10.14639/0392-100X-N1463
Objective. Function-sparing surgery is the cornerstone for the treatment of benign parotid neoplasms. We assessed the incidences and determinants of the main postoperative complications, reappraising their influence on the patient’s quality of life (QoL).Methods. Patients who underwent parotid surgery for benign neoplasms were reviewed (2016-2019). Parotidectomy Outcome Inventory-8 (POI-8) and condition-specific questionnaires were used to investigate the patient’s perspective.Results. We enrolled 211 patients. Preservation of the posterior branch of the great auricular nerve (GAN) seemed to reduce early dysfunction (87% vs 96%, p = 0.053), but not the late one. Deep lobe dissection and resection of more than one parotid segment favoured first bite syndrome (FBS) and Frey’s syndrome (FS), respectively (16% vs 3%, p = 0.003; 37% vs 15%, p = 0.003). Neither GAN impairment, FBS, nor FS influenced patient QoL. Facial weakness affected 19 patients (9%), being more likely after total parotidectomy (23% vs 7%, p = 0.034). According to POI-8, QoL was mainly jeopardised by fear of revision surgery, especially in females (p = 0.005) and those experiencing early complications (p = 0.004).Conclusions. Reappraisal of the patient’s perspective after functional parotid surgery is fundamental to tailor preoperative counselling.
text/xml
1827-675X
1463
en
Mario Bussi
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
quality of life
The importance of the patient’s perspective in function-sparing parotid surgery for benign neoplasms: clinical reappraisal
Text.Serial.Journal
https://www.actaitalica.it/
41
Head and neck
2021-11-05
2021-02-19
2021-11-02
2021-11-02
410-418
1
Mario Bussi
2021/11/05
10.14639/0392-100X-N1463
410
Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy
1827-675X
quality of life
en
418
The importance of the patient’s perspective in function-sparing parotid surgery for benign neoplasms: clinical reappraisal
https://www.actaitalica.it/article/download/1463/676
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:410-418; doi: 10.14639/0392-100X-N1463




Head and neck


The importance of the patient’s perspective
in function-sparing parotid surgery for benign
neoplasms: clinical reappraisal
L’importanza della prospettiva del paziente nella chirurgia funzionale parotidea
per neoplasie benigne: rivalutazione clinica
Andrea Galli, Michele Tulli, Adriana Vella, Marco Familiari, Leone Giordano, Stefano Bondi, Davide Di Santo,
Matteo Biafora, Mario Bussi
Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy


SUMMARY
Objective. Function-sparing surgery is the cornerstone for the treatment of benign parotid
neoplasms. We assessed the incidences and determinants of the main postoperative compli-
cations, reappraising their influence on the patient’s quality of life (QoL).
Methods. Patients who underwent parotid surgery for benign neoplasms were reviewed
(2016-2019). Parotidectomy Outcome Inventory-8 (POI-8) and condition-specific ques-
tionnaires were used to investigate the patient’s perspective.
Results. We enrolled 211 patients. Preservation of the posterior branch of the great auricu-
lar nerve (GAN) seemed to reduce early dysfunction (87% vs 96%, p = 0.053), but not the
late one. Deep lobe dissection and resection of more than one parotid segment favoured         Received: February 19, 2021
first bite syndrome (FBS) and Frey’s syndrome (FS), respectively (16% vs 3%, p = 0.003;        Accepted: March 3, 2021
37% vs 15%, p = 0.003). Neither GAN impairment, FBS, nor FS influenced patient QoL.
Facial weakness affected 19 patients (9%), being more likely after total parotidectomy         Correspondence
(23% vs 7%, p = 0.034). According to POI-8, QoL was mainly jeopardised by fear of revi-        Andrea Galli
sion surgery, especially in females (p = 0.005) and those experiencing early complications     San Raffaele Scientific Institute, Department of
(p = 0.004).                                                                                   Otorhinolaryngology, via Olgettina 60, 20132
Conclusions. Reappraisal of the patient’s perspective after functional parotid surgery is      Milan, Italy
fundamental to tailor preoperative counselling.                                                Tel. +39 02 26432172. Fax +39 02 26433508
                                                                                               E-mail: agalli89@gmail.com
KEY WORDS: parotid, salivary glands, benign neoplasms, complications, quality of life
                                                                                               Funding
                                                                                               None.
RIASSUNTO
Obiettivo. La chirurgia funzionale è il caposaldo del trattamento delle neoplasie benigne
                                                                                               Conflict of interest
parotidee. Abbiamo valutato incidenze e determinanti delle principali complicanze, stu-        The Authors declare no conflict of interest.
diandone l’influenza sulla qualità di vita (QoL) dei pazienti.
Metodi. Abbiamo raccolto le parotidectomie eseguite per neoplasie benigne dal 2016 al
2019, valutando la QoL dei pazienti attraverso il Parotidectomy Outcome Inventory-8              How to cite this article: Galli A, Tulli M, Vella
(POI-8) e questionari specifici per ogni complicanza.                                            A, et al. The importance of the patient’s per-
Risultati. Sono stati selezionati 211 pazienti. La preservazione della branca posteriore del     spective in function-sparing parotid surgery for
                                                                                                 benign neoplasms: clinical reappraisal. Acta
nervo grande auricolare (GAN) ne ha ridotto la disfunzione precoce, non quella a distanza.
                                                                                                 Otorhinolaryngol Ital 2021;41:410-418. https://
La dissezione del lobo profondo e la resezione di più di un segmento ghiandolare hanno           doi.org/10.14639/0392-100X-N1463
incrementato, rispettivamente, le chance di first bite (FBS) e Frey’s syndrome (FS) (16%
vs 3% e 37% vs 15%). Né la disfunzione del GAN, né FBS o FS hanno influenzato la QoL           © Società Italiana di Otorinolaringoiatria
dei pazienti. Una paralisi faciale è stata riportata da 19 pazienti (9%), più frequentemente   e Chirurgia Cervico-Facciale
dopo parotidectomia totale (23% vs 7%). La paura di una chirurgia di revisione è stata
l’elemento più impattante sulla QoL, soprattutto nelle donne e nei pazienti con complicanze                   OPEN ACCESS
precoci.
                                                                                               This is an open access article distributed in accordance with
Conclusioni. la rivalutazione della prospettiva dei pazienti dopo chirurgia funzionale pa-     the CC-BY-NC-ND (Creative Commons Attribution-Non-
rotidea è essenziale per ricalibrarne il counselling preoperatorio.                            Commercial-NoDerivatives 4.0 International) license. The
                                                                                               article can be used by giving appropriate credit and mentio-
PAROLE CHIAVE: parotide, ghiandole salivari, neoplasia benigne, complicanze, qualità           ning the license, but only for non-commercial purposes and
della vita                                                                                     only in the original version. For further information: https://
                                                                                               creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                   The importance of patient perspective in function-sparing parotid surgery for benign neoplasms




