POSTERIOR AURICULAR NERVE – A NOVEL LANDMARK FOR IDENTIFICATION OF THE FACIAL NERVE IN SUPERFICIAL PAROTIDECTOMY

ABSTRACT Background-Facial nerve identification and preservation is the most critical step in parotid surgery. Though there are described landmarks to locate the facial nerve trunk, they have individual variations. The posterior auricular nerve (PAN) is a branch of the facial nerve and is always present, it can be followed to reach the facial nerve trunk. MATERIALS AND METHODS A retrospective cohort study in which analysis of parotidectomy performed from January 2017 to November 2018 at our tertiary referral center was done. RESULTS A total of 23 parotidectomies were performed, of which 18 cases were pleomorphic adenoma. In four cases of pleomorphic adenoma we could clearly identify and preserve the PAN. Using PAN as the landmark the facial nerve trunk was located, all its peripheral branches were dissected and preserved. PAN identification narrows down the target area of dissection to identify the facial nerve trunk. CONCLUSION The posterior auricular branch of the facial nerve can be used as a standard landmark in parotid surgeries, that almost always leads to the facial nerve trunk. CLINICAL SIGNIFICANCE Though identification of PAN may be difficult in all cases, effort must be made to identify it under magnification. If done meticulously PAN can be an ideal landmark to identify facial nerve in parotid surgery. KEYWORDS Parotid surgery, Superficial Parotidectomy, Posterior auricular nerve, Facial nerve.

Correlation between Electrophysiological Change and Facial Function in Parotid Surgery Patients

This observational study investigated intraoperative electrophysiological changes and their correlation with postoperative facial expressions in parotidectomy patients with visual confirmation of facial nerve (FN) continuity. Maximal electromyography(EMG) amplitudes of the facial muscles corresponding to temporal, zygomatic, buccal and mandibular branches were compared before/after FN dissection, and facial function at four facial regions were evaluated before/after parotidectomy in 112 patients. Comparisons of 448 pairs of EMG signals revealed at least one signal decrease after FN dissection in 75 (67%) patients. Regional facial weakness was only found in 13 of 16 signals with >50% amplitude decreases. All facial dysfunctions completely recovered within 6 months. EMG amplitude decreases often occur after FN dissection. An amplitude decrease >50% in an FN branch is associated with a high incidence of dysfunction in the corresponding facial region. This study tries to establish a standard facial nerve monitoring (FNM) procedure and a proper facial function grading system for parotid surgery that will be useful for the future study of FNM in parotid surgery.

Controversy in the Surgical Extent of Parotidectomy, Neck Treatment, and Adjuvant Treatment of Parotid Gland Cancer

This paper analyzed previous research data to identify the most important issues to be considered during treatment of parotid gland cancer (PGC) and reviewed recent advancements in techniques in parotid surgery. For successful treatment of PGC, a preoperative surgical plan should be designed with consideration of the histologic characteristics and anatomical complexity of the tumor, and the functional and anatomical integrity of the facial nerve should be carefully inspected during surgery and damage to the nerve minimized. The need for adjuvant radiotherapy should be determined based on intraoperative findings and pathologic findings of the specimen after surgery. To optimize treatment outcomes for PGC, the extent of surgery and adjuvant radiotherapy should be decided according to histologic characteristics and risk stratification.

Parotidectomy and Facial Paralysis, A Retrospective Review at A Tertiary Care Hospital

