Variations of Parotidectomy Variations of Parotidectomy - - PDF document

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Variations of Parotidectomy Variations of Parotidectomy - - PDF document

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Variations of Parotidectomy Variations of Parotidectomy Indications and Technique Indications and Technique Kerry D. Olsen, M.D. Kerry D. Olsen, M.D. Professor and Chair Professor and Chair Head and Neck Surgery Head and Neck

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Variations of Parotidectomy – Indications and Technique Variations of Parotidectomy – Indications and Technique

Kerry D. Olsen, M.D.

Professor and Chair Head and Neck Surgery Mayo Clinic

Kerry D. Olsen, M.D.

Professor and Chair Head and Neck Surgery Mayo Clinic

Parotidectomy

  • 60 – 100 cases per year
  • Variety of neoplasms and

anatomic variations

  • Minimal morbidity overall
  • Recurrent neoplasms –

challenging cases

  • Personal experience > 32 years
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Parotid Surgery - Challenges

  • Patient expectations
  • Variety of tumors

encountered

  • Relationship and size
  • f the tumor to the

nerve

  • Extend the operation

as needed

  • Role of pathology

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Parotidectomy

  • Surgical options:
  • Superficial parotidectomy
  • Partial parotidectomy
  • Deep lobe parotidectomy
  • Total parotidectomy
  • Extended parotidectomy
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Surgical Technique

  • Superficial parotidectomy
  • Deep lobe parotidectomy
  • Surgeons will spend their entire career

trying to learn when it is safe or necessary to do more or less than a superficial parotidectomy

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Superficial Parotidectomy

  • Indications
  • Neoplasm
  • Risk of metastasis
  • Recurrent

infection/abscess

  • Surgical exposure –

deep lobe/ parapharynx/ infratemporal fossa

  • Cosmesis
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Pre-operative Discussion

  • Individualized
  • Goals – rational – risks
  • Goals – safe and complete removal

with surrounding margin of normal tissue and preservation of facial nerve function

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9 10

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11 12

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13 14

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Facial Nerve Identification

  • Helpful:
  • Cartilaginous

pointer

  • Posterior belly
  • f the digastric

muscle

  • Mastoid tip
  • Retrograde dissection
  • Mastoid dissection

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Superficial Parotidectomy

  • Surgical goals
  • Avoid facial nerve

injury

  • Remove tumor

with surrounding parotid tissue

  • Minimize capsular

dissection

  • Avoid tumor spillage

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Partial Parotidectomy

  • Inferior parotidectomy
  • Posterior parotidectomy
  • Accessory parotidectomy
  • Deep lobe partial parotidectomy
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Deep Lobe of the Parotid Gland

  • Largest portion between ramus of

mandible and mastoid process

  • Small amount deep

to facial nerve and

  • ver masseter

muscle

  • Smaller extension

retromandibular into the parapharyngeal space

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Deep Lobe Parotidectomy Indications

  • To understand the indications one must

know:

  • Regional anatomy
  • Embryology
  • Lymphatic drainage of the parotid

area

  • Parotid tumor behavior
  • Effective surgical technique
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Parotid Lymph Nodes Parotid Lymph Nodes

  • 15-20 parotid regional nodes
  • Paraglandular – intraglandular
  • Number lymph

nodes superficial lobe > number lymph nodes deep lobe

  • 15-20 parotid regional nodes
  • Paraglandular – intraglandular
  • Number lymph

nodes superficial lobe > number lymph nodes deep lobe

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Parotid Lymph Nodes Parotid Lymph Nodes

Mean ± SD Range Superficial lobe 7.6±3.4 3-19 Deep lobe 2.3±1.8 0-9 Mean ± SD Range Superficial lobe 7.6±3.4 3-19 Deep lobe 2.3±1.8 0-9

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Deep Lobe Parotidectomy Indications

  • Both benign and malignant tumors
  • Deep lobe parotidectomy alone –

usually benign disease

  • For malignant disease – deep lobe

parotidectomy generally done in conjunction with a superficial parotidectomy

  • Facial nerve preserved or removed

depending on the individual case

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Deep Lobe Parotid Surgery Partial Removal

  • Identification of facial

nerve portion or all

  • Mobilization of

facial nerve

  • Removal portion

gland by tumor

  • Preservation most

deep structures

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Deep Lobe Removal

Total Parotidectomy

  • Concept lymphatic spread
  • Primary parotid neoplasms
  • Metastasis to superficial parotid

nodes

  • Frequently misunderstood aspect of

the treatment of parotid malignancy

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Case Report

  • Melanoma temple with

palpable mass lower pole of parotid

  • PET scan / CT

negative except for single parotid node

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Case Report

  • Treatment
  • Excision of the primary
  • Superficial parotidectomy

 One 2 x 2 cm node pos.  1 / 6 other nodes

positive

  • Deep lobe removed

 1 / 3 nodes positive

  • Select neck dissection

 1 / 8 upper nodes

positive

 0 / 10 mid  0 / 6 low

  • Treatment
  • Excision of the primary
  • Superficial parotidectomy

 One 2 x 2 cm node pos.  1 / 6 other nodes

positive

  • Deep lobe removed

 1 / 3 nodes positive

  • Select neck dissection

 1 / 8 upper nodes

positive

 0 / 10 mid  0 / 6 low

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Deep Lobe Removal

Positive Superficial Parotid Nodes

  • 66 year old male
  • Parotid gland adenocarcinoma
  • Pathology findings
  • 8 of 9 superficial parotid nodes

positive

  • 5 of 6 deep lobe nodes positive
  • 15 of 41 neck nodes positive

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Deep Lobe Removal

High Grade Parotid Malignancy

  • 64 year old male
  • Carcinoma Ex-pleomorphic – superficial

lobe

  • Sarcomatoid salivary duct carcinoma type
  • Pathology findings
  • 3x3x2 cm parotid mass – sup. lobe
  • 4 parotid nodes

negative

  • 42 neck nodes negative
  • 2 deep lobe nodes

positive

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Deep Lobe Parotidectomy Indications

  • Actual or presumed metastasis to deep

parotid nodes

  • All cases of metastasis to superficial

parotid nodes (Parotid and extra- parotid primaries)

  • Any parotid malignancy with cervical

metastasis

  • High grade aggressive parotid

malignancies

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Deep Lobe Parotid Surgery

Total Removal

Deep Lobe Parotid Surgery

Total Removal

  • Initial superficial parotidectomy
  • Complete facial nerve mobilization
  • Removal vessels – key step!
  • External carotid
  • Superficial

temporal

  • Internal

maxillary

  • Initial superficial parotidectomy
  • Complete facial nerve mobilization
  • Removal vessels – key step!
  • External carotid
  • Superficial

temporal

  • Internal

maxillary

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Deep Lobe Parotidectomy Deep Lobe Parotidectomy

  • En-bloc removal
  • Preserve facial nerve
  • Remove gland and deep parotid

nodes

  • Safe and effective
  • En-bloc removal
  • Preserve facial nerve
  • Remove gland and deep parotid

nodes

  • Safe and effective
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Summary

  • Surgeon should be

able to match patient’s expectations of a safe successful tumor removal with preservation of facial nerve function

  • Challenges – unknowns –

unexpected – unusual