Introduction                                                         nance imaging (MRI). Clinical, surgical and pathological
                                                                     data were collected from medical charts (Tab. I).
Parotid neoplasms are relatively rare entities, accounting
                                                                     Procedures and removed parotid levels were defined accord-
for about 2% of all head and neck tumours 1. Surgery is the
                                                                     ing to Quer et al. 8. Type of surgical procedure was graded
mainstay of treatment for most parotid lesions, but since
                                                                     as follows: extracapsular dissection (ECD), segmental parot-
the majority are benign it becomes a compromise between
                                                                     idectomy (SP, removal of segments I or II), lateral parotidec-
adequate tumour excision and functional outcomes. Al-
                                                                     tomy (LP, removal of both segments I and II) and total paro-
though many studies have been published on which surgi-
                                                                     tidectomy (TP, removal of segments I, II, III and/or IV). SP
cal technique should be preferred in the settings of benign
                                                                     or LP partially extending to one of the deep segments of the
parotid tumors, a clear consensus is still lacking 2,3. Com-
                                                                     gland (III or IV), depending on the specific location of a le-
plexity may rise as far as malignancies are concerned, as
                                                                     sion, were considered as limited procedures. The term “ECD”
it is often difficult to preoperatively detect the malignant
                                                                     was used whenever ≤ 1 segment was removed and/or no for-
nature of a parotid lesion: 50-70% of cancers may present
                                                                     mal dissection of the main trunk of the facial nerve (FN) was
as asymptomatic, demarcated, small tumuors of the super-
                                                                     performed. Suspected pathology of the tumour (pleomorphic
ficial lobe, without clear suspicious signs 4.
                                                                     adenoma vs Warthin’s tumour vs others), size (≤ or > 3 cm)
Moreover, even when surgery is performed in high-volume
                                                                     and location within the gland (superficial vs deep, single or
centres, postoperative complications do occur and are po-
                                                                     multiple involved levels) were the three main factors influ-
tentially expected events of which patients should be made
                                                                     encing the extent of surgery, according to Quer et al. 3.
aware 5-7. The face is the centre of human expression and
                                                                     All surgical procedures were performed under general anaes-
slight defects or motion dysfunctions can be readily ob-
                                                                     thesia by senior surgeons of comparable expertise, with bin-
served and noted. Thus, it is imperative to understand how
                                                                     ocular loupe and visual FN monitoring. Cold dissection along
complications develop and prevent their occurrence, and
                                                                     with bipolar forceps and haemoclips were used during all
it is likewise of paramount importance to appreciate how
                                                                     procedures; no further vessel-sealing devices were employed
these conditions may affect the patient’s perception and
quality of life (QoL), allowing proper preoperative coun-            during dissection. From June 2016, an electromyographic
seling. This was the aim of the present study; we exam-              intraoperative nerve monitoring system (IONM; NIM-Re-
ined our recent series of patients who underwent parotid             sponse® 3.0, Xomed Medtronic, Inc, Jacksonville, FL, USA)
surgery at a single, high-volume centre for proven benign            was also regularly introduced into our surgical routine, even
neoplasms. We started with the assessment of frequencies             for primary procedures. The superficial muscular aponeurotic
and promoting factors of main postoperative complications            system (SMAS) was always integrated in the skin flap. We
and ended with a clinical reappraisal of their influence on          did not usually perform reconstructive techniques (sterno-
the patient’s everyday life, which is the ultimate goal of any       cleidomastoid muscle flap, SMAS flap) or free abdominal fat
function-sparing surgery.                                            graft (FFG); we excluded those who were occasionally sub-
                                                                     mitted to these procedures from the analysis.
                                                                     Records of regular follow-up visits were used to collect data
Materials and methods                                                about the incidence and severity of postoperative complica-
                                                                     tions. As far as FN palsy was concerned, barely perceptible
Selection criteria and data collection                               asymmetry and/or muscle weakness on maximal volition
We retrospectively reviewed our series of 240 consecutive pa-        were classified as “normal FN function”, since these were
tients who underwent parotid surgery between January 2016            often not even perceived by the patients themselves and
and December 2019 at the ENT department of San Raffaele              spontaneously resolved within a few days or weeks. Subse-
Scientific Institute in Milan (Italy). Patients who underwent        quently, patients were contacted by phone and interviewed
surgery for malignancies, recurrent neoplasms, or pure para-         about the long-term outcome of postoperative complica-
pharyngeal lesions were excluded. We ruled out minors, pa-           tions and, finally, general and complication-related QoL af-
tients with a previous history of head and neck radiotherapy         ter parotid surgery was assessed through specific question-
or surgery, and any kind of preoperative facial nerve dysfunc-       naires. All the reports of the questionnaires were formally
tion or peripheral neuropathy to avoid potential functional          endorsed by patients themselves.
bias. A minimum 12-month follow-up was required.                     We excluded patients who did not answer our calls, unable
All patients were evaluated preoperatively with clinical             or refused to respond to our questions, or who reported a
examination, neck ultrasonography (US) with fine-needle              recurrence of disease from the analysis. All procedures per-
aspiration cytology (FNAC) and, when appropriate, com-               formed and data management were in accordance with the
puted tomography (CT) or multiparametric magnetic reso-              ethical standards of our institutional and national research



