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Background: A parotid abscess (PA) is a complication of an acute bacterial parotitis with a potentially life-threatening course. To date, data on the diagnosis and therapy of PA is sparse and mostly consists of case reports or case series. Therefore, this study aimed at comprehensively analyzing the microbiological spectrum and the therapeutic management in a bi-institutional setting., Methods: A retrospective clinical chart review was performed to identify all patients surgically treated for PA at two tertiary care centers in Germany. Data on demographics, clinical management and microbiological data including species identification, pathogenicity, type of antibiotic therapy, adjustment of antibiotics, antibiotic sensitivity testing, and smear test results were extracted. Intervention-related variables and etiology were analyzed for their statistical association with outcome variables., Results: Overall, 85 patients were included. Most patients (92.9%) underwent surgical incision. Around half of the patients (45.9%) were treated under local anesthesia. No facial nerve palsy was observed. The most frequently detected pathogens were Streptococci (n = 23), followed by Staphylococcus aureus (n = 6) including one case of methicillin-resistant Staphylococcus aureus. Most patients (68.2%) received an aminopenicillin ± beta-lactamase inhibitor as empiric antibiotic therapy. In 6 cases the antibiotic therapy was modified after receiving the antibiogram. Four patients (5.2%) presented with recurrent PA. Etiology was idiopathic (42.4%), followed by tumorous (12.9%), obstructive, and immunosuppressive (each 11.8%). Patients with a dental focus (p = 0.007) had a longer duration of hospitalization., Conclusion: The results show that the surgical therapy of PA under local anesthesia is safe. A dental examination should routinely be performed to rule out a dental focus. Obtaining a microbiological specimen in order to modify antibiotic therapy if necessary and a histopathological specimen to rule out a tumorous etiology is obligate., (© 2024. The Author(s).)

Objective: The aim of this communication was to introduce a novel combined image (magnetic resonance and computed tomography-guided and sialendoscopy-assisted transoral approach for the treatment of a parotid duct stenosis with megaduct., Methods: A 46-year-old woman was referred to our department for recurrent infections of the right parotid gland following unsuccessful multiple transoral surgical approaches for a Stensen's duct stricture with megaduct. An image (magnetic resonance and computed tomography)-guided and sialendoscopy-assisted transoral sialodochoplasty was planned and performed., Results: No complications occurred. The patient was discharged 2 days after surgery. No more swelling or infections occurred. The patient is currently symptom-free after a follow up of 11 months., Conclusion: Although imaging navigation means more technical effort and costs, this novel approach can be considered a viable surgical opportunity for distal and mid-third parotid duct stenosis with concomitant megaduct, particularly in cases of persistent inflammation or iatrogenic scars due to previous surgery.

