been traditionally preferred starting 1950s [1]. The main reason is the hypothesis that the pleomorphic adenomas mainly spread out from the capsules, which increases the risk of recurrence [2,3]. Dissecting the intraparotid facial nerve and resection of normal parotid tissue may cause postoperative compilations like transient facial nerve paralysis, the sunken defect on the preauricular skin due to the loss of volume and Frey syndrome [4]. Extracapsular dissection (ECD) was described as preserving the tumour capsule and meticulous dissection immediately outside the tumour capsule while still preserving the facial nerve and normal parotid tissue [5]. In contrast to enucleation, many studies are showing that ECD is an alternative to SP with similar recurrence rates. Additionally, studies reported ECD as having lower rates of early and late postoperative complications [6,7].
Supporting the use of adjuvant radiotherapy in recurrent pleomorphic adenoma of the parotid
Published in Acta Oto-Laryngologica, 2021
Justin M. Hintze, Fergal O’Duffy, Ailbhe White-Gibson, Paul O’Neill, John Kinsella, Conrad Timon, Paul Lennon
Injury to the facial nerve is discussed in many of the articles reviewed but there was no systematic approach to the reporting of these complications and therefore it is difficult to draw substantial conclusions. Some describe high rates of post-operative temporary facial nerve weakness (67%), the majority of which resolve, leaving only few with permanent injuries (8%). When compared against rates of nerve palsies post primary parotidectomies, Renehan et al. found the rates of facial palsy to be 6 times greater in recurrent cases [7]. Rates of facial nerve injury were higher in patients that had previous parotidectomy than in those that had an enucleation (29 versus 10%). In general, most agree that there is an increased risk with increase number of surgeries. With regards to RT, it has been suggested that the chance of fibrosis and forming of scar tissues increases, with relatively higher risk of injuring the facial nerve in any subsequent reoperation [13].
Related Knowledge Centers
- Digastric Muscle
- Pleomorphic Adenoma
- Stylohyoid Muscle
- Neoplasm
- Parotid Gland
- Malignancy
- Saliva
- Salivary Gland
- Nerve
- Posterior Auricular Muscle