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A. Galli et al.




Table I. Demographics and patient and disease characteristics.
 Demographics                                                             Gender                                              Male: 100/211 (47.4%)
                                                                                                                             Female: 111/211 (52.6%)
                                                                      Age at surgery                                              51.0 ± 15.6 years
                                                                                                                           ≥ 60 years: 137/211 (64.9%)
                                                                                                                           < 60 years: 74/211 (35.1%)
 Disease                                                             Side of disease                                          Right: 105/211 (49.8%)
                                                                                                                              Left: 106/211 (50.2%)
                                                               Lesion maximum diameter                                        Median: 20 mm [3-60]
                                                                                                                            ≤ 20 mm: 95/211 (45.0%)
                                                                                                                           > 20 mm: 116/211 (55.0%)
                                                               Site of disease (segments)                                           I: 13/211 (6.2%)
                                                                                                                                I-II: 42/211 (19.9%)
                                                                                                                                 II: 131/211 (62.1%)
                                                                                                                                III-IV: 20/211 (9.5%)
                                                                                                                              Multifocal: 5/211 (2.4%)
 Preoperative workup                                                  US + FNAC                                                   211/211 (100.0%)
                                                                           CT                                                       21/211 (10.0%)
                                                                          MRI                                                      126/211 (59.7%)
 Type of surgery                                                          ECD                                                         20/211 (9.5%)
                                                                Segmental parotidectomy                                             40/211 (19.0%)
                                                                 Lateral parotidectomy                                             129/211 (61.1%)
                                                                  Total parotidectomy                                               22/211 (10.4%)
 Incision                                                             Redon-Blair                                                   62/211 (29.5%)
                                                                    Modified facelift                                              146/211 (69.2%)
                                                                Extended submandibular                                                 3/211 (1.4%)
 VII CN IONM                                                              Yes                                                       96/211 (45.5%)
US: ultrasound; FNAC: fine-needle aspiration cytology; CT: computed tomography; MRI: magnetic resonance imaging; ECD: extracapsular dissection; IONM: intraoperative nerve
monitoring.



ethical committee and with the principles stated in the 1964
Declaration of Helsinki and its later amendments. Informed
consent for retrospective data management was obtained for
all patients.

General QoL assessment
General QoL assessment was performed through the Paro-
tidectomy Outcome Inventory 8 (POI-8), a questionnaire
validated by Baumann et al. to measure health-related QoL
after parotid surgery in patients affected by benign tu-
mours 9. It consists of 8 Likert-type questions scaled from
0 to 5 evaluating pain at the surgical site, sensory impair-
ment, scar, facial appearance related to tissue loss and fa-                           Figure 1. Results of the Parotidectomy Outcome Inventory 8 (POI-8) ques-
cial palsy, gustatory sweating, dryness of mouth and fear of                           tionnaire, a validated tool for measuring health-related quality of life after pa-
eventual revision surgery (Fig. 1). The reliable application                           rotid surgery in patients affected by benign tumours.
and comparability of POI-8 to other validated QoL surveys
were demonstrated previously 5.                                                        the area innervated by the great auricular nerve (GAN),
                                                                                       first-bite syndrome (FBS), Frey’s syndrome (FS) or FN
Condition-specific QoL assessment                                                      deficit, as depicted in Tables II, III, IV and V, respec-
Condition-specific questionnaires assessing complica-                                  tively 10-12. Those who were no longer suffering from a
tion-related QoL were submitted to patients referring                                  specific condition (GAN deficit, facial weakness) were
symptoms compatible with alteration of sensitivity in                                  asked to answer these questionnaires with regard to the



412
                                                                  The importance of patient perspective in function-sparing parotid surgery for benign neoplasms




