Surgical treatment of parotid tumors in the general community hospital.ABSTRACT: We reviewed 51 consecutive parotidectomies done at a general community hospital and gathered data on age and sex of the patients, length of stay in the hospital, perioperative perioperative /peri·op·er·a·tive/ (-op´er-ah-tiv) pertaining to the period extending from the time of hospitalization for surgery to the time of discharge.
adj. outcome, complications, and surgical pathology surgical pathology
A field in anatomical pathology concerned with examination of surgical specimens of tissues removed from living patients for the purpose of diagnosis of disease and guidance in the care of patients. . Statistical method included logistic regression and ANOVA anova
see analysis of variance.
ANOVA Analysis of variance, see there to determine relationship and dependence of the variables. There were 24 male and 27 female patients. Thirty-six (70.6%) of the parotid parotid /pa·rot·id/ (pah-rot´id) near the ear.
1. Situated near the ear.
2. Of or relating to a parotid gland.
A parotid gland. tumors were benign. There were no major complications. Treatment of parotid tumors in the community hospital is feasible and safe if basic guidelines are implemented. The epidemiology of parotid tumors in the relatively smaller hospital should resemble that reported in the literature. Our data suggest that parotid malignancy may occur more frequently in elderly men and that length of stay in the hospital may be longer for patients having surgery for malignant than for benign parotid tumors.
MOST SERIES on parotid tumors are based on the experience of large institutions, with data collected over a long period. The absence of articles on the subject from smaller community hospitals may be related to the inability of these centers to generate large numbers of cases of parotid tumors. Indeed, local physicians and surgeons Physicians and surgeons are medical practitioners who treat illness and injury by prescribing medication, performing diagnostic tests and evaluations, performing surgery, and providing other medical services and advice. may be too willing to refer patients with these tumors to tertiary hospitals either because of their relative infrequency, concern about the lack of expertise required to treat them, or to avoid the potential for catastrophic facial nerve paralysis Facial nerve paralysis is a common problem that involves the paralysis of any structures innervated by the facial nerve. The pathway of the facial nerve is long and relatively convoluted, and so there are a number of causes that may result in facial nerve paralysis. or complication. Because information is needed on epidemiology, complication rate, and outcome of treatment of parotid tumors in smaller hospitals, we reviewed 51 consecutive parotidectomies done by our community based otolaryngology practice. Our series attempts to compare its data with that of larger published reports and analyzes perioperative and short-term results.
A total of 51 consecutive parotidectomies were analyzed to determine statistical relationships among the patient's sex, age, postoperative length of stay in the hospital, and final pathology results. In all cases, surgery was done to treat a parotid mass or tumor. These procedures were done at a 160-bed general community hospital in Broward County, Florida Broward County is a county located in the U.S. state of Florida. As of 2000, the population is 1,623,018; this makes it the second most populated county in the state. According to 2006 U.S. Census estimates, its population had grown to 1,787,636 . from 1991 to 1999 by board certified board certified,
adj the status of a dental specialist such as an orthodontist who has become a board diplomate by successfully completing the certification program of the recognized certification board in that area of practice. otolaryngologists/head and neck surgeons. Most of the patients had a lateral lobe parotidectomy Parotidectomy Definition
Parotidectomy is the removal of the parotid gland, a salivary gland near the ear.
The main purpose of parotidectomy is to remove cancerous tumors in the parotid gland. with dissection and preservation of the facial nerve facial nerve
Either of a pair of nerves that originate in the pons, traverse the facial canal of the temporal bone, and pass through the parotid gland, reach the facial muscles through various branches, control facial muscles, and relay sensation . Patients with malignancy required a more extensive operation. The surgical equipment used in most procedures included a standard thyroid surgery tray, bipolar electrocautery electrocautery /elec·tro·cau·tery/ (-kaw´ter-e) an apparatus for surgical dissection and hemostasis, using heat generated by a high-voltage, high-frequency alternating current passed through an electrode. , a contact Nd:YAG laser used to dissect dissect /dis·sect/ (di-sekt´) (di-sekt´)
1. to cut apart, or separate.