Parotid gland fistula after microtia reconstruction is relatively rare, with only 3 cases having been reported in the literature. It may be caused by the presence of an accessory parotid gland or surgical damage to parotid gland tissues. The principal treatment is dressing the wound. Here, we report the first case of parotid fistula after microtia reconstruction using a delayed retroauricular flap, which healed following wound dressing and an injection of botulinum toxin type A (CBTXA) into the parotid gland., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This review will focus on the key steps in the recognition of parotid gland and duct injuries focusing on the important steps needed at the initial assessment. Management planning is presented in the way that trauma surgeons interact with patients, highlighting the important parts of the informed consent conversation followed by the key information that must be communicated to the anesthesia and operating room teams, which ensures proper monitoring and equipment needs are in place. Short-term and long-term outcomes for patients with persistent sequelae of the trauma and their management are reviewed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to determine the MRI features of sporadic/simple lymphoepithelial cyst (SLEC) of the parotid gland., Methods: Ten patients (seven men, three women; mean age, 60 years; age range, 38-77 years) with histopathologically and clinically proven SLEC of the parotid gland who underwent MRI before surgical resection were enrolled in this study. No enrolled patient had HIV infection or Sjögren syndrome. MRI findings of SLEC were retrospectively assessed., Results: We confirmed 10 SLECs larger than 10 mm with a mean maximum diameter of 26.6 mm (range, 12-42 mm). Nine patients (90%) had a single cyst, and one (10%) had a large cyst accompanied by small cysts (<10 mm) within the ipsilateral parotid gland. Eight SLECs (80%) were unilocular, and two (20%) were bilocular, with complete septa. Among seven SLECs (70%) with internal septa, five unilocular SLECs (50%) had incomplete septa. Six SLECs (60%) had eccentric cyst wall thickening, and five (50%) were surrounded by small solid nodules that were isointense relative to lymph node. On T1-weighted images, all cyst contents were homogeneously hyperintense relative to cerebrospinal fluid., Conclusion: SLECs of the parotid gland are usually single unilocular lesions. Internal septa, eccentric cyst wall thickening, and small solid nodules surrounding the lesion were often observed. Cyst contents are always homogeneously hyperintense on T1-weighted images., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of this study was to comparatively evaluate the indications and treatment outcomes of two transcutaneous approaches for the removal of impacted parotid stones. Sixty-eight consecutive patients with impacted parotid stones underwent endoscopy-assisted lithotomy via a direct mini-incision or a peri-auricular flap. Clinical safety and outcomes were evaluated. Complete stone extraction was achieved in all patients. In the mini-incision group (52 patients), the stones were in the middle third of the main duct in 31 patients, at the hilum in 16, and in the intraglandular duct in five. In the flap group (16 patients), they were in the middle third of the main duct in one patient, at the hilum in seven, and in the intraglandular duct in eight. Salivary fistula occurred in five mini-incision group patients (9.6%) and four flap group patients (25%). The clinical outcome in the mini-incision group (47 patients, median 25 months of follow-up) was good in 28 patients, fair in 13, and poor in six (12.8%). The clinical outcome in the flap group (16 patients, median 84 months of follow-up) was good in nine patients, fair in five, and poor in two (12.5%). The direct mini-incision approach was found to be safe and effective for impacted stones in the middle third, hilum, and proximal third of the main duct, while the peri-auricular approach would be best reserved for deeper intraglandular stones., (Copyright © 2022 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess the long-term outcome of sialendoscopy-assisted combined approach for parotid sialolithotomy with gland preservation., Patients and Methods: A retrospective study of patients treated with a combined sialendoscopic and open approach was conducted between 2011 and 2020. Demographic data of patients such as operative technique, stone size, stone location, complications, and symptom relief were collected. Patients were followed up via clinical examination and questionnaires., Results: Seventy-four patients were included and underwent endoscopy-assisted combined operations for the removal of 98 parotid stones. Of the 98 stones, 92(94%) stones were completely removed and 6(6%) were partially removed. At a mean follow-up of 47.1 ± 35 months, 65 of 74 patients (88%) achieved long-term success. Patients with stone incomplete removal were significantly more often to develop the recurrence of obstructive symptoms (p = 0.000) There were no cases of facial nerve injury or fistula formation. Gland function was preserved in 73 of 74 patients (99%)., Conclusions: The combined approach for parotid stones is a safe and gland-preserving alternative to parotidectomy. The techniques described here show high success rates and good long-term results, and they avoided the need for gland resection in >95% of cases., (© 2021 Wiley Periodicals LLC.)

Posterior parotid lithiasis may in some cases require a combined surgical approach associating sialendoscopy to an external intraoral or transfacial approach. This single-center retrospective study describes the surgical technique for parotid lithiasis extraction by a combined external and sialendoscopic approach with the help of CT-navigation. Five patients were included between November 2014 and July 2020. The sialolith was extracted in 100% of cases. Navigation and transillumination localizations matched consistently. No patients showed postoperative facial paresis. At 2 to 21 months' follow-up, there was no recurrence of sialolithiasis. Navigation can be a complement to transillumination, improving surgical comfort and safety, but does not replace first-line sialendoscopy. Visual control is required whenever possible after extraction. In combined procedures, it enables accurate identification of parotid sialoliths. In case of impassable stenosis, it could be a therapeutic alternative to parotidectomy., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Postparotidectomy sialocele is a frustrating challenge. Published rates of postparotidectomy fluid collections range from 6% to 39%. We report our experience of 398 parotidectomies performed over a 6-year period., Methods: A retrospective chart review of parotidectomies performed over a 6-year period was completed. Drain placement, smoking status, tumor size, and postoperative utilization of scopolamine were analyzed. Binary logistical regression and odds ratio calculations were performed., Results: Postparotidectomy sialocele occurred in 25% of patients. Neither suction drain placement nor usage of immediate postoperative scopolamine (in a 22-patient subset) prevented sialocele formation. Smoking status also did not correlate. Increasing resection size was linearly correlated with the risk of sialocele., Conclusion: Drain placement and smoking status do not correlate with sialocele prevention after parotidectomy. Sialocele formation directly correlates with the resection size. These data may guide preoperative counseling; however, additional work is necessary to identify effective prevention mechanisms for postparotidectomy sialocele., (© 2021 Wiley Periodicals LLC.)