Table II. Questionnaire about sensorial impairment in the territory of the great auricular nerve (GAN) and its influence on patient quality of life.
 Have you ever noticed any change in tactile perception in the operating area?
 ¨ Yes ¨ No
 In the early postoperative phase did you experience hypoaesthesia/hyperaesthesia in the operating area?
 ¨ Yes ¨ No
 The hypoaesthesia has: ¨ Improved ¨ Worsened                ¨ Remained the same
 How long did it take to improve? ________ months
 The hyperaesthesia has: ¨ Improved ¨ Worsened ¨ Remained the same
 How long did it take to improve? ________ months
 At follow-up did you experience hypoaesthesia/hyperaesthesia in the operating area?
 ¨ Yes ¨ No
 How did the change in tactile perception affect your quality of life?
 ¨ No influence
 ¨ Limited influence
 ¨ Heavy influence

Table III. Results of the first part of the questionnaire about quality of life in subjects affected by first bite syndrome (FBS), according to Lee et al. 10.
                                                                                             Our cohort               Fiacchini, 2018 13           Lee, 2009 10
 Pain without sour or bitter food                                                             4.00                        4.38                         5.40
 Pain with sour or bitter food                                                                4.73                        5.86                         8.20
 Interference with daily activities                                                           1.00                        2.88                         4.80
 Interference with enjoying meal                                                              1.64                        4.13                         7.20

Table IV. Results of the questionnaire about quality of life in subjects affected by Frey’s syndrome (FS), according to Hartl et al. 11.
                                                                                          Our cohort             Fiacchini, 2018 13              Hartl, 2008 11
 Functional domain                                                                            3.12                        2.76                         6.60
 Social domain                                                                                0.21                        1.14                         2.60
 Emotional domain                                                                             0.77                        0.90                         3.80

Table V. Results of the Facial Disability Index (FDI) questionnaire 22.
                                                                                                         Our cohort                    Prats-Golczer, 2017 22
 Physical function subscore                                                                                81.05                                79.13
 Social functioning and well-being subscore                                                                93.47                                79.00


postoperative period in which that complication was ac-                              consisting of 14 questions about functional, social and
tually present.                                                                      emotional consequences of gustatory sweating on their
In particular, if patients reported any postoperative change                         QoL, rating their replies on a 0-3 scale. An individual score
in GAN sensitivity, they were questioned about the exact                             was provided for each section (Tab. IV).
nature of the condition (anaesthesia/hypoaesthesia vs hy-                            Finally, for patients reporting signs or symptoms related to
peraesthesia), its behaviour over time (improved, wors-                              facial weakness, we asked them to complete the Facial Dis-
ened, unchanged; with recovery time) and how the change                              ability index (FDI), a questionnaire originally elaborated
in tactile perception affected their QoL (Tab. II).                                  by VanSwearingen et al. 12 to assess the influence of FN
When patients reported symptoms compatible with FBS,                                 deficit on patient QoL. It consists of 10 questions divided
they were asked to complete a specific questionnaire, origi-                         into two subscales: five questions associated with physical
nally proposed by Lee et al. 10. It consists of four questions,                      well-being and five with psycho-social well-being. Each
with 0-10 scaled answers, evaluating the intensity of the                            item is scored up to 5 (for the physical part) or 6 (for the
pain experienced, with or without sialogogues, and its inter-                        social one) points on a scale that ranges from “no disabili-
ference in enjoying meals or everyday activities (Tab. III).                         ty” to “severe disability”. Both subscales were transformed
In those complaining of symptoms related to FS, we sub-                              into a 100-point scale. The higher the score, the better the
mitted a specific questionnaire proposed by Hartl et al. 11                          facial function (Tab. V).



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A. Galli et al.




Statistics and data management
Statistical analysis was performed with IBM-SPSS statisti-
cal package, version 25 (IBM Corp., Armonk, NY, USA).
Categorical variables were represented as absolute values
and percentages and analysed by chi-square test or Fisher’s
exact test, when appropriate. Continuous variables were
represented as mean values and standard deviation and ana-
lysed by Mann-Whitney U-test or Kruskal-Wallis H test. A
p < 0.05 was considered to be statistically significant.