2. to expose structures of a cadaver for anatomical study.
v. the parotid gland parotid gland
Either of a pair of major salivary glands situated below and in front of each ear and opening into the parotid duct; the largest of the major salivary glands. , and a nerve stimulator used to identify and preserve the facial nerve. Home discharge criteria required that the patient be stable in general terms and exhibit adequate wound healing wound healing Physiology The repair of a wound Steps Inflammation, repair and closure, remodeling, final healing; repair of incisions may be either simple–'clean' wounds with little loss of tissue heal by 'primary intention', or 'dirty' wounds heal by , with a wound drainage rate less than 20 mL within the previou s 24 hours. These patients had follow-up in the office 1 week postoperatively and as necessary afterward.
The statistical analysis used to study the sample included logistic regression to determine the relationship between age and sex, and pathology, age, and sex. ANOVA was used to determine the dependence of the length of stay on pathology, age, and sex.
Of the 51 patients who had parotidectomy, 24 were male, with a mean age of 66.9 years, and 27 were female, with a mean age of 60.1 years. Benign disease was found in 36 cases (71%) and malignant disease in 15 (29%). The most common benign tumors were pleomorphic adenoma pleomorphic adenoma (plē´ōmôr´-fik ad´nō´m or mixed tumor mixed tumor
A tumor composed of two or more types of tissue.
mixed tumor Pleomorphic adenoma A usually benign salivary gland tumor which may also be seen in breast and pancreas; MT comprises 60% of parotid gland , comprising 50% of all benign tumors (88% occurring in women), and Warthin's tumor War·thin's tumor
A benign tumor of the parotid gland.
Mentioned in: Salivary Gland Scan
Warthin's tumor or adenolymphoma, mostly seen in men. The most frequently reported malignancies were squamous cell carcinoma squamous cell carcinoma
A carcinoma that arises from squamous epithelium and is the most common form of skin cancer. Also called cancroid, epidermoid carcinoma. , comprising 40% of all cancers, seen predominantly in men, and adenocarcinoma adenocarcinoma: see neoplasm. , comprising 33% of all malignancies reported (Table 1).
Statistical analysis suggested that sex was a significant predictor of malignancy versus nonmalignancy (P = .019), indicating that malignancy was more frequent in men (Table 2). Stratifying the data by age group revealed a significant interaction between age and sex; in the group more than 65 years of age, again sex was a significant predictor of malignancy vs nonmalignancy (P = .036), men being significantly more likely to have malignant disease than women (Table 3). Length of hospital stay was 2 days for 62% of the patients who had benign disease, whereas 50 of those with malignant disease had a length of stay of 3 days and another 25%, 2 days (Table 4).
Our results are in general agreement with published epidemiologic data on parotid tumors. (1-7) The majority of the tumors were benign, the most frequent being pleomorphic adenoma and Warthin's tumor. Pleomorphic adenoma and inflammatory tumors were more frequent in women. The majority of Warthin's tumors and malignancies were seen in men. Mucoepidermoid carcinoma, one of the most frequent malignancies reported in large series, is missing in our sample, perhaps because its incidence peaks in younger individuals.
Parotid neoplasms are uncommon, comprising approximately 3% of all head and neck tumors and presenting an incidence of less than 3 per 100,000 population. (8) Most articles on parotid tumors have originated at large institutions and over a long period. Because these tumor are infrequent, few publications on the subject have come from relatively small general community hospitals such as ours. Our experience may be skewed skewed
curve of a usually unimodal distribution with one tail drawn out more than the other and the median will lie above or below the mean.
