10.14639/0392-100X-N1728
Objective. Parotidectomy worsens quality of life (QoL) in the short-term, but the long-term impact is unknown. In this study, we analysed the long-term effects of parotidectomy on QoL. Methods. In this prospective long-term follow-up study, participants were divided into three groups: short-term (ST) follow-up of six weeks, long-term (LT) follow-up of 13 years and short- and long-term (SLT) follow-up. QoL was assessed using the Parotidectomy Outcome Inventory (POI-8). Parotidectomies were classified based on whether the great auricular nerve (GAN) had been preserved or sacrificed. Results. In total, 164 observations were analysed, 74 in the LT group, 57 in the ST group and 33 in the SLT group. Hypoaesthesia was a major problem and facial palsy was a minor problem. Pain (p &lt; 0.01) and hypoaesthesia (p &lt; 0.001) were significantly lower after 13 years compared with after six weeks, and QoL was higher after 13 years compared with after six weeks (p = 0.04). The disease-specific impairment rate decreased from 70% at short-term follow-up to 30% at long-term follow-up. Removal of the GAN was associated with hypoaesthesia in the ST group (p = 0.028). Conclusions. Hypoaesthesia has a long-term impact on the QoL, and this should be emphasised during preoperative discussions.
text/xml
1827-675X
1728
en
Karim Zaoui
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
POI-8
Long-term outcomes and quality of life following parotidectomy for benign disease
Text.Serial.Journal
https://www.actaitalica.it/
42
Head and neck
2022-06-30
2021-06-07
2022-07-26
2022-07-26
215-222
1
Karim Zaoui
2022/06/30
10.14639/0392-100X-N1728
215
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Heidelberg, Heidelberg, Germany
1827-675X
POI-8
222
Long-term outcomes and quality of life following parotidectomy for benign disease
https://www.actaitalica.it/article/download/1728/816
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:215-222; doi: 10.14639/0392-100X-N1728




Head and neck


Long-term outcomes and quality of life following
parotidectomy for benign disease
Risultati a lungo termine e qualità della vita dopo parotidectomia per patologie benigne
Michaela Plath1, Matthias Sand2, Carlo Cavaliere3, Peter K. Plinkert1, Ingo Baumann1, Karim Zaoui1
1
 Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Heidelberg, Heidelberg, Germany; 2 GESIS-
Leibniz-Institute for the Social Sciences, Mannheim, Germany; 3 Department of Oral and Maxillofacial Sciences, Sapienza University
of Rome, Rome, Italy


SUMMARY
Objective. Parotidectomy worsens quality of life (QoL) in the short-term, but the long-term
impact is unknown. In this study, we analysed the long-term effects of parotidectomy on
QoL.
Methods. In this prospective long-term follow-up study, participants were divided into
three groups: short-term (ST) follow-up of six weeks, long-term (LT) follow-up of 13 years
and short- and long-term (SLT) follow-up. QoL was assessed using the Parotidectomy Out-
come Inventory (POI-8). Parotidectomies were classified based on whether the great auricu-
lar nerve (GAN) had been preserved or sacrificed.
Results. In total, 164 observations were analysed, 74 in the LT group, 57 in the ST group
and 33 in the SLT group. Hypoaesthesia was a major problem and facial palsy was a minor
problem. Pain (p < 0.01) and hypoaesthesia (p < 0.001) were significantly lower after 13
years compared with after six weeks, and QoL was higher after 13 years compared with
after six weeks (p = 0.04). The disease-specific impairment rate decreased from 70% at
short-term follow-up to 30% at long-term follow-up. Removal of the GAN was associated
with hypoaesthesia in the ST group (p = 0.028).
Conclusions. Hypoaesthesia has a long-term impact on the QoL, and this should be empha-
sised during preoperative discussions.
                                                                                                 Received: June 7, 2021
KEY WORDS: parotidectomy, benign disease, long-term outcome, quality of life, POI-8              Accepted: November 19, 2021