Results

Patient and surgical characteristics
In total, 211 patients completed the study. Mean follow-up
time was 46.0 ± 12.6 months (range: 16-60 months). De-
mographics, patient and disease characteristics are shown
in Table I. Permanent sections revealed pleomorphic ade-
noma (PA) in 136 cases (64.5%), Warthin’s tumour (WT) in         Figure 2. Effective preservation of the posterior branch of the great auricu-
59 (28.0%), basal cell adenoma in 5 (2.4%), oncocytoma in        lar nerve.
4 (1.9%), salivary duct cyst in 2 (0.9%) and lipoma, chronic
sialadenitis, atypical lymphoid proliferation, cystadenoma,      sition from hypoaesthesia to hyperaesthesia/dysaesthesia.
and angiomatous hamartoma each in 1 patient (0.5% each).         Among those suffering from initial GAN alteration, 164
IONM was employed in almost half of the procedures               (86.3%) referred no significant effect of that condition on
(96/211, 45.5%), whereas anatomical FN preservation was          their QoL, 22 (11.6%) a limited impact and only 4 (2.1%)
achieved in all cases. Concurrent preservation of the poste-     a substantial influence (Tab. II). No significant association
rior branch of the GAN (pbGAN) was feasible in 140 cases         was found between early postoperative GAN deficit or
(66.4%; Fig. 2), according to the location of the mass.          GAN deficit at follow-up and extent of surgery or size of
ECD was performed in 20/211 patients (9.5%), and formal          the lesion. Preservation of the pbGAN (Fig. 2) seemed to
parotidectomy in 191 (90.5%), according to the indications       reduce early sensorial impairment, although this evidence
postulated by Quer et al. 3. Mean duration of surgery was        failed to reach statistical significance (122/140, 87.1%
138.2 ± 40.7 min (range 40-253 min). Duration of ECD             early deficit with preservation of the pbGAN vs 68/71,
(78.9 ± 23.9 min) was significantly shorter compared to SP       95.8% with nerve sacrifice; OR 0.30, 95% CI 0.85-1.05;
(137.7 ± 30.3 min; p < 0.001), and LP (141.6 ± 36.3 min)         p = 0.053). Conversely, sensorial impairment at follow-up
was significantly shorter compared to TP (173.0 ± 40.6           did not seem to be influenced by the nerve preservation
min; p = 0.001); no statistically significant differences were   strategy (79/140, 56.4% deficit at follow-up with preserva-
detected between SP and LP with regards to operative time        tion of the pbGAN vs 46/71, 64.8% with nerve sacrifice;
(p = 0.997).                                                     OR 0.70, 95% CI 0.39-1.27; p = 0.243).
Mean hospital stay was 3.8 ± 1.3 days (range 2-9 days);          Fifty patients experienced sialocele/salivary fistula
unless early specific complications occurred, patients were      (23.7%). Among these, 45 patients were managed conserv-
discharged after removal of the drain.                           atively with compressive dressings and bland diet, while 5
                                                                 patients underwent wound revision with infiltration of hu-
Postoperative complications and condition-specific QoL           man fibrin glue (median recovery time: 4 weeks, range 1-9
assessment                                                       weeks). No significant correlation was found between this
Sensorial impairment in the area innervated by the GAN           complication and size of lesion (25/95, 26.3% for lesions
was the most commonly referred complication (190/211,            < 20 mm vs 25/116, 21.6% for lesions ≥ 20 mm; OR 0.77,
90.0%). Sixty-five patients (34.2%) recovered fully (me-         95% CI 0.41-1.45; p = 0.418) or extent of surgery (12/52,
dian recovery time: 6 months, range 5-48 months), while          23.1% in the case of resection of one parotid segment at
residual hypoaesthesia or hyperaesthesia/dysaesthesia            most vs 38/159, 23.9% with more extended resections; OR
was reported at follow-up by 94 (49.5%) and 31 patients          1.05, 95% CI 0.50-2.20; p = 0.904).
(16.3%), respectively. Nineteen patients experienced a tran-     Postoperative bleeding/haematoma was reported in 5 pa-



414
                                                                  The importance of patient perspective in function-sparing parotid surgery for benign neoplasms




tients (2.4%): the haematoma was drained at bedside in                              FS, according to functional, social and emotional domains.
three cases, while in two patients revision surgery was                             None of our patients recveived botulinum toxin A (BTX-A)
needed. Eleven patients experienced a postoperative wound                           or anticholinergic drug application.
infection (5.2%); they were all treated with bedside wound                          Postoperative facial weakness was documented in 19 pa-
cleaning and irrigation and concurrent systemic antibiotic                          tients (9.0%): the affected branch was the temporofacial in
course (e.g. amoxicillin/clavulanic acid 1 g TID for 7 days).                       1 case (5.3%), cervicofacial in 14 (73.7%) and both in 4
The limited number of these outcome events prevented us                             (21.1%). Mean early House-Brackmann (HB) score was
from performing statistical analysis.                                               2.4 ± 0.9. Only one patient reported FN deficit at follow-up
Eleven patients referred symptoms compatible with FBS                               (40 months after surgery, HB 3 in the cervicofacial area),
(5.2%). Deep lobe dissection around the external carotid                            which was considered permanent, while in the other 18 pa-
artery (ECA) (Fig. 3) significantly increased the chances                           tients FN function fully recovered within 12 months (me-
of developing FBS (6/180, 3.3% for more superficial pro-                            dian recovery time: 6.0 months, range 14 days-24 months).
cedures vs 5/31, 16.1% for resections of segments III/IV;                           All patients with postoperative facial weakness underwent
OR 5.58, 95% CI 1.59-19.59; p = 0.003). No correlation                              a course of tapered steroid therapy in the first weeks af-
was found between FBS and size of the lesions (4/95, 4.2%
                                                                                    ter surgery. Physiokinetic therapy (PKT) and neuro-taping
for lesions < 20 mm vs 7/116, 6.0% for lesions ≥ 20 mm;
                                                                                    were also applied. As far as extent of resection was con-
OR 1.46, 95% CI 0.41-5.15; p = 0.553). Interestingly, the
                                                                                    cerned, no statistically significant differences were noted
presence of pain at diagnosis was associated with a higher
                                                                                    between resections of one parotid segment, or less, and
chance of experiencing postoperative FBS (7/184, 3.8%
                                                                                    more extended procedures with regard to FN deficit (5/52,
in asymptomatic patients vs 4/16, 25.0% in those report-
                                                                                    9.6% vs 14/159, 8.8%, respectively; OR 0.91, 95% CI
ing pain preoperatively; OR 6.57, 95% CI 1.73-24.86;
p = 0.013). Table III summarises the results of the question-                       0.31-2.65; p = 0.859). Regular use of IONM did not af-
naire about QoL in patients affected by FBS.                                        fect the risk of postoperative facial weakness (8/115, 7.0%
Sixty-seven patients (31.8%) reported clinical FS. Resec-                           for unmonitored procedures vs 11/96, 11.5% for IONM-
tion of more than one parotid segment significantly in-                             equipped surgical procedures; OR 1.73, 95% CI 0.67-4.49;
creased occurrence of FS (8/52, 15.4% for ECD and SP vs                             p = 0.255). However, facial palsy was significantly higher
59/159, 37.1% for more extended surgical procedures; OR                             in patients submitted to TP in comparison to less extensive
3.24, 95% CI 1.3-7.36; p = 0.003). Table IV shows the re-                           procedures (5/22, 22.7% vs 14/189, 7.41%, respectively;
sults of the questionnaire about QoL in patients affected by                        OR 3.68, 95% CI 1.18-11.54; p = 0.034). Results for the
                                                                                    Facial Disability Index are shown in Table V.

