EXTRACAPSULAR DISSECTION WITH FACIAL NERVE MONITORING FOR PAROTID TUMORS

Transcription

1 EXTRACAPSULAR DISSECTION WITH FACIAL NERVE MONITORING FOR PAROTID TUMORS Arnold Komisar, MD, DDS, MS Medical Director New York Head and Neck Institute Lenox Hill Hospital-Northshore LIJ Health System Clinical Professor of Otolaryngology NYU School of Medicine New York, NY

2 CLASSIC SUPERFICIAL PAROTIDECTOMY Classic operation: removal of entire lobe Margin of normal parotid tissue Locate and preserve facial nerve Has withstood the test of time as to oncological feasibility

3 CLASSIC OPERATION Facial Nerve weakness Ear and Facial numbness Contour deformity Frey s Syndrome Questionable logic

4 IS IT LOGICAL? Always a bare area or positive margin where tumor touches facial nerve, thus there is no true margin We take out deep lobe, buccal space tumors without parotid tissue around it, as we do parapharyngeal tumors.

5 IS IT LOGICAL? Is the capsule really different in these tumors? Probably not Pseudopods may be an artifact introduced by slide processing

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11 BUCCAL SPACE

12 MINOR SALIVARY GLAND

13 AN EVOLUTIONARY PROCESS Mra,Z., Komisar A., Blaugrund, S. Facial Nerve Weakness After Parotidectomy - A Multivariate Analysis of 65 Patients" Head and Neck Surgery 15 : , March/April 1993

14 EXTRACAPSULAR DISSECTION Age > 65 Marginal most common Incidence was 15% transient May have been related to blood supply to the facial nerve (end vessel distribution)

15 FACIAL NERVE MONITORING

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21 EXTRACAPSULAR DISSECTION This is not enucleation which is to be condemned Enucleation was performed with a small incision over the tumor The tumor was then curetted Failure rate of over 50%

22 ONCOLOGIC SAFETY/RATIONALE First performed at Christie Hospital in Manchester, England by Nicholson. Then popularized by Gleave and Hancock E.N. Gleave and M. McGurk have reported the UK experience with ECD: Recurrence rates for benign tumors equal to the North American experience with traditional parotid surgery Renehan, et al (1996) British Journal of Surgery, 83: McGurk, et al (2003) British Journal of Cancer, 89:

23 ONCOLOGIC SAFETY/RATIONALE 1.6% recurrence at median 12.5 years Follow-up in series of 551 primary parotid pleomorphic adenomas* Even when clinically benign tumors prove to be cancer, survival and local recurrence rates equivalent to results of superficial parotidectomy**

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43 TAIL TUMOR

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45 THE FACIAL NERVE

46 FACIAL NERVE FUNCTION

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65 INTERIM SUMMARY

66 INDICATIONS Benign tumors (including cysts and lymph nodes) of the superficial lobe Mobility in two directions or planes No prior history of parotid surgery No history of facial weakness

67 WIDE EXTRACAPSULAR DISSECTION Wide exposure. Removal of tumor by dissecting in extracapsular plane. Avoids dissection of VII Minimizes soft tissue defect Results may be operator-dependent

68 SURGICAL TECHNIQUE Facial nerve monitor: periorbital (upper division) perioral (lower division) Muscle paralytics avoided throughout case. Approach: Modified Blair incision. dissection in subcutaneous plane to beyond Tumor. GAN preserved.

69 SURGICAL TECHNIQUE Cruciate incision. Normal gland is retracted away from tumor. Hemostasis with bipolar cautery. Once perimeter is defined, tumor is rolled from side-to-side to free from deep plane attachments.

70 SURGICAL TECHNIQUE Optional closed suction (JP) drainage x 6-8 hours. Closure in two layers.

71 SURGICAL TECHNIQUE Facial Nerve Preservation Use a monitor. Use magnification. Nerve is rarely visualized Never dissected in entirety. Avoids permanent sensory deficit, since GAN need not be taken to mobilize gland. Nerve Loupe Nerve is

72 METHODS Study Design: Retrospective Chart Review Study Period: January October 2006 Inclusion Criteria: Parotid mass. History, physical exam consistent with: benign neoplasm. location in superficial lobe. If imaging, FNA performed, consistent with: benign neoplasm. location in superficial lobe.

73 Tumor Characteristics Median Size range = 2-4 cm 3 Histology: Pleomorphic Adenoma 40% (11/27) Warthin s Tumor 22% (6/27) Other (Benign) 30% (8/27) parotid cyst lymphoid hyperplasia Other (Malignant) 7% (2/27) Merkel cell CA Kaposi s Sarcoma

74 RESULTS N = 27 patients Median follow-up time = 41 months (range.5 6 yrs) All patients NED at time of last follow-up

75 COMPLICATIONS Complications: Transient ear numbness (5/27) One patient required conversion to traditional superficial parotidectomy. Seroma (1/27) There was NO incidence of: facial weakness (temporary or permanent), hematoma, contour deformity or Frey s syndrome

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82 DISCUSSION/CONCLUSIONS Large series with long-term follow-up have demonstrated wide extracapsular dissection to be oncologically sound treatment for selected parotid tumors by experienced surgeons. In our series, the most common complication was transient ear numbness; there was no incidence of postoperative facial weakness. Use of the facial nerve monitor may contribute to the safety and low complication rate of this procedure.

83 The localized approach.. is not recommended for an inexperienced surgeon in training. However, it is an approach the can be considered by surgeons with a special interest in parotid surgery. It is a technique for a surgical connoisseur E N Gleave, 1995

84 REFERENCE Limited Parotidectomy: The Role of Extracapsular Dissection in Parotid Gland Neoplasms. Laryngoscope 117(7): , July Smith, Sarah L. MD; Komisar, Arnold MD, DDS.