skewed Epidemiology adjective Referring to an asymmetrical distribution of a population or of data because ours is a teaching multispecialty group practice known for advanced tertiary medicine. The demographics of Broward County also may have influenced our statistics, since the hospital services a large elderly retired population living in the county and it is known that parotid tumors peak in frequency in the sixth and seventh decades. (9,10)
Review of the medical records did not reveal any significant or major intraoperative or postoperative complications postoperative complications,
n.pl unexpected problems that arise following surgery. The most frequent are bleeding, infection, and protracted pain. . Measured anesthesia and surgery times were considered reasonable and unremarkable. In all procedures, the main trunk of the facial nerve and all associated or adjacent branches were identified before excision of the tumor and were preserved. No major complications were reported either for benign or malignant disease, even though procedures done for malignancy were more extensive. The patients who had parotidectomy for malignant disease were subjected to wider excisions, more extensive dissections of the facial nerve, and/or total parotidectomy or neck dissection neck dissection Surgery The excision of lymph nodes and other tissues grossly (|a|) (macroscopically) involved by CA in the neck for the staging of cancer. See Commando operation, Radical neck dissection. as indicated. (11,12) None of the patients had permanent facial paralysis or paresis paresis /pa·re·sis/ (pah-re´sis) slight or incomplete paralysis.
general paresis paralytic dementia; a form of neurosyphilis in which chronic meningoencephalitis causes gradual loss of cortical as a result of the operation. The most significant and frequent postoperative complication was temporary marginal mandibular nerve branch paresis, resulting in lower lip weakness but resolving within a period of 16 weeks. This transient nerve injury was most likely caused by iatrogenic iatrogenic /iat·ro·gen·ic/ (i-a´tro-jen´ik) resulting from the activity of physicians; said of any adverse condition in a patient resulting from treatment by a physician or surgeon. neurapraxia due to either stretching or pulling of the nerve during dissection or close cauterization cauterization /cau·ter·iza·tion/ (kaw?ter-i-za´shun) destruction of tissue with a cautery.
destruction of tissue with a cautery. of adjacent tissue with the bipolar electrocoagulator. The marginal mandibular mandibular
adj pertaining to the lower jaw. branch is at greater risk for weakness than the rest of the nerve because of its close proximity to the tail and inferoposterior part of the parotid, an area most commonly affected by tumors. Additionally this branch is the longest and may require more manipulation during dissection. Another complication reported by the vast majority of our patients consisted of transient paresthesia paresthesia /par·es·the·sia/ (par?es-the´zhah) morbid or perverted sensation; an abnormal sensation, as burning, prickling, formication, etc.
par·es·the·sia or par·aes·the·sia
n. of the ipsilateral ipsilateral /ip·si·lat·er·al/ (ip?si-lat´er-al) situated on or affecting the same side.
Located on or affecting the same side of the body. auricle auricle /au·ri·cle/ (aw´ri-k'l)
1. pinna; the flap of the ear.
2. the ear-shaped appendage of either atrium of the heart.
3. formerly, the atrium of the heart. . This symptom is usually caused by mobilization or by discontinuity of the greater auricular auricular /au·ric·u·lar/ (aw-rik´u-lar)
1. pertaining to an auricle.
2. pertaining to the ear.
1. nerve, which courses in close proximity to the parotid tail and supplies sensory function to the periauricular region.
In all of these parotidectomies, the nerve stimulator was considered an essential tool to identify, dissect, and preserve the facial nerve. Under no circumstances would surgeons have operated without this piece of equipment for fear of injuring the facial nerve. On the other hand, the facial nerve monitor was not available for use in this group of operations and although useful, was not considered then as standard of care. (13, 14) The use of bipolar cautery aided in the control of electrocoagulation electrocoagulation /elec·tro·co·ag·u·la·tion/ (-ko-ag?ul-a´shun) coagulation of tissue by means of an electric current.
n. by limiting the spread of energy into adjacent tissue, minimizing collateral injury. The contact Nd:YAG laser used in most of these operations provided some advantage with hemostasis hemostasis /he·mo·sta·sis/ (he?mo-sta´sis) (he-mos´tah-sis)
1. the arrest of bleeding by the physiological properties of vasoconstriction and coagulation or by surgical means.
2. and accuracy of dissection and was considered a preferred tool but not essential.