                                                                                    Parotidectomy Outcome Inventory-8 (POI-8)
                                                                                    Results for POI-8 are highlighted in Figure 1. Patients sub-
                                                                                    mitted to TP were significantly more annoyed by “changed
                                                                                    appearance due to facial palsy” (p = 0.003). Larger lesions
                                                                                    (≥ 20 mm) were associated with a lesser degree of trouble
                                                                                    as a result of hypoaesthesia (p = 0.007). Type of incision
                                                                                    did not seem to affect QoL related to the “appearance of
                                                                                    the scar” (p = 0.506), even when considering only younger
                                                                                    patients (p = 0.647). Even the size of the lesion did not
                                                                                    influence POI-8 outcome with regard to “changed appear-
                                                                                    ance due to substance loss” (p = 0.715). Fear of a poten-
                                                                                    tial revision surgery was higher in females (p = 0.005)
                                                                                    and those who experienced early postoperative complica-
                                                                                    tions (p = 0.004). Finally, QoL of older patients (age ≥ 60
                                                                                    years) was significantly less impaired by hypoaesthe-
                                                                                    sia (p = 0.004), scar appearance (p = 0.045), substance
                                                                                    loss in the parotid region (p = 0.022), gustatory sweating
                                                                                    (p = 0.001) and fear of revision surgery (p < 0.001). No sig-
Figure 3. Total parotidectomy with complete facial nerve dissection and ex-
ternal carotid artery exposure, a procedure involved in occurrence of first bite    nificant association was detected between length of follow-
syndrome.                                                                           up and POI-8 parameters.



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A. Galli et al.




Discussion                                                          ports 7,17. Grosheva et al., who described this complication
                                                                    only in patients with visible residual parotid tissue by ultra-
Surgical treatment of benign parotid tumours has always             sound, did not demonstrate any influence of a limited FN
been considered to have little impact on the patient’s QoL,         dissection or a greater volume of excised tissue on FS oc-
especially when performed in high-volume centres. Nev-              currence 19. Our results agree with the latter findings, with
ertheless, the reported rates of postoperative complica-            no significant correlation found between sialocele/salivary
tions are not negligible and vary widely among different            fistula and size of parotid lesion or extent of surgery.
series 5-7,13. In this retrospectively designed study on a large,   FBS is usually considered as a minor complication; indeed,
single-centre series of parotidectomies performed for be-           it occurred in only 5.2% of our patients. We found that deep
nign neoplasms, we analysed the incidence and possible              lobe dissection (Fig. 3) significantly increased the chances
promoting factors of early and late complications, trying to        of developing it, as previously reported 13. Linkov et al.
appreciate how these conditions may actually affect patient         showed that the incidence of FBS was particularly high
perception and QoL.                                                 in patients undergoing parapharyngeal space dissection
An impairment in tactile perception in the area innervat-           (22.4%), resection of the deep lobe of the gland (38.4%)
ed by the GAN was reported by almost all of the patients            and sacrifice of the sympathetic chain (48.6%), with a pos-
(90.0%) in the early postoperative period. Although only            sible role of ECA ligation 20. In a study by Lee et al., 5 pa-
34.2% fully recovered, the residual sensorial alteration did        tients with FBS were treated with BTX-A and were asked
not seem to significantly affect QoL, with 97.9% report-            to complete a specific questionnaire to assess the severity
ing no or limited impact. The mean value of POI-8 item              of their symptoms 10. Our results for that questionnaire
with regard to “numbness on the site of surgery” was very           (Tab. III) are consistent with the findings of Fiacchini et al.
low (0.35). This finding is consistent with those of Patel          (who also employed it) and lower than those of Lee et al.
et al.: in their patients referring a sensorial impairment in       reported before BTX-A application; this is justified by the
the GAN area (30/53, 57%), 77% reported only a little or            fact that, in this latter study, they only selected patients who
no inconvenience caused by the symptoms, and 90% no                 were candidates for treatment, with significant interference
interference or almost none with their daily activities 14.         of FBS in everyday activities 10,13. Interestingly, in our co-
We also noticed that patients affected by larger lesions            hort, the presence of pain at diagnosis was associated with
were associated with a lesser degree of trouble as a result         a higher chance of experiencing postoperative FBS; this
of hypoaesthesia, according to the POI-8 questionnaire,             may advocate a lower pain threshold and/or a pre-existing
probably as a consequence of the aesthetic improvement              disruption of the regional sympathetic innervation due to
linked to the removal of a disfiguring facial lump, which           an expanding mass towards the parapharyngeal space, en-
underplayed subsequent sensorial troubles. Moreover, we             hanced by the surgical procedure.
found that preservation of the pbGAN (Fig. 2) seemed to             The occurrence of FS varies between 0% and 66% in the
reduce early postoperative sensorial impairment in the ar-          literature, strongly depending on the methods employed to
ea, while not at all tactile function at long-term assessment.      detect it 5,16. In our cohort, FS was diagnosed upon patient
This is in agreement with the findings of Bulut et al., who         complaint, since our aim was to highlight clinically relevant
demonstrated that a preservation technique improved short-          complications. Nevertheless, it has been reported quite fre-
term tactile sensation (2 weeks after surgery; 2.8 vs 2.1,          quently (31.8%). Resection of more than one parotid level
p = 0.017 according to POI_2), but not long-term tactile            doubled the risk of FS, as previously demonstrated 17,19. We
sensation (at 5-year follow-up; 1.7 vs .13, p = 0.145), advo-       did not routinely perform sternocleidomastoid or SMAS
cating some kind of collateral reinnervation 15.                    flap to cover the parotid bed, and we excluded those who
Sialocele and salivary fistula are common sequelae after            were occasionally submitted to these procedures from the
parotid surgery, with typical occurrence after discharge            analysis to avoid potential bias. Severity and influence
from hospital. There is a large reported variability with           of FS on QoL, assessed through a specific questionnaire
regards to their incidence (5% to 39% for sialocele, 2%             (Tab. IV), were consistent with the findings of Fiacchini
to 17% for salivary fistula), since most of these complica-         et al. (who also employed it) and lower than those of Hartl
tions are self-limiting over a few weeks, even without ac-          et al. reported before a course of BTX-A; this is, again,
tive treatment 16,17. Witt et al. found SP to be associated with    justified by selection bias 11,13. None of our patients were
increased risk of sialocele compared to TP 18. The same             submitted to BTX-A or anticholinergic drug application
finding was reported by Tuckett et al. 6; this would seem           and the results of this questionnaire are coherent with our
coherent with a persistent secretion of saliva by remain-           management.
ing parotid tissue; however, there are some conflicting re-         Postoperative facial weakness was noted in 19 patients