Objective: To describe and evaluate a combined approach for sialendoscopic stone localization with microscopic mini-preauricular incision external stone extraction as a gland-sparing minimally invasive surgical management in cases of large proximal duct or intraparenchymal parotid gland sialolithiasis., Methods: A retrospective chart review of a single primary surgeon's patient series of 21 cases operated in a 5-year period in a tertiary care university and private practice hospitals., Results: Study included 16 males and five females, with age range 12-68 years (mean 40.9 ± 14.5). Nineteen out of the 21 patients had their stones completely removed (90.5%), with two not completing the procedure due to inability of intraoperative endoscopic stone visualization. In total 25 stones were extracted with six patients having two stones. Longest diameter of single (or first) stone was 5-16 mm (mean 9.1 ± 2.9) and second was 3-5 mm (mean, 3.9 ± 0.6). Endoscopic findings showed 14/25 stones in the proximal main parotid duct and 11/25 in one of its secondary parenchymal branches. Stents were used in 4/19 cases (21.1%). No major complications occurred. Minor complications included two postoperative conservatively managed seromas. All 19 cases had completely intact facial nerve function, good parotid salivary flow and acceptable esthetic result after median follow-up period of 26 months (range 6-62)., Conclusion: The combined sialendoscopic/microscopic mini-preauricular approach is a highly effective and safe gland-preserving method for large proximal parotid sialolithiasis management with a main limitation being inability to visualize the stone endoscopically., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest to disclose., (Copyright © 2021. Published by Elsevier B.V.)

Background: Frey's syndrome is a well-known complication of parotid surgery; its prevention may be achieved by the use of an interpositional barrier between the overlying flaps and the exposed parenchymal bed of parotid gland. The aim of this study was to retrospectively evaluate clinical outcomes with and without the interpositional placement of a porcine dermal collagen graft (PDCG) for prevention of syndrome occurrence., Methods: We conducted a 20-year retrospective study including the patients who had undergone "formal" (superficial, total, or subtotal) parotidectomies for benign pathologies. The inclusion criteria also involved patients that were (i) regularly monitored about clinical symptoms related to syndrome, and (ii) examined with Minor starch-iodine test. The severity of the diagnosed syndrome was retrospectively evaluated according to the grading score system of Luna-Ortiz. To assess group differences in terms of the extent of dissection in operating sites, we estimated the tumor and histological specimen volumes using the available dimensions., Results: We included 73 patients who had undergone 76 formal parotid surgeries. The surgical sites were divided into 2 groups: (1) Group A consisted of 44 sites that were reconstructed with a SMAS flap, and (2) Group B, comprised 32 sites where a PDCG was additionally applied as an artificial preventive barrier. At a mean follow-up of 26.3 months, a significantly lower incidence of clinically diagnosed Frey's syndrome was found after the use of dermal collagen interpositional barrier ( P  = .031). Specifically, subjective symptoms were reported at an incidence of 31.8% in Group A and 6.7% in Group B. Minor's test was positive at an incidence of 59.09% in Group A and 21.87% in Group B ( P  = .004, 95% CI). Severe Frey's syndrome was observed in 31.82% of the patients of Group A and in 3.12% of the patients of Group B ( P  = .002, 95% CI). Since there were no statistical significant differences between the volumes of the removed tumors and the excised histological specimens, the extent of dissection was not proved to influence the occurrence of Frey's syndrome in the compared groups., Conclusion: Porcine dermal collagen is a safe, practical, and useful means for parotid reconstruction, since it seems to contribute in prevention of Frey's syndrome when increased amount of glandular tissue has to be removed. Additional randomized controlled studies with bigger samples are required to better assess the PDCG use in parotid surgery.

Introduction: Twenty percent of the total lithiasis that affect a major salivary gland will be found in the parotid gland. An exclusive sialoendoscopic approach has achieved success rates close to 80%. In a significant percentage of these remaining cases, combined transfacial approaches assisted by sialendoscopy are presented as an option to be taken into account., Patients and Methods: A prospective analysis of cases treated by combined transfacial approach assisted by sialendoscopy for lithiasis of the parotid gland and the impact of the facial nerve stimulator used during surgery., Results: Five patients were included; all of them operated satisfactorily. In 4 of them, the approach proposed by McGurk and modified by Capaccio was used, and in 1 of them, the approach proposed by Nahlieli was used. We suffered a complication in just case due to the appearance of postoperative sialocele., Conclusion: According to our results and those previously published, the transfacial approach assisted by sialendoscopy can be considered a useful technique. Proper planning ensures an optimal result in the treatment of parotid gland lithiasis. The use of facial nerve stimulator guarantees extra security when working near to a branch of the facial nerve is suspected.

Objectives: To evaluate the rate of surgical site infection (SSI) and associated risk factors after parotid gland surgery including the impact of antibiotic prophylaxis., Design: Retrospective single-centre clinical study., Setting: Tertiary referral centre for head and neck surgery., Participants: Seven hundred and fifty four patients who underwent parotid gland surgery at the University Hospital Heidelberg, Germany, between 2007 and 2014 were enrolled in this study. Data on patient age, American Society of Anesthesiologists (ASA) classification system, smoking status, diabetes mellitus, operation time, and antibiotic prophylaxis were collected. Additionally, the National Healthcare Safety Network (NHSN) risk index was calculated. Association of these factors with SSI was evaluated in univariate analyses and a multivariate logistic regression model., Main Outcome Measures: Rate of SSI., Results: Twenty four patients (3.2%) had an SSI according to the NHSN definition. In univariate analyses, only smokers (P = .048) and male patients (P = .01) had a significantly higher rate of SSI. Since the majority of smokers were men (62.3%), the effect of male gender, smoking, together with the NHSN risk index was further investigated as predictors of SSI within a logistic regression model. All three predictors showed a significant effect on SSI., Conclusions: Parotid gland surgery has a low rate of SSI. In our cohort, male gender, smoking and high NHSN risk index scores were significantly associated with SSI, whereas antibiotic prophylaxis had no protective effect., (© 2021 John Wiley & Sons Ltd.)