Background: Facial Nerve is in close proximity with parotid gland and encountered during parotid surgery. Facial nerve paralysis has 15 to 66% occurrence rate after parotidectomies. The objective of this study was to find out the frequency of facial paralysis resulting from superficial or total parotidectomies done for various parotid tumors. Material and Methods: This retrospective study was conducted at the Department of ENT, Khyber Teaching Hospital, Peshawar from January 2018 to May 2020. A total of 203 patients were reviewed for data on demographics, parotidectomies, histopathology and facial paralysis. The information on facial paralysis was compared against various parameters. Results: The mean age of the participants was 46.12 ± 11.11 years. The most common parotid tumor was pleomorphic adenoma (68.9%) followed by mucoepidermoid carcinoma. 57 (28.07%) patients showed facial paralysis with a higher rate of occurrence in total parotidectomy (40.90%). Among 57 patients with facial paralysis, 6 (10.53%) showed permanent facial paralysis. Conclusion: Tendency of permanent facial paralysis is high with total parotidectomies. Female population and elderly have a slightly higher rate of facial paralysis. The duration of procedure has no effect on the occurrence of facial paralysis.

1153 “To FNA Or to Not FNA, That Is the Question.” A 5-Year Retrospective Epidemiological Study Of 238 Surgical Parotid Cases Treated at An East Yorkshire OMFS Unit

Introduction Fine needle aspiration (FNA) is a surgical procedure used to aid with diagnosis and subsequent treatment planning. This study compares FNA histology with final histology (gold standard) for diagnostic accuracy in parotid surgery patients. Method A retrospective investigation of patient records from January 2014-January 2019 was performed to find eligible patients that underwent parotid surgery. Histology reports of the ultrasound (US) FNA and final parotid sample were compared for diagnostic accuracy and ability to differentiate between malignant & benign tumours. Results 240 parotid surgeries on 238 patients were undertaken between 2014-2019 under OMFS and ENT specialities. 137 US FNA’s were performed, of these, there was an 85% diagnostic rate. Of the diagnostic FNA’s 79% reach gold standard, with the histology matching that of the final histology. Of the 24 without diagnostic accuracy, 2/3 were still able to differentiate between malignant and benign lesions. Overall, the US FNA’s were able to differentiate malignant and benign parotid lesions in 93% of cases. Conclusions The audit has proven US FNA to be an accurate diagnostic test, it gives extra data to aid in the decision making and planning for parotid surgeries. Although US FNA has shown to be more accurate in diagnosing benign parotid tumours; it is useful in detecting cellular change which could be indicative of malignancy.

Haemostatic devices in parotid surgery: a systematic review

Objective The Harmonic Scalpel and Ligasure (Covidien) devices are commonly used in head and neck surgery. Parotidectomy is a complex and intricate surgery that requires careful dissection of the facial nerve. This study aimed to compare surgical outcomes in parotidectomy using these haemostatic devices with traditional scalpel and cautery. Method A systematic review of the literature was performed with subsequent meta-analysis of seven studies that compared the use of haemostatic devices to traditional scalpel and cautery in parotidectomy. Outcome measures included: temporary facial paresis, operating time, intra-operative blood loss, post-operative drain output and length of hospital stay. Results A total of 7 studies representing 675 patients were identified: 372 patients were treated with haemostatic devices, and 303 patients were treated with scalpel and cautery. Statistically significant outcomes favouring the use of haemostatic devices included operating time, intra-operative blood loss and post-operative drain output. Outcome measures that did not favour either treatment included facial nerve paresis and length of hospital stay. Conclusion Overall, haemostatic devices were found to reduce operating time, intra-operative blood loss and post-operative drain output.

Cervico-facial flap: a versatile option among various reconstructive options for skin defects in parotid surgery-our experience in a tertiary care center