416
                                                     The importance of patient perspective in function-sparing parotid surgery for benign neoplasms




(9.0%), with only one permanent deficit at follow-up (0.5%).           is consistent with the study by Ciuman et al. in which over
Reviewing the literature, the reported incidence of tempo-             87% of all patients rated the cosmetic result as “very good”
rary FN dysfunction after parotidectomy ranges between                 or “good”, even if a standard modified Blair S-shaped inci-
23% and 66% 6,17,21. This large variability is likely related to       sion was systematically applied 5. Our assessment and that
different indications for surgery, size of lesions and surgi-          of Ciuman et al. were exclusively patient-based, while in
cal techniques, but mainly definition and diligence in assess-         the study by Bianchi et al. a concurrent objective evalu-
ment of postoperative FN function. For instance, our rate is           ation by a blinded panel was provided; this may suggest
even below the lower end of the range mentioned; in fact, we           that the patient’s perspective may often underplay cosmetic
did not apply stringent criteria for characterisation of post-         outcome.
operative facial motion, in order to highlight only clinically         The same evidence involved “changed appearance due to
relevant complications and their influence on everyday life.           substance loss”. While the size of the lesion did not seem
Although the extent of surgery has been widely recognised              to influence cosmetic satisfaction from the patients’ stand-
as a risk factor for facial weakness 17,19, we did not find sig-       point (p = 0.715), in a recent report by Grosheva et al. the
nificant differences between resections of one parotid seg-            independent assessment of facial contour revealed a sig-
ment or less, and more extended procedures with regard to              nificant correlation of poor results with higher volume and
facial palsy. However, the FN dysfunction rate was signifi-            mass of excised specimens 19.
cantly higher in patients submitted to TP in comparison to             Particular mention should be made about the elderly
less extended surgical procedures (22.7% vs 7.44%). This               (age ≥ 60 years). In our assessment, their QoL seemed sig-
clear discrepancy was also evident in the work of Grosheva             nificantly less impaired by hypoaesthesia, scar appearance,
et al., with 75% of FN dysfunction after TP, 39% after LP              substance loss, gustatory sweating and fear of eventual
and 48% after PSP 19. In our cohort, patients submitted to             revision surgery compared to their younger counterparts,
TP were significantly more annoyed by “changed appear-                 and these findings could be taken into account in surgical
ance due to facial palsy” according to the POI-8 question-             planning.
naire. The necessary tractions and circumferential dissec-             Lastly, a remark should be made about fear of revision
tion (with possible devascularisation) of the FN, performed            surgery. Although irrational for many reasons, it was the
to mobilise the deep portion of the parenchyma and/or le-              aspect that most impacted patient QoL, with the highest
sions located beyond the plane of the nerve, are the poten-            mean value in the POI-8 questionnaire (1.19), especially
tial harmful manoeuvers in TP, rather than the simple de-              in females (p = 0.005) and in those who experienced early
tection and superficial dissection of the nerve, regardless of         postoperative complications (p = 0.004). These findings
its craniocaudal extension. In fact, regular use of IONM did           were previously reported by Wolber et al., who also showed
not influence the rate of facial weakness. Moreover, since             that the POI_8 score did not decrease significantly from 6
just one permanent paralysis was present, we could assume              to 24 months after surgery 24. Thus, we can assume that
that the extent of surgery, regardless of its definition, did          proper preoperative counselling and an effort in trying to
not affect the final FN function, as long as its anatomical            limit early postoperative complications are key in achiev-
integrity was preserved, as previously stated 19. Results for          ing a satisfying long-term functional outcome.
the Facial Disability Index are shown in Table V; they are             Our study has some limitations. First of all, its retrospec-
generally good and substantially consistent with the results           tive design prevented us from performing an ongoing re-
of Prats-Golczer et al. evaluated at 1 week after surgery              assessment of complication severity and POI-8 values.
with regards to the physical function subscore, but higher             Nevertheless, the design allowed the recruitment of a large,
than the social subscore, possibly because of our deferred             single-centre series of parotidectomies performed for be-
administration of the questionnaire 22.                                nign neoplasms by senior surgeons of comparable expertise
Cosmetic outcome was deemed satisfactory by the vast                   and surgical technique, which is the main strength of our
majority of our sample according to the POI-8 question-                work. Second, a clear classification of the extent of sur-
naire, as demonstrated by the low values of “appearance of             gery based upon dissection of facial branches was lacking;
the scar” and “changed appearance due to substance loss”               this would have allowed a more precise analysis of compli-
(0.18 and 0.20, respectively) (Fig. 1). Bianchi et al. showed          cation determinants, especially with regards to the recent
that using a modified facelift incision alone led to a sig-            work by Grosheva et al. 19.
nificant improvement in aesthetic outcome 23. However, in
our cohort, no differences in POI_3 results were noted with
regards to skin incision (modified facelift vs Redon-Blair;
                                                                       Conclusions
p = 0.506), not even only younger patients (p = 0.647). This           Even when parotid surgery for benign neoplasms is per-