                                                                                                 Correspondence
RIASSUNTO                                                                                        Karim Zaoui
Obiettivi. La parotidectomia peggiora la qualità della vita (QoL) a breve termine; l’impatto     Department of Otorhinolaryngology, Head and
a lungo termine non è noto e abbiamo voluto analizzarlo in questo studio.                        Neck Surgery, University Hospital Heidelberg,
Metodi. Questo è uno studio prospettico di follow-up a lungo termine. I partecipanti sono        Ruprecht-Karls-University, Im Neuenheimer Feld
stati divisi in tre gruppi: follow-up a breve termine (ST) di sei settimane, follow-up a lungo   400, D-69120 Heidelberg, Germany
termine (LT) di 13 anni e follow-up a breve e lungo termine (SLT). La QoL è stata valutata       Tel. +49 (0)6221 5639510
utilizzando il Parotidectomy Outcome Inventory (POI-8). Le parotidectomie sono state di-         E-mail: karim.zaoui@med.uni-heidelberg.de
stinte in base alla conservazione o al sacrificio del nervo grande auricolare (GAN).
Risultati. Sono stati arruolati 164 pazienti, 74 nel gruppo LT, 57 nel gruppo ST e 33 nel          How to cite this article: Plath M, Sand M, Cava-
gruppo SLT. L’ipoestesia è stato il problema principale, la paralisi facciale un problema          liere C, et al. Long-term outcomes and quality of
minore. Il dolore (p < 0,01) e l’ipoestesia (p < 0,001) erano significativamente ridotti dopo      life following parotidectomy for benign disease.
13 anni rispetto a dopo sei settimane e la QoL era maggiore dopo 13 anni rispetto a sei            Acta Otorhinolaryngol Ital 2022;42:215-222. htt-
settimane (p = 0,04). Il tasso di compromissione della malattia è diminuito dal 70% a breve        ps://doi.org/10.14639/0392-100X-N1728
termine al 30% a lungo termine. La rimozione del GAN ​​è stata associata a ipoestesia nel
gruppo ST (p = 0,028).                                                                           © Società Italiana di Otorinolaringoiatria
Conclusioni. L’ipoestesia ha un impatto a lungo termine sulla QoL e dovrebbe essere di-          e Chirurgia Cervico-Facciale
scussa durante i colloqui preoperatori.
                                                                                                                OPEN ACCESS
PAROLE CHIAVE: parotidectomia, malattia benigna, outcome a lungo termine, qualità
                                                                                                 This is an open access article distributed in accordance with
della vita, POI-8
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                 Commercial-NoDerivatives 4.0 International) license. The
                                                                                                 article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
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M. Plath et al.