Background: A sialendoscopy-assisted combined approach is well established in the surgery of sialolithiasis. In cases of proximal salivary stones, transcutaneous sialendoscopy-assisted extractions with parotid and submandibular gland preservation is the primary intention of treatment. We recently added computer tomography (CT) navigation to improve the results of this challenging surgery equally in both localizations., Patients and Methods: Al l the patients who submitted to sialendoscopy and sialendoscopy-assisted procedures at the tertiary institution between January 2012 and October 2020 were included in the present study. From November 2019, CT navigation was added in cases with sialolithiasis and a presumably poor sialendoscopic visibility. We evaluated the parameters of the disease, diagnostic procedures, sialendoscopic findings and outcomes, with or without optical surgical navigation., Results: We performed 178 successful salivary stone removals in 372 patients, of which 118 were combined sialendos-copy-assisted approaches, including 16 transcutaneous proximal, 10 submandibular and 6 parotid stone operations. Surgical navigation was used in six patients, four times for submandibular and twice for parotid sialolithiasis. These were all non-palpable, sialendoscopically invisible or partially visible stones, and we managed to preserve five of the six salivary glands., Conclusions: The addition of CT navigation to sialendoscopy-assisted procedures for non-palpable, sialendoscopically invisible and fixed stones is a significant advantage in managing sialolithiasis. By consistently performing sialendoscopy and related preservation procedures, we significantly reduced the need for sialoadenectomies in patients with obstructive salivary gland disease., (© 2021 Aleksandar Anicin, Jure Urbancic, published by Sciendo.)

Objectives: To report descriptive statistics for minor parotidectomy complications., Methods: A systematic review was performed, selecting 235 studies for analysis. The incidence of complications was tabulated, and descriptive statistics calculated. Outlier studies, 1 standard deviation above the mean, were reexamined to determine potential causal factors for each complication. All studies were examined for statistically significant differences for any potential causal factor., Results: The pooled incidence of minor complications reported were hematoma 2.9% (95% confidence interval [CI]: 2.4-3.5), wound infection 2.3% (95% CI: 1.8-2.9), sialocele 4.5% (95% CI: 3.5-5.7), salivary fistula 3.1% (95% CI: 2.6-3.7), flap necrosis 1.7% (95% CI: 1.1-2.5), scar issues 3.6% (95% CI: 2.4-5.4), numbness 33.9% (95% CI: 25.6-43.4), and deformity 11.8 (95% CI: 6.9-19.5). Implants result in more wound complications, such as hematoma, sialocele, or salivary fistula. Sialocele and salivary fistula appear more frequently after less extensive parotid surgery, whereas hematoma, wound infections, flap necrosis, and aesthetic considerations are worse with more extensive resections., Conclusions: Minor parotidectomy complications are more frequent than generally assumed and related to certain factors that should be investigated. Laryngoscope, 131:571-579, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Recent literature suggests that outpatient head and neck surgery is safe and may decrease costs. This study assesses whether outpatient parotidectomy differs in complication type and rate from inpatient surgery., Methods: Patients who underwent parotidectomy at our institution from 2011 to 2019 were retrospectively reviewed and divided by inpatient or outpatient status. Complications including infection, seroma, salivary fistula, hematoma, and flap necrosis, as well as readmission rates were tabulated. Drain placement, related to tumor size, was also analyzed using a receiver operating curve., Results: 144 patients had available data for analysis. Nine of the 144 patients had complications. Seven of 98 outpatients and two of 46 inpatients had complications. There was no statistically significant difference in complication rate between the two groups ( P  = .518). Tumor size ≥4.62 cm 3 was associated with drain placement ( P  = .044)., Conclusion: Outpatient parotidectomy is a safe and viable alternative for carefully selected patients.