                                                                                                                                             417
A. Galli et al.




formed in high-volume centres, postoperative compli-                                Lebensqualität nach Parotidektomie bei benignen Erkrankungen
cations do occur and may influence the everyday life of                             [Development and validation of the Parotidectomy Outcome Inven-
                                                                                    tory 8 (POI-8). Measurement of quality of life after parotidectomy
patients. Preservation of the pbGAN seemed to minimise                              in benign diseases]. HNO 2009;57:884-888. https://doi.org/10.1007/
early sensory disturbance, while not influencing long-term                          s00106-009-1991-3
function. Deep lobe dissection around the ECA enhanced                         10
                                                                                    Lee BJ, Lee JC, Lee YO, et al. Novel treatment of first bite syndrome
the risk of experiencing FBS. Resection of more than one                            using botulinum toxin type A. Head Neck 2009;31:989-993. https://
                                                                                    doi.org/10.1002/hed.21054
parotid level doubled the risk of FS, whereas TP seemed to                     11
                                                                                    Hartl DM, Julieron M, LeRidant AM, et al. Botulinum toxin A for
be the most important single determinant for postoperative                          quality of life improvement in post-parotidectomy gustatory sweating
facial weakness.                                                                    (Frey’s syndrome). J Laryngol Otol 2008;122:1100-1104. https://doi.
The assessment of the patient’s perspective in function-                            org/10.1017/S0022215108001771
sparing parotid surgery is as important as the traditional                     12
                                                                                    VanSwearingen JM, Brach JS. The Facial Disability Index: reliability
analysis of incidence and possible promoting factors of                             and validity of a disability assessment instrument for disorders of the
                                                                                    facial neuromuscular system. Phys Ther 1996;76:1288-1300. https://
postoperative complications, since this evaluation may help                         doi.org/10.1093/ptj/76.12.1288
physicians to properly counsel patients before surgery, un-                    13
                                                                                    Fiacchini G, Cerchiai N, Tricò D, et al. Frey Syndrome, First Bite
deremphasising (e.g. GAN sensorial impairment, cosmetic                             Syndrome, great auricular nerve morbidity, and quality of life follow-
outcome) or, conversely, overplaying (e.g. fear of eventual                         ing parotidectomy. Eur Arch Otorhinolaryngol 2018;275:1893-1902.
                                                                                    https://doi.org/10.1007/s00405-018-5014-4
revision surgery) the weight of some of the expected condi-                    14
                                                                                    Patel N, Har-El G, Rosenfeld R. Quality of life after great auricular
tions.                                                                              nerve sacrifice during parotidectomy. Arch Otolaryngol Head Neck
                                                                                    Surg 2001;127:884-888.
Acknowledgements                                                               15
                                                                                    Bulut OC, Hohenberger R, Oladokun D, et al. Long-term quality of
                                                                                    life and sensory impact of great auricular nerve preservation in pa-
The authors acknowledge Dr. Colin Woodham for the pro-                              rotid surgery as measured with the Parotidectomy Outcome Inven-
fessional editing of the manuscript.                                                tory-8. Clin Otolaryngol 2019;44:743-748. https://doi.org/10.1111/
                                                                                    coa.13366
                                                                               16
                                                                                    Klintworth N, Zenk J, Koch M, et al. Postoperative complications af-
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