Introduction                                                      patients, (57 from the original survey in 2006, 74 after the
                                                                  invitation in 2018 and 33 from both groups). Due to the
Tumours of the parotid gland constitute approximately 3%
                                                                  overlap in study cohorts, these observations originated
of head and neck tumours, and 80% are benign. Benign
                                                                  from 98 patients.
tumours like pleomorphic salivary adenoma, cystadeno-
                                                                  We assigned participants to long-term (LT), short-term (ST)
lymphoma, and basal cell adenoma are indications for pa-
                                                                  and short- and long-term (SLT) groups. The LT cohort com-
rotid surgery 1,2. Parotid surgery aims to partially or totally
                                                                  prised 74 patients who participated in our prospective study
remove the gland while preserving facial nerve function
                                                                  in 2018 and returned the POI-8 questionnaire 12-16 years
and preventing tumour recurrence 3. Extracapsular dissec-
                                                                  after parotidectomy. The SLT cohort comprised 33 patients
tion (ECD), partial lateral (superficial) parotidectomy, lat-
                                                                  from the original retrospective study who responded to our
eral or superficial parotidectomy (SP) and total parotidec-
                                                                  2018 invitation and returned the POI-8 six weeks 9 and 12-
tomy with preservation of the facial nerve are the different
                                                                  16 years after parotid surgery. The ST cohort included 57
surgical options used to treat a benign parotid tumour 4.
                                                                  patients from the original retrospective study who returned
The overall reported complication rate of parotidectomy
                                                                  the POI-8 six weeks after surgery 9.
is 21.6% 5,6. Complications such as postoperative numb-
                                                                  The POI-8 is a validated and reliable questionnaire for
ness, Frey’s syndrome, pain, mouth dryness and scar-re-
                                                                  patient-reported QoL after parotid surgery. It consists of
lated problems all affect the quality of life (QoL) 7. The
                                                                  eight Likert-scale questions with answers from 0 (no prob-
superficial musculoaponeurotic system (SMAS) flap for re-
                                                                  lems) to 5 (the worst problems) with a total possible score
construction of the parotid lodge reduces the cosmetic and
                                                                  of 40. Low POI-8 scores indicate high functionality and
functional complications following the removal of a benign
                                                                  high QOL 9. In addition to the POI-8, patients answered
parotid tumour 8.
                                                                  questions about parotidectomy-related impairment (no,
Measuring health-related quality of life (HRQoL) is be-
                                                                  low-grade, moderate, severe, and very severe impairment),
coming more important in clinical medicine. The Parot-
                                                                  postoperative satisfaction, and whether they would rec-
idectomy Outcome Inventory (POI-8) is a reliable and valid
instrument for measuring HRQoL in patients after parot-           ommend this operation to friends and family. Participants
idectomy for benign disease 9. While the short-term effects       also answered questions about physician visits, rehabilita-
(usually 6 months to 1 year) of parotidectomy have been           tive measures and incapacitated workdays in the last six
well described 3,7,10-13, little is known about the long-term     months. Results were compared between the ST and LT
effects of parotidectomy on QoL.                                  groups (intergroup) and within the SLT group (intragroup).
The study aimed to determine the long-term effects of             Lastly, operative reports and clinical notes were used to
parotidectomy on QoL using the disease-specific POI-8             classify whether parotidectomies sacrificed or preserved
questionnaire and to compare long-term data with pub-             the great auricular nerve (GAN).
lished short-term data. To increase objectivity, we divided
our participants into long-term (LT), short-term (ST), and        Statistical analysis
short- and long-term (SLT) groups and analysed the data           A certified expert of survey analysis performed the statisti-
for each group separately.                                        cal analysis at the GESIS-Leibniz-Institute for the Social
                                                                  Sciences. The data were analysed using R, versions 3.6.1
                                                                  and 4.0.2. Metric variables are presented as means ± stand-
Materials and methods                                             ard deviation, while factorial variables are presented as
We used the German version of the POI-8 questionnaire             proportional distributions. Additionally, t-statistics were
to measure QoL in 199 patients undergoing partial or total        used to compare mean values between variables for the dif-
parotidectomy for benign disease 9 between 2003 and 2006          ferent cohorts (intergroup comparisons). The distribution
in our department. Fifty-seven patients (28.6%) returned          of particular variables was tested for relatedness/independ-
their POI-8 questionnaire six weeks after parotid surgery.        ence using -tests for intragroup comparisons since a) most
All histopathological results were retrieved, and patients        variables were categorical or nominally distributed, b) the
with malignant diseases were excluded. In 2018, we invited        sample size was not too large to lead to false positive re-
199 patients from the original retrospective study 9 to par-      sults, and c) it is the most commonly used test for such
ticipate in this prospective study. Seventy-four of these pa-     comparisons 14. Furthermore, -tests are more suitable for
tients (37.2%) responded (12-16 years after surgery), 108         multiple comparisons.
patients (54.3%) did not respond, 16 patients (8%) had died       For some variables however, Pearson’s correlation test was
and one patient (0.5%) actively declined to participate in        carried out and the correlation coefficient r was estimat-
the study. In total, we obtained data from 164 of the 199         ed. The non-parametric Wilcoxon test was used to detect



216
                                                                                             Long-term quality of life after parotidectomy