Background: Superficial parotidectomy has a potential to be performed as an outpatient procedure. The objective of the study is to evaluate the safety and selection profile of outpatient superficial parotidectomy compared to inpatient parotidectomy., Methods: A retrospective review of individuals who underwent superficial parotidectomy between 2006 and 2016 at a tertiary care center was conducted. Primary outcomes included surgical complications, including transient/permanent facial nerve palsy, wound infection, hematoma, seroma, and fistula formation, as well as medical complications in the postoperative period. Secondary outcome measures included unplanned emergency room visits and readmissions within 30 days of operation due to postoperative complications., Results: There were 238 patients included (124 in outpatient and 114 in inpatient group). There was no significant difference between the groups in terms of gender, co-morbidities, tumor pathology or tumor size. There was a trend towards longer distance to the hospital from home address (111 Km in inpatient vs. 27 in outpatient, mean difference 83 km [95% CI,- 1 to 162 km], p = 0.053). The overall complication rates were comparable between the groups (24.2% in outpatient group vs. 21.1% in inpatient, p = 0.56). There was no difference in the rate of return to the emergency department (3.5% vs 5.6%, p = 0.433) or readmission within 30 days (0.9% vs 0.8%, p = 0.952)., Conclusion: Superficial parotidectomy can be performed safely as an outpatient procedure without elevated risk of complications.

Importance: Conventional reconstruction techniques for superficial parotidectomy have been criticized for their ability to provide long-term volumetric correction and to prevent Frey's syndrome. Objective: To demonstrate the long-term effectiveness of a pedicled and innervated sternocleidomastoid muscle flap (PISCMMF) to reconstruct superficial parotidectomy defects. Design, Setting, and Participants: This is a retrospective cohort study of patients treated by a single surgeon in a tertiary care center from July 2012 to March 2018. Seventeen of a possible 34 eligible adults having undergone reconstruction with a PISCMMF for benign parotid disease with at least 1 year of follow-up were included through convenience sampling. Patients with revision parotid surgery, malignant parotid tumors, neck dissections, or prior spinal accessory nerve dysfunction were excluded. Intervention: A PISCMMF was used to immediately reconstruct superficial parotidectomy defects. Main Outcomes and Measures: Participants underwent three-dimensional facial imaging, starch-iodine testing for Frey's syndrome, and completed a validated satisfaction questionnaire. The surface area of the positive starch-iodine tests was calculated. An average model was generated from participant images, allowing the calculation of surface millimeter differences comparing the operative with nonoperative sides. Results: Seventeen patients [7 male (41.2%), mean age 50.82 ± 12.37 years] underwent a PISCMMF to reconstruct excision (mean specimen weight = 21.45 ± 12.22 g) of benign lesions [9 pleomorphic adenomas (52.9%), 5 Warthin's tumors (29.4%), 2 cysts (11.8%), 1 chronic parotitis (5.9%)], with a mean follow-up time of 35.41 ± 12.30 months. Rates of objective and subjective Frey's syndrome were 29.4% and 11.8%, respectively. The average surface area affected was 2.32 cm 2 [standard deviation (SD) = 1.95 cm 2 ] compared with the average surface area of 16.35 cm 2 (SD = 9.20 cm 2 ) of the excised specimens. Facial symmetry analysis revealed an average millimeter difference of -1.57 ± 2.55 mm that was not significant at a threshold of 2 mm [ t (16) = 0.69, p  = 0.50]. No participants had postoperative shoulder or neck dysfunction. Overall satisfaction was 95.4%. Age ( β  = -0.51, p  = 0.02) and case number ( β  = 0.44, p  = 0.04) were significant predictors of smaller millimeter difference ( R 2  = 0.48, F (2,14) = 6.41, p  = 0.01). The specimen mass ( β  = -0.05, p  = 0.35) did not predict millimeter difference ( R 2  = 0.11, F (1,8) = 0.10, p  = 0.35). Conclusions and Relevance: A PISCMMF immediately reconstructing parotidectomy defects successfully restores facial symmetry, prevents clinically significant Frey's syndrome, and results in high patient satisfaction in the long term without significant morbidity.

Background: Patients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey's syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement., Methods: All patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010-2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement., Results: Fifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient's (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey's Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery., Conclusion: In the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.

Background: Facial nerve weakness is the most common and most concerning complication after parotidectomy. Risk factors for this complication following surgery for benign diseases remain controversial., Objective: Review the frequency and prognosis of facial nerve weakness after parotidectomy and analyze potential risk factors., Design: Retrospective review of medical records., Settings: Two tertiary care centers., Patients and Methods: We included all parotidectomies performed for benign diseases from January 2006 to December 2018. Details about the development and recovery of postoperative facial weakness were recorded. Patient, disease and surgery-related variables were analyzed using bivariate and multivariate analyses to identify risk factors., Main Outcome Measures: Frequency, recovery rates and risk factors for facial nerve weakness SAMPLE SIZE: 191 parotidectomies, 183 patients, 61 patients with facial weakness., Results: The frequency of postoperative facial weakness was 31.9% (61/191 parotidectomies). Among patients with temporary weakness, 90% regained normal facial movement within 6 months. Steroid therapy was not associated with a faster recovery. Postoperative weakness was not associated with age, diabetes, smoking, disease location, use of an intraoperative facial nerve monitor or direction of facial nerve dissection. Risk factors for temporary weakness were total parotidectomy and surgical specimens larger than 60 cubic centimeters. Revision surgery was the only identified risk factor for permanent weakness., Conclusion: Larger parotid resections increase the risk of temporary facial nerve weakness while permanent weakness is mainly influenced by previous surgeries., Limitations: Retrospective nature, underpowered sample size, selection bias associated with tertiary care cases., Conflict of Interest: None.