<p class="abstract"><strong>Background:</strong> Cutaneous defects of the cheek and external ear present a reconstructive challenge. Even when free flap reconstructions and tissue transfer are commonly proposed, fewer patients with these malignancies are candidates for lengthy reconstructive surgery. The cost effectiveness, time consumption, long waiting period of head and neck malignancy patients and less availability of reconstruction teams in developing countries like India, are challenging factors.</p><p class="abstract"><strong>Methods:</strong> In our study, retrospectively 46 cases operated for parotid neoplasm were identified and the operative reports were reviewed from September 2018 to April 2021. Data on patient demographics, pathological diagnosis, defect type, type of flap used, co-morbid disease, and smoking history was collected. </p><p class="abstract"><strong>Results:</strong> The mean defect size was 4×5 cm, however for defects larger than 4×4 cm and lesser than 7 cm a cervico-facial flap was used for reconstruction. The average time for surgery was 2 and a half hours extra for the free flap reconstruction. Post-operative wound complications were higher in free flap reconstruction. Partial/DTN was observed in 16% patients and necrosis that needed intervention- 6% of all patients. Patients with cervico-facial flap reconstruction had an excellent final functional and cosmetic result, with good skin color and texture match.</p><p class="abstract"><strong>Conclusions:</strong> The cervico-facial flap is a versatile technique with excellent vascularity and good esthetic outcome, which should be utilized liberally in the reconstruction of facial defects, slight modifications in the flap harvesting and careful selection of patient can give excellent results in moderate defects after parotid surgeries, especially in a resource limited country like India.</p>

Study of salivary gland tumors and its management outcome in tertiary care hospital in Chennai

Background: Salivary gland tumors can arise from either the major salivary glands (parotid, submandibular and sublingual) or the minor salivary glands which are located throughout the submucosa of the upper aerodigestive tract. They can show a striking range of morphological diversity between different tumor types and sometimes within an individual tumor mass. Aim of the study was to study the role of fine needle aspiration cytology (FNAC) in the diagnosis of salivary gland tumors.Methods: This study was conducted comprising 34 patients attending the department of general surgery at Rajiv Gandhi government general hospital, MMC from January 2019 to December 2020 period of 24 months. A standard protocol was followed consisting of detailed history and physical examination, radiological evaluation followed by fine needle cytological examination. Histopathological examination was done in all the excised tumors for final diagnosis.Results: FNAC was done only in 20 out of 29 parotid tumors of which 12 were benign, 5 were malignant and 3 were inconclusive. In the present study superficial parotidectomy was done in 24 cases. Total parotidectomy was done in 3 out of 5 cases. Two patients refused surgery. Following surgery, 5 patients developed transient facial nerve paralysis and one patient developed permanent facial nerve paralysisConclusions: In tumors of the parotid gland, post-operative facial nerve palsy was rarely noticed. The best means of reducing iatrogenic facial nerve injury in parotid surgery remains an understanding of the anatomy coupled with a gentle technique.

Is the 3D exoscope better than the surgical microscope in parotid surgery: a prospective, randomized single-center study

Background High-definition, three-dimensional (3D) exoscopes are being used to perform a growing number of head and neck surgeries. However, the use of the 3D exoscope in parotid gland surgery has not been previously described. Our initial experience with the VITOM 3D exoscope in the surgical treatment of parotid gland tumors is detailed here. Methods We made a prospective study of patients with benign parotid gland tumors indicated for surgical resection. Between January and December 2018, patients were randomly assigned to undergo surgery assisted with the VITOM 3D system (n = 31) or an operating microscope (n = 40). Visualization quality (greater auricular nerve, digastric muscle, tragal pointer), operating time, conversion rates, and surgical outcomes were compared. Results A total of 71 patients underwent superficial (n = 18) or total parotidectomy (n = 53). No exoscope-related complications were observed. Five patients undergoing exoscope-guided deep lobe surgery required intraoperative conversion to a microscope. No differences were observed in the subjective quality of intraoperative visualization of key anatomical structures. However, a significantly higher percentage of patients in the exoscope group developed transient facial nerve paralysis (n = 9; 29% vs. n = 4, 10%). Conclusions These findings suggest that the VITOM 3D is a valid visualization tool for parotid gland surgery, comparable to the operating microscope but with higher resolution 3D visualization, an increased degree of freedom of movement, and better ergonomics. However, the high rate of transient nerve palsy, possibly related to decreased depth perception and the brief learning curve, merits further investigation.