meaningful differences between the POI-8 outcomes de-               xerostomia (p = 0.14) and anxiety about revision surgery
pendent of groups and other variables. A p-value less than          (p = 0.73). However, the mean POI-8 scores were signifi-
0.05 was considered statistically significant. Graphs were          cantly different between the two groups to describe QoL
programmed using the ggplot2 library of R.                          based on symptoms after parotidectomy (POI-8 score: 7.47
                                                                    for ST group, 5.15 for LT group; p = 0.04) (Fig. 1).
Results                                                             In the ST cohort, 64.9% of patients reported that their dis-
                                                                    ease-specific QoL was slightly affected after parotid sur-
                                                                    gery, and 68.4% said they were “very satisfied” with the
Patient cohorts                                                     results of their operation. In the LT cohort, 27% of patients
Seventy-four patients (LT cohort; 41 men, 33 women;                 still reported impairment after parotidectomy, which was
mean age 66.5 ± 12.3 years) prospectively completed the             described as “severe” by 4.1% of patients. The long-term
POI-8 questionnaire, with a mean follow-up of 13.3 ± 1.1            satisfaction rate was 81.8%. Negligible physician visits
years (range: 12-16). 51.4% of patients underwent a partial         (6.8%), days of incapacitation (2.7%) and no rehabilitative
superficial and 48.6% a superficial parotidectomy.                  measures (0%) were also reported by the LT cohort.
Fifty-seven patients (ST cohort; 27 men, 30 women; mean             POI-8 scores for postoperative impairment, operation sat-
age 68 ± 14.8 years) from the original retrospective study          isfaction and parotidectomy recommendation were signifi-
of Baumann et al. 9 were additionally included herein, of           cantly different within the ST cohort (p < 0.001), whereas
which 47.4% had been operated by partial superficial and            POI-8 scores for hypoaesthesia were not, indicating that
52.6% by superficial parotidectomy.                                 hypoaesthesia POI-8 scores best reflect the QoL six weeks
33 patients (SLT cohort; 16 men, 17 women; mean age                 after parotidectomy. Within the LT cohort, POI-8 scores
68 ± 12.6 years) prospectively and retrospectively partic-          for postoperative impairment, operation satisfaction and
ipated in this study. 45.5% of SLT patients underwent a             operation recommendation were all significantly different
partial superficial parotidectomy, 54.5% of patients a su-          (p < 0.001), demonstrating that the influence of parotidec-
perficial parotidectomy.                                            tomy on QoL decreased over time.
Patient details and disease characteristics are shown in Table I.
                                                                    Intragroup differences in POI-8 outcomes in the SLT cohort
Intergroup differences in POI-8 outcomes between ST and             Six weeks after parotidectomy, 84.8% of the SLT cohort
LT cohorts                                                          characterised hypoaesthesia as their most disturbing prob-
Six weeks after parotidectomy, 77.2% of patients in the ST          lem, followed by the scar (54.5%) and pain (51.5%). Facial
cohort referred hypoaesthesia as the most disturbing prob-          palsy was reported to be a minor problem (87.9%). At the
lem, followed by xerostomia (47.4%) and the scar (45.6%).           13-year follow-up, hypoaesthesia was still a problem for
Facial palsy was reported to be a minor problem by 87.7%            60.6% of patients, but only 3% described this problem as se-
of patients. In the LT cohort, hypoaesthesia was reported           vere. Frey’s syndrome (48.5%) and fear of revision (42.4%)
as a major problem by 54.1% of patients, followed by fear           were also reported as problems in this group, whereas facial
of revision surgery (44.6%) and the scar (39.2%). Most pa-          palsy was not referred. Patients reported that problems with
tients in this group (95.9%) did not think facial palsy was         hypoaesthesia (p < 0.001) and pain (p = 0.004) improved
problematic.                                                        from six weeks to 13 years after surgery. Problems caused
Patients in the ST cohort had significantly more pain at the        by the scar (p = 0.13), postoperative appearance (p = 0.17),
site of surgery than patients in the LT cohort did (mean POI-       Frey’s syndrome (p = 0.36), xerostomia (p = 0.09), fear of
8 score: 0.93 in the ST cohort and 0.34 in the LT cohort;           revision surgery (p = 0.75) and facial palsy (p = 0.08) did
p = 0.002). In the LT group, 77% of patients reported no            not significantly ameliorate after surgery. The total POI-
pain or painful sensations at 13 years after parotidectomy.         8 score significantly decreased from 8.24 at 6 weeks after
Hypoaesthesia had improved significantly over the years             surgery to 5.15 at 13 years after surgery, indicating increas-
but was still a problem: 77.2% of ST patients were dis-             ing satisfaction over time (p = 0.04; Fig. 1).
turbed by hypoaesthesia at six weeks after surgery (mean            Six weeks after parotidectomy, 72.7% of patients reported
POI-8 score: 1.86), and 54.1% of LT patients reported sen-          slight impairment and 69.7% were satisfied. At the 13-year
sation loss as a problem 13 years after surgery (mean POI-8         follow-up, 33.3% of patients still felt impaired after parotid
score: 0.88; p < 0.001).                                            surgery and 78.8% were satisfied. No incapacitated work-
POI-8 scores were not different between the ST group and            days, no rehabilitative measures and very few medical vis-
LT group for the scar (p = 0.07), facial palsy (p = 0.21),          its (6.1%) were reported in the last six months.
substance loss (p = 0.37), Frey’s syndrome (p = 0.64),              All group comparisons are illustrated in Figure 2.



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M. Plath et al.