Background: Parotidectomy is often performed as an inpatient procedure largely due to drain insertion; however, outpatient parotidectomy has increasingly become an attractive alternative for its shorter hospital stays and greater efficiency in cost-effectiveness., Objective of Review: To assess the safety and feasibility of outpatient (or same-day discharge) parotidectomy compared with inpatient parotidectomy., Type of Review: Systematic review of the literature and meta-analysis, in accordance with the PRISMA guidelines., Methods: Pubmed/Medline, Embase, CINAHL, Google Scholar, Web of Science, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) were searched for articles published in English between 01/01/1990 and 05/10/2019. The Newcastle-Ottawa Scale was used for quality assessment and Review Manager 5.3 for meta-analyses., Main Outcome Measures: Primary outcomes assessed were postoperative complications including bleeding/haematoma, surgical site infection, seroma and facial weakness. Secondary outcome was readmission rate., Results: Out of 445 studies identified, 6 were selected for systematic review. The overall quality of evidence was moderate. A total of 3664 patients were included (1646 in the outpatient group and 2018 in the inpatient group). Comparing the outpatient with inpatient cohorts, there were lower complications in outpatient groups though not statistically significant for haematoma (OR = 0.45; 95% CI = 0.11-1.92; P = .28), surgical site infection (OR = 0.88; 95% CI = 0.46-1.69; P = .70), seroma (0.79; 95% CI = 0.21-3.03; P = .74), facial nerve weakness (OR 0.39; 95% CI = 0.14-1.08; P = .07) and hospital readmission (OR 0.58; 95% CI = 0.33-1.04; P = .07)., Conclusions: Outpatient parotidectomy appears to be safe and compares favourably to inpatient procedure in postoperative complication and readmission rates., (© 2020 John Wiley & Sons Ltd.)

Objective: Parotidectomies are commonly performed procedures by head and neck surgeons. Although parotidectomies are historically inpatient procedures, recent observational evidence has highlighted the potential for parotidectomies to be performed on an outpatient basis. This systematic review and meta-analysis sought to compare complications and unplanned health care utilization between patients undergoing outpatient versus inpatient parotidectomy., Data Sources: A systematic review was performed using MEDLINE, EMBASE, and the Cochrane Library., Review Methods: Studies comparing the outcomes of outpatient parotidectomy with those of inpatient parotidectomy were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. Postoperative complications (hematoma, facial nerve dysfunction, seroma, fistulisation, Frey syndrome, and wound infection) and rates of 30-day readmission, reintervention, and emergency department presentation were compared., Results: We screened 1018 nonduplicate articles to include 5 studies, all of which were retrospective cohort studies. There were fewer complications found in the outpatient group (relative risk = 0.61, 95% confidence interval: 0.40-0.93). Outpatient procedures were more commonly performed on patients who lived close to the hospital, had fewer comorbidities, and had less extensive planned surgery., Conclusion: Outpatient parotidectomy appears safe in select patients with outcomes comparable with inpatient surgery. However, evidence overall is of low quality, and further work is needed to delineate a satisfactory set of criteria for appropriate patient identification.

Objectives: To evaluate the incidence, causes, risk factors, and costs associated with 30-day readmissions in parotidectomy patients utilizing the Nationwide Readmissions Database (NRD)., Study Design: Retrospective cohort study., Methods: We examined the NRD for patients who underwent parotidectomy between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission., Results: Among 15,102 included patients, 594 (3.9%) were readmitted within 30 days. The average cost per readmission was $12,502. Infectious (22.7%) and wound (11.2%) complications were the two most common causes of readmission. After controlling for other covariates, significant predictors of readmission included advanced comorbidity (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.09-2.37), a malignant parotid tumor (OR, 2.37; 95% CI, 1.63-3.43), length of stay ≥2 days (OR, 1.54; 95% CI, 1.09-2.18), and nonroutine discharge destinations (home with care [OR, 1.88; 95% CI, 1.27-2.78] and nursing facility [OR, 2.69; 95% CI, 1.55-4.67])., Conclusion: In this nationwide database analysis, we found that nearly 4% of all patients undergoing parotidectomy are readmitted within 30 days. Readmissions are commonly due to infections and wound complications. Quality improvement proposals targeting avoidable readmissions should focus on early recognition and prevention of infection and wound complications. Risk factors contributing to readmission include advanced comorbidity, malignant parotid tumor, prolonged index hospitalization, and nonroutine discharge destinations., Level of Evidence: NA Laryngoscope, 130:1212-1217, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