Successful surgical treatment of parotid tumors is feasible in the general community hospital and can greatly enhance the medical services that these institutions provide. Greater statistical power could be gained in this series by adding more observations. It is important to note that this work reports on short-term clinical perioperative outcome but does not address any long-term issues.
Epidemiologic data suggest that the majority of parotid tumors likely to be encountered in the clinical setting will be benign. Indeed, the incidence of parotid tumors in a community hospital should resemble that reported in the literature. The frequency of all parotid tumors and specifically malignancies may increase if the hospital services an older population.
The most common procedure done to treat benign tumors consisted of lateral lobe parotidectomy with dissection and preservation of the facial nerve. Malignancies may have required more extensive operations including neck dissection. The complications that were recorded in this series were considered either expected or minor and were all transient.
To successfully treat parotid tumors in such a setting requires, at the very least, the presence of board certified surgeons with special expertise in the head and neck area, a competent pathology department, and nerve stimulation equipment. Statistical analysis of this series suggests that parotid malignancy may occur more frequently in elderly men and that the hospitalization may be longer for patients having surgery for malignancy than for benign parotid disease.
TABLE 1 Distribution and Frequency of Parotid Tumors by Pathology and Patient Sex Type of Tumor Male Female Benign Pleomorphic adenoma 2 16 Warthin's tumor 6 2 Inflammatory 1 5 Monomorphic adenoma 3 Lipoma 1 Subtotal 13 23 Malignant tumors Squamous cell carcinoma 5 1 Adenocarcinoma 3 2 Lymphoma 1 1 Merkle cell carcinoma 1 Basaloid neoplasm 1 Subtotal 11 4 Total 24 27 Type of Tumor Total Benign Pleomorphic adenoma 18 Warthin's tumor 8 Inflammatory 6 Monomorphic adenoma 3 Lipoma 1 Subtotal 36 Malignant tumors Squamous cell carcinoma 6 Adenocarcinoma 5 Lymphoma 2 Merkle cell carcinoma 1 Basaloid neoplasm 1 Subtotal 15 Total 51 TABLE 2 Pathology as Function of Sex Sex Nonmalignant Malignant Total Female 23 4 27 Male 13 11 24 Total 36 15 51 DF Value Probability Chi-square 1 5.888 .015 TABLE 3 Pathology as Function of Sex and Age > 65 Years Sex Nonmalignant Malignant Total Female 13 2 15 Male 9 9 18 Total 22 11 33 DF Value Probability Chi-square 1 4.950 .026 TABLE 4 Length of Hospital Stay as Function of Pathology Length of Stay (Days) Pathology 1 2 3 4 5 6 Benign 2 8 1 1 1 0 Inflammatory 4 0 0 0 0 0 Malignant 0 2 4 0 1 1 Total 6 10 5 1 2 1 Pathology Total Benign 13 Inflammatory 4 Malignant 8 Total 25
Acknowledgments. We thank Gerald Zuckier, PhD, from Bayer Pharmaceutical Division for epidemiology and data analysis.
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* The epidemiology of parotid tumors presenting at a general community hospital should parallel that described by large series from tertiary referral medical centers.
* Guidelines to ensure safety and feasibility of treatment of parotid tumors should include participation of qualified surgeons and pathologists, as well as use of the facial nerve monitor.
* Postoperative length of stay after parotidectomy is longer in elderly men presenting with malignancy.
From the Department of Otolaryngology, University of Miami This article is about the university in Coral Gables, Florida. For the university in Oxford, Ohio, see Miami University.
The University of Miami (also known as Miami of Florida, UM, or just The U School of Medicine, Miami, Fla. (Mr. Ackerman is a first-year medical student at the University of Miami. Dr. Hanft is now with Holy cross Medical center, Fort Lauderdale, Fla, and Dr. Sheth, with St. Mary's Hospital, Rhinelander, Wis.)
Reprint requests to Frank C. Astor, MD, University of Miami School of Medicine, PO Box 016960 (D-48), Miami, FL 33101.