Table I. Surgical and clinico-pathological characteristics of the three study cohorts.
 Characteristics                                                             ST - cohort      LT - cohort     SLT - cohort
                                                                               (n = 57)         (n = 74)         (n = 33)
 Age (years): time of operation                                               55 ± 14.9        53 ± 12.2        55 ± 12.7
                                                                           (range: 17-78)   (range: 28-76)   (range: 30-76)
 Age (years): time of survey                                                  68 ± 14.8      66.5 ± 12.3        68 ± 12.6
                                                                           (range: 31-92)   (range: 40-90)   (range: 45-90)
 Gender
   Female                                                                    30 (52.6%)      33 (44.6%)       17 (51.5%)
   Male                                                                      27 (47.4%)      41 (55.4%)       16 (48.5%)
 Operation extent
   Extracapsular dissection                                                     0 (0%)         0 (0%)           0 (0%)
   Partial superficial parotidectomy                                         27 (47.4%)      38 (51.4%)       15 (45.5%)
   Superficial parotidectomy                                                 30 (52.6%)      36 (48.6%)       18 (54.5%)
   Total parotidectomy                                                          0 (0%)         0 (0%)           0 (0%)
 Complication of facial paralysis
   Permanent                                                                    0 (0%)         0 (0%)           0 (0%)
   Temporary                                                                 18 (31.6%)      18 (24.3%)       13 (39.4%)
 Operation site
   Left                                                                      32 (56.1%)      43 (58.1%)       20 (60.6%)
   Right                                                                     25 (43.9%)      31 (41.9%)       13 (39.4%)
 Histopathological diagnoses
   Cystadenolymphoma                                                         21 (36.8%)      30 (40.5%)       12 (36.4%)
   Pleomorphic adenoma                                                       20 (35.1%)      21 (28.4%)       10 (30.3%)
   Parotid cyst                                                                 4 (7%)        5 (6.8%)        4 (12.1%)
   Chronic sialadenitis                                                        5 (8.8%)       5 (6.8%)         2 (6.1%)
   Basal cell adenoma                                                          2 (3.5%)       3 (4.1%)          1 (3%)
   Epitheloid cell granuloma                                                   1 (1.8%)       2 (2.7%)          1 (3%)
   Haemangioma                                                                 1 (1.8%)       1 (1.4%)          1 (3%)
   Myoepithelioma                                                              1 (1.8%)       1 (1.4%)          1 (3%)
   Oncocytoma                                                                   0 (0%)        2 (2.7%)          0 (0%)
   Morbus Sjögren                                                              2 (3.5%)       2 (2.7%)          1 (3%)
   Lymphadenitis                                                                0 (0%)        2 (2.7%)          0 (0%)
 Marital status
   Married                                                                   39 (68.4%)      26 (35.1%)       25 (75.8%)
   Separated                                                                 17 (29.8%)       7 (9.5%)        7 (21.2%)
   Widowed                                                                     1 (1.8%)       1 (1.4%)          1 (3%)
   No data                                                                         /         40 (54.1%)            /
 Graduation
   Secondary school                                                          25 (43.9%)      12 (16.2%)       12 (36.4%)
   Junior high school                                                        11 (19.3%)       8 (10.8%)       7 (21.2%)
   High school                                                               19 (33.3%)      13 (17.6%)       13 (39.4%)
   No data                                                                     2 (3.5%)      41 (55.4%)         1 (3%)
 Professional activities
   House work                                                                12 (21.1%)       6 (8.1%)        6 (18.2%)
   Job seeking                                                                 2 (3.5%)        0 (0%)           0 (0%)
   College student                                                             2 (3.5%)        0 (0%)           0 (0%)
   Retirement                                                                20 (35.1%)      11 (14.9%)       11 (33.3%)
   Employed                                                                  18 (31.6%)      14 (18.9%)       13 (39.4%)
   No data                                                                     3 (5.3%)      40 (54.1%)        3 (9.1%)
 Smoking history
   Currently                                                                 14 (24.6%)       9 (12.2%)       9 (27.3%)
   Former                                                                    19 (33.3%)      11 (14.9%)       10 (30.3%)
   Never                                                                     23 (40.4%)      13 (17.6%)       13 (39.4%)
   No data                                                                     1 (1.8%)      41 (55.4%)         1 (3%)




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                                                                                                         Long-term quality of life after parotidectomy