A 23 year female presented with bilateral recurrent swelling of eyelids along with ptosis and proptosis for last 3 years. She also had swellings over the right cheek, parotid gland, and retro auricular area along with regional lymphadenopathy. Systemic laboratory workup revealed raised serum IgE and a high peripheral eosinophil count. Computed tomography and magnetic resonance imaging showed bilateral enlargement of extraocular muscles, lacrimal glands, and ipsilateral parotid gland. Excision biopsy of the retro-auricular lymph node was suggestive of Kimura's disease (KD). The patient responded well to systemic corticosteroid. KD rarely affects orbit, but it should be included in the differential diagnosis of inflammatory diseases of the orbit. To our knowledge, this is the first reported case of KD from India involving the orbit, lacrimal gland, extraocular muscles, parotid gland and buccal area., Competing Interests: None

Postsurgical trigeminal neuralgia (TN), although rare, can lead to significant hemodynamic perturbations by triggering the trigeminocardiac reflex (TCR). The combination can lead to diagnostic as well as management challenges for clinicians. We present the case of a patient with a parotid abscess, which developed as a complication of his otolaryngologic surgery, and which led to repeated episodes of symptomatic bradycardia associated with cardiovascular collapse. This case highlights the importance of heightened awareness, early diagnosis, and timely treatment of postsurgical neuropathic pain syndromes to avoid life-threatening complications.

Background: The recently described Milan system provides a unified way of categorizing salivary gland fine-needle aspiration (FNA) cytology. We aim to use this system to stratify risk of malignancy in parotid FNAs., Methods: In this retrospective case series, 376 FNAs were preoperatively performed for 573 parotidectomies over 14 years., Results: Risk of malignancy on FNA is as follows: nondiagnostic 14.5%, non-neoplastic 26.7%, atypia of undetermined significance 29.3%, benign neoplasm 2.7%, neoplasm of uncertain malignant potential 19.1%, suspicious for malignancy 87.5%, and malignant 100%. The specific diagnoses of pleomorphic adenoma and Warthin tumor on FNA have high positive predictive value of 97.5% and 96.6%, respectively. Multivariate regression associates smaller size of lesion with a nondiagnostic or indeterminate result. Seniority of operator is associated with a lower likelihood of a nondiagnostic result., Conclusions: This large Asian series validates the Milan system as a valuable tool in stratifying malignancy risk of parotid FNAs., (© 2019 Wiley Periodicals, Inc.)

Objectives/hypothesis: To describe a previously unreported variant of Frey syndrome. Gustatory sweating is a common complication of parotidectomy and typically directly overlies the surgical site or parotid bed. In some instances, the sweating may occur beyond the parotid bed or involve tissue that was undisturbed during the procedure., Study Design: Retrospective case series., Methods: All cases of temporoparietal Frey syndrome in a single surgeon's experience were reviewed., Results: Seven patients were found to have temporoparietal Frey syndrome. Three patients had concomitant first bite syndrome. Three patients had some form of reconstruction at time of surgery. The mean time to onset of symptoms was 11.5 months, with a range of 7 to 21 months. Four patients did not require any treatment for their symptoms, but two patients required intradermal Botox injections for symptomatic relief., Discussion: This study describes a previously unreported variant of Frey syndrome with symptoms occurring distal to the parotid gland. This likely develops either by regeneration of severed postganglionic fibers into sympathetic targets distally along the course of the auriculotemporal nerve or by regeneration into fibers of the sympathetic plexus traveling along the superficial temporal artery., Level of Evidence: Laryngoscope, 129:2071-2075, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: To determine whether the use of fibrin sealant impacted the rate of postoperative wound complications following parotidectomy., Methods: We retrospectively reviewed 100 consecutive parotidectomies with and without fibrin sealant. Primary outcomes were development of seroma, sialocele, abscess, or hematoma within the first 30 days as well as length of hospital stay for drain output if one was placed. Secondary outcomes analyzed wound complications based on several patient and surgical factors., Results: In our cohort, there were 82 superficial parotidectomies (82%), and the most common pathology was pleomorphic adenoma (39%) followed by Warthin's tumor (27%). Fibrin sealant was used in 46 patients (46%). Postoperative wound complications occurred in 20 patients, and were not statistically different with or without fibrin sealant placement (23.9% vs. 16.7%, p = 0.454). Fibrin sealant did not significantly reduce wound complications regardless of tissue volume removed, use of acellular dermis, history of smoking, diagnosis of diabetes, or active anticoagulant/antiplatelet use. Only four patients without fibrin sealant (7.4%) required hospitalization beyond 24 h for high drain output., Conclusions: In our retrospective cohort, the development of postoperative wound complications following parotidectomy did not appear to be significantly impacted by the use of a fibrin sealant.

