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Addressing the Controversies in Parotid Surgery

Controversies in Parotid Surgery: Is There Evidence?

On-Demand Session

Richard V. Smith, MD

Parotid tumor surgery is not always complicated, but unfortunately, it’s usually the complicated cases that lack clarity in surgical decision-making.

“Much of parotid tumor surgery is decidedly not controversial,” said panel moderator Richard V. Smith, MD, of Montefiore Medical Center in New York City.  “Obviously, with many of these tumors, the majority are benign and there are general principles we all follow. But things can go poorly and be quite complicated, and we’re going to talk about some of those situations  with respect to development of thought and controversy in those areas.”

Dr. Smith and panelists Carol R. Bradford, MD, MS,  AAO-HNS/F President, and of the University of Michigan in Ann Arbor at the time of presentation; Samir Khariwala, MD, of the University of Minnesota in Edina; Bevan Yueh, MD, MPH, of the University of Minnesota in Minneapolis; and Derrick T. Lin, MD, of Massachusetts Eye and Ear Infirmary in Boston, discussed five particularly controversial aspects of parotid surgery in the on-demand session, which was originally presented live on Tuesday, September 15.

  1. Extracapsular Dissection

If you’re looking for an alternative to intracapsular dissection and parotidectomy, said Dr. Yueh, there is one: extracapsular dissection. This allows for the removal of parotid tumors without identifying the facial nerve trunk or exposing the entire gland, as well as direct and meticulous dissection of the mass in the layer of areolar connective tissue surrounding the tumor. The goal here is to avoid exposure of the tumor capsule.

While concerns surrounding extracapsular dissection involve potentially higher rates of local recurrence, Dr. Yueh cited studies that indicate this may not actually be true. Another concern regarding potentially higher rates of facial nerve injury, he said, is actually false.

“On this one I think it’s pretty clear—we in fact see lower rates of facial nerve injury, permanent injury, with extracapsular dissection compared to superficial parotidectomy,” he said.

  1. Superficial versus Total Parotidectomy

“Superficial parotidectomy with appropriate postoperative radiotherapy may be an acceptable procedure without potential morbidity, such as postoperative facial palsy, in the treatment of low-grade parotid cancers confined to the superficial lobe if the facial nerve is sufficiently distant from the tumor,” said Dr. Bradford. This applies mostly to T1/T2 tumors where wide surgical margins can be attained.

“Radical parotidectomy is reserved for high-grade malignances where clearly the nerve is invaded, flattened, involved, and stuck to the tumor and in recurrent malignant tumors where it’s almost impossible to save the facial nerve,” she said.

  1. Facial Nerve Management

“Management of the facial nerve is really a critical part of the treatment of any parotid tumor,” said Dr. Moore. “And although it has many functions, the one that really gets the most attention with regard to quality of life is its impact on motor function.

“In patients with normal preoperative nerve function, the facial nerve should be preserved if the nerve is not grossly involved,” he said. If the nerve is involved, resection should be performed to achieve negative pathologic margins, if possible.

  1. Neck Dissection

“The nature of pathology is the most important factor in deciding upon neck dissection,” said Dr. Khariwala. High-grade tumors, including mucoepidermoid, carcinoma ex-pleomorphic, salivary duct carcinoma, adenocarcinoma NOS, and maybe even adenoid cystic carcinoma, should have neck treatment, he said.

  1. Complications

“Facial paralysis is the most common and most devastating complication after parotidectomy,” said Dr. Lin. “Immediate repair is the key. Recognize the injury and try to go forward with the repair immediately.”

Other concerns are hematoma, Frey’s syndrome, and sialocele. Dr. Lin said that tumor, patient, and surgical factors all play a role in leading to possible complications, but—as with facial paralysis—the key is prevention if possible and early recognition and treatment of the complication if not.