                                                                               auricle and along the anterior border of the sternocleido-
                                                                               mastoid muscle (55 vs 45%). In general, patients did not
                                                                               feel that their QoL was limited; 55% described the hypo-
                                                                               aesthesia as “marginal”, 35% as “slight” and 10% as “mod-
                                                                               erate”, “severe” or “very severe”. Of these 40 patients, no
                                                                               significant correlations were detected between GAN sac-
                                                                               rifice, hypoaesthesia, operation procedure (partial vs. to-
                                                                               tal) and the location of numbness using the chi-square and
                                                                               Wilcoxon test. According to the chi-square test, sacrifice
                                                                               of the GAN was associated with hypoaesthesia in the ST
                                                                               cohort (p = 0.028). Using the Wilcoxon test, we detected
                                                                               significant differences in the ST cohort between GAN sac-
                                                                               rifice and hypoaesthesia (p < 0.001) and GAN sacrifice and
                                                                               facial palsy (p < 0.001); and in the LT cohort between GAN
                                                                               sacrifice and pain (p < 0.001), GAN sacrifice and facial
                                                                               palsy (p < 0.001), and GAN sacrifice and substance loss
                                                                               (p < 0.04). However, the Wilcoxon test had little informa-
Figure 1. Group comparison of the total Parotidectomy Outcome Inventory        tive value for this calculation as it does not meet the test
(POI-8) score. The red line represents the overall mean POI-8 score of the     conditions.
combined results at both time points. The bold line shows the median whereas
the box represents the interquartile range. Dots resemble outliers.
                                                                               Discussion
                                                                               This study provides the first data on the short-term (six
Non-neoplastic versus neoplastic parotid diseases                              weeks after surgery) and long-term (13 years after surgery)
We further divided our patient cohorts according to their                      HRQoL after parotidectomy using the validated POI-8
neoplastic or non-neoplastic parotid disease profile. Most                     questionnaire. A key goal of parotid surgery to treat be-
patients (ST cohort: 80.7%, LT cohort: 81% and SLT co-                         nign lesions is to remove the tumour, minimise morbidity
hort: 78.8%) suffered from neoplastic parotid diseases. For                    and maintain patients’ QoL. In the literature, QoL is scaled
the ST, LT and SLT cohorts, we did not find any evidence                       corresponding to the type of surgery, although the width
that the POI-8-score is affected by the type of histology.                     of parotid gland surgery differs for each patient according
Information regarding the POI-8 results of both groups ac-                     to tumour location, size of the tumour, course of the fa-
cording to the different observation interval is presented in                  cial nerve and surgeon’s preference 15. Partial superficial
Table II.                                                                      parotidectomy was associated with fewer complications,
                                                                               especially temporary facial paralysis and Frey’s syndrome,
Preservation of the facial nerve                                               with a recurrence rate comparable to that of superficial pa-
Permanent facial paralysis occurred in no patient, whereas                     rotidectomy 16. In our study, only benign parotid tumours
31.6% of ST, 24.3% of LT, and 39.4% of SLT patients had a                      were included, 3-4 selected surgeons performed the opera-
postoperative temporary facial palsy. There were no statis-                    tions and the majority of parotidectomies were superficial
tically significant correlations between the temporary facial                  or partial superficial. To compare functional and aesthetic
paralysis and the fourth question of the POI-8 questionnaire                   results, regardless of the type of surgery, Aydin et al. estab-
(about facial nerve) or with the surgical type.                                lished the amount of residual parotid tissue remaining after
                                                                               parotid surgery as a new objective parameter and reported
Preservation of the great auricular nerve (GAN)                                that the maximum amount of disease-free tissue of the
Based on the available surgical reports (n = 98), the GAN                      parotid gland should be left in place to increase patients’
was preserved in 45.9% of cases, sacrificed in 33.7% of                        QoL as well as to minimise complications 15. Generally,
cases and not reported in 20.4%.                                               only few studies have addressed the patients’ perspective
All patients in the LT cohort who reported sensation loss in                   on HRQoL 7,10-12,15,17-19. Most of these have only reported
their first POI-8 questionnaire (n = 40; 23 men, 17 wom-                       short-term results, i.e., from 6 months to 1-2 years after
en) were contacted again and asked about the location of                       surgery, and have used different symptom-specific QoL as-
numbness. The area overlying the parotid gland and at the                      sessments. Beutner et al. 11 used the EORTC QLQ-C30 and
angle of the mandible were slightly more affected than the                     EORTC QLQ-H&N 35 and reported no changes in QoL one



                                                                                                                                                219
M. Plath et al.




Figure 2. Group comparison of the different Parotidectomy Outcome Inventory (POI-8) items. The red line represents the overall mean of an item of the combined
results, measured at both time points. The bold line represents the median whereas the box represents the interquartile range. Dots resemble outliers.


Table II. Group Classification of the non-neoplastic (parotid cyst, chronic sialadenitis, Morbus Sjögren and Lymphadenitis) versus neoplastic (cystadenolympho-
ma, pleomorphic adenoma, basal cell adenoma, epitheloid cell granuloma, hemangioma, myoepithelioma and oncocytoma) parotid disease profile according to the
short (ST)-, long (LT)-, and to the short- and long-term (SLT) observation interval.
 POI-8 results       ST neoplastic         ST non-        LT neoplastic        LT non-        SLT_short        SLT_short         SLT_long          SLT_long
                         (n = 46)         neoplastic         (n = 60)         neoplastic      neoplastic         non-           neoplastic           non-
                                           (n = 11)                            (n = 14)        (n = 26)        neoplastic        (n = 26)          neoplastic
                                                                                                                (n = 7)                             (n = 7)
 POI-8 mean              7.3              8.27             5.02              5.71              7.96             9.29              4.65               7.0
 score
 Major problem         1.76            2.27              1.1                  1.5               2.0            2.29             1.04                2.29
                  (hypoaesthesia) (hypoaesthesia) (fear of revision         (Frey’s       (hypoaesthesia) (hypoaesthesia) (fear of revision        (Frey’s
                                                      surgery)            syndrome)                                           surgery)           syndrome)
 Minor problem          0.26              0.91              0.1                0               0.23               0                 0                 0
                    (facial palsy)    (pain) / 0.91    (facial palsy)    (facial palsy)    (facial palsy)   (facial palsy)    (facial palsy)    (facial palsy)
                                       (substance
                                          loss)


year after superficial parotidectomy compared with before                           follow-up, we still do not know which factors affect pa-
surgery. Nitzan et al. used a modified version of the Uni-                          tients’ QoL in the long-term after parotidectomy.
versity of Washington Quality of Life Questionnaire during                          To our knowledge, the present study is the most extend-
a 1-year follow-up period and detected that the sequelae                            ed follow-up reported after parotid surgery for benign
did not significantly affect QoL 12. Bulut et al. made use of                       tumours. We found that hypoaesthesia was perceived as
the POI-8 and measured QoL based on sensory dysfunction                             the most significant long-term problem after parotid sur-
due to GAN sacrifice and described a significant increase                           gery followed by fear of revision surgery, whereas facial
in long-term QoL (100 months postoperatively) compared                              palsy posed a minor problem. In the literature, hypoaes-
with short-term QoL (two weeks post-operatively) after pa-                          thesia is described as the greatest concern of patients at
rotid surgery 19. Since most studies only performed a short                         short- (about six months) 7,10,12,17,20 and long-term (about



220
                                                                                         Long-term quality of life after parotidectomy




two years) 10,19,21,22 after parotidectomy. Most sensory im-    symptoms related to this syndrome, whereas the long-term
provements occurred in the first six months after surgery 23    follow-up period was probably too long (13 years after sur-
and after two years, when symptoms are either no longer         gery) to have a significant residual impact on quality of life
present or have stabilised 24. The GAN innervates the skin      of patients. Moreover, about 50% of patients did not re-
overlying the lower aspect of the pinna and angle of the        spond to the questionnaire.
mandible and is divided into anterior and posterior branch-     There are some limitations to the present study. Global
es. The anterior branch is usually sacrificed during parotid    QoL is a multidimensional construct affected by economic,
surgery, whereas the posterior branch can technically be        social, interpersonal, physical and psychological aspects 11,
preserved 7, explaining why the areas overlying the parotid     and the subjective perception of post-parotidectomy com-
gland and at the angle of the mandible were slightly more       plications in our study might also be influenced by these
affected than the auricle and along the anterior border of      factors 3. However, there is no objective method to evaluate
the sternocleidomastoid muscle. GAN preservation can            QoL in the head and neck region 19. Another limitation of
significantly improve short-term but not long-term sensa-       our study is the different group sizes, and further prospec-
tion, and does not increase the patient’s QoL in the long       tive studies with larger sample sizes are needed. There are
term 19. Our data showed that hypoaesthesia significantly       also strengths to our study. To our knowledge, this is the
improved, but was still present 12-16 years after parot-
                                                                most extended follow-up study assessing HRQoL in pa-
idectomy and that QoL was not affected by hypoaesthesia.
                                                                tients undergoing parotidectomy. It uses a validated tool
Indeed, 77.2% of patients in the ST group were affected
                                                                (the POI-8) to measure patient-reported QoL and compares
by hypoaesthesia at six weeks after surgery and 64.9% re-
                                                                these findings between LT, ST and SLT groups.
ported impairment, whereas 54.1% of patients in the LT
group referred that sensation loss was a problem and 27%
reported impairment. These findings suggest that patients       Conclusions
should be preoperatively informed about the possibility of      Patients perceived hypoaesthesia and fear of revision
prolonged or permanent hypoaesthesia. In agreement with         surgery as the most significant long-term impairments,
Bulut et al. 19, we only found a positive association be-       whereas facial palsy was considered a minor problem.
tween GAN preservation and improved hypoaesthesia in
                                                                Despite being a major problem, hypoaesthesia signifi-
the ST cohort, but not in the LT cohort.
                                                                cantly improved over the years and did not affect QoL in
We found that patients adapted to postoperative functional
                                                                the LT group. Our findings indicate that hypoaesthesia
impairment over time and focused less on the reduced abil-
                                                                should be discussed when asking patients for informed
ity to feel temperature and pain on the facial skin over the
                                                                consent.
parotid gland and auricle. In agreement with our findings,
Wolber et al. 10 and Nitzan et al. 12 reported a 30-40% inci-
                                                                Conflict of interest statement
dence of postoperative pain during short follow-up. In ac-
cord with Kaya et al. 13, we argue that pain is an important    The authors declare no conflict of interest.
early complication following parotidectomy that improves
in the long-term. The total POI-8 score significantly im-       Funding
proved from six weeks after surgery to 13 years after sur-      This research did not receive any specific grant from fund-
gery, indicating that parotidectomy does not impair QoL         ing agencies in the public, commercial, or not-for-profit
in the long term. Specifically, problems associated with        sectors.
hypoeasthesia and pain improved significantly from the pa-
tient’s perspective over time. Strikingly, problems associ-     Authors’ contributions
ated with postoperative scars, facial palsy, substance loss,    All authors made substantial contributions to the study.
xerostomia, anxiety about revision surgery and Frey’s syn-      MP: designed and coordinated the study, participated in da-
drome were not significantly different between the ST and       ta acquisition and analysis, interpreted the data, and drafted
LT groups. In our study, 82.5% of ST and LT patients re-        the manuscript; MS: participated in data interpretation and
ported no or only “marginal” to “slight” post-parotidecto-      statistical analysis; CC: participated in data interpretation
my Frey’s syndrome complaints, although Frey’s syndrome         and revision of the manuscript; PKP: participated in data
is the best described and more frequent complication fol-       interpretation; IB: participated in data interpretation; KZ:
lowing parotidectomy with a clinical incidence as high as       designed and coordinated the study, and participated in
50% 25. One explanation could be that the short follow-up       data acquisition and analysis, critically revised the manu-
period was too short (6 weeks) to show the occurrence of        script for important intellectual content.



                                                                                                                                221
M. Plath et al.




Ethical consideration                                                        10
                                                                                  Wolber P, Volk GF, Horstmann L, et al. Patient’s perspective on long-
This study was approved by the Ethics Committee of the                            term complications after superficial parotidectomy for benign le-
                                                                                  sions: prospective analysis of a 2-year follow-up. Clin Otolaryngol
Medical Faculty at the University of Heidelberg grant-                            2018;43:1073-1079. https://doi.org/10.1111/coa.13104
ed permission to conduct the study (Project Trial No:                        11
                                                                                  Beutner D, Wittekindt C, Dinh S, et al. Impact of lateral parotidectomy
S-300/2007 and S-443/2018).                                                       for benign tumors on quality of life. Acta Otolaryngol 2006;126:1091-
The research was conducted ethically, with all study pro-                         1095. https://doi.org/10.1080/00016480600606731
cedures being performed in accordance with the require-
                                                                             12
                                                                                  Nitzan D, Kronenberg J, Horowitz Z, et al. Quality of life follow-
                                                                                  ing parotidectomy for malignant and benign disease. Plast Re-
ments of the World Medical Association’s Declaration of                           constr Surg 2004;114:1060-1067. https://doi.org/10.1097/01.
Helsinki.                                                                         prs.0000135326.50939.c1
All patients were informed about the study aims and pro-                     13
                                                                                  Kaya BV, Kilic C, Ozlugedik S, et al. Long-term effects of parotidec-
tocol, and participants were enrolled after giving informed                       tomy. Eur Arch Otorhinolaryngol 2016;273:4579-4583. https://doi.
                                                                                  org/10.1007/s00405-016-4173-4
written consent.                                                             14
                                                                                  Hazra A GN. Biostatistics series module 4: comparing groups - cat-
                                                                                  egorical variables. Indian J Dermatol 2016;61:385-392. https://doi.
Data availability                                                                 org/10.4103/0019-5154.185700
The datasets generated during and/or analysed during the                     15
                                                                                  Aydin S, Erbay MF, Kizilay A. The effects of residual parotid volume
current study are available from the corresponding author                         on symptom-specific quality of life and complications in patients un-
on reasonable request.                                                            dergoing parotid surgery. Eur Arch Otorhinolaryngol 2021;278:5003-
                                                                                  5011. https://doi.org/10.1007/s00405-021-06742-4
                                                                             16
                                                                                  Mlees MA, Elbarbary AH. Superficial or partial superficial parotidec-
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