Objectives: This study aimed to evaluate sensory dysfunction resulting from great auricular nerve (GAN) sacrifice versus preservation in parotid surgery for benign lesions and its imact on long-term health-related quality of life (QOL)., Design: Retrospective., Setting/main Outcome Measures: Participants were divided into two groups (GAN and non-GAN), and both short-term (two postoperative weeks) and long-term (at least 5 years) QOL were assessed. The second item of the Parotidectomy Outcome Inventory-8 (POI-8) was used to analyse postoperative sensory loss. All items of the POI-8 questionnaire were used to determine health-related QOL.We used t test for dependent samples and Mann-Whitney U-test to compare patient groups PARTICIPANTS: A total of 137 patients (65 male and 72 female) enrolled in this study. Average age at the time of surgery was 53 years (±12.8)., Results: The GAN preservation group had significantly better sensation than the GAN sacrifice in short term (2.8 vs 2.1; P = 0.017). Both groups experienced improved sensation in the long term, and there was a trend towards better QOL in the GAN-preservation group. However, the difference in sensation was not statistically significant (1.7 vs 1.3; P = 0.145). Health-related QOL also increased in the long term (compared to short term) for both groups (7.6 ± 6.2 to 12 ± 7.6; P < 0.0001) postoperatively. GAN preservation did not significantly improve sensation in long term, nor did it increase health-related QOL postoperatively., Conclusion: Although GAN preservation was easily feasible, it only improved sensation in short term. We report a negative result: GAN preservation did not significantly improve sensation in long-term, nor did it increase health-related QOL postoperatively when compared to GAN sacrifice., (© 2019 John Wiley & Sons Ltd.)

Purpose: Parotidectomy is the definitive procedure for diagnosis and treatment of most parotid masses but, due to the risk of haematoma and seroma formation, has traditionally included a drain. The drain itself comes with its own risks and, in most hospitals, the need for overnight admission, which has significant cost implications (Mallon et al. Ann R Coll Surg Engl 95(4):258-262; 2013). Fibrin glue, with its haemostatic and adhesive properties, reduces the risk of collection or haematoma and therefore may negate the need for a drain. This is the first study to look at the use of ARTISS as an alternative to drains in parotidectomy., Methods: We performed a retrospective study of all the patients who underwent a partial parotidectomy over a 4-year period from 2014 until 2018 under the same senior surgeon. Patients were divided into those that had a drain and those that had ARTISS. Their operative record, inpatient notes and clinic letters were reviewed to record information regarding length of stay, histology, complications and recurrence., Results: A total of 34 patients were identified; 17 ARTISS and 17 drain patients. We showed that the mean length of stay improved significantly from 1.6 days with the drain to 0.5 days with ARTISS (Fig. 1) but without a difference in complication rate (Fig. 2), which was 5/17 (29%) in each group., Conclusions: In conclusion, parotidectomy can be undertaken safely as a day-case procedure with the application of ARTISS. This new approach to parotid surgery not only offers less morbidity for patients but also positive financial revenue for public health institutions.

Objectives/hypothesis: Salivary fistulas are a common minor complication of parotid surgery. botulinum toxin has repeatedly been reported to be an adequate treatment of this entity. To date, there is little scientific evidence for clinical decision making after appearance of a salivary fistula., Study Design: Retrospective chart analysis of 16 patients who had been treated with botulinum toxin for salivary fistula., Methods: All patients who had been treated for salivary fistula at a tertiary referral hospital from 2010 to 2016 were included. Patient files were used to obtain characteristics of patients, treatment, and follow-up., Results: Sixteen patients with salivary fistula received 27 injections of botulinum toxin. Nine patients required one injection for the fistula to heal, five patients needed two injections, and one patient needed three and four injections, respectively. No patient underwent additional surgery or radiotherapy. We observed no adverse effects in any patient treated with botulinum toxin., Conclusions: In most cases of salivary fistula, injections of botulinum toxin are a valid treatment. If the initial injection is not successful, injections may be repeated once. Otherwise, revision surgery should be considered. In general, treatment with botulinum toxin should be commenced in an earlier stage and with higher dosages., Level of Evidence: 4 Laryngoscope, 129:403-408, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes., Objective: To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database., Design, Setting, and Participants: This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018., Main Outcomes and Measures: Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures., Results: Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003)., Conclusions and Relevance: In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population., Level of Evidence: NA.

Purpose: Given the increasing costs of medical care, there has been a shift to outpatient elective surgeries in certain patient populations among all surgical specialties. The goal of this study was to compare the safety and efficacy of outpatient parotidectomy with traditional inpatient parotidectomy., Materials and Methods: This is a retrospective chart review of all patients who underwent a parotidectomy at a single tertiary academic center from 2007 through 2017., Results: There were 568 patients who met the inclusion criteria. There was no difference in demographics or patient comorbidities between the inpatient and outpatient groups. There was no increased incidence of postoperative complications or extent of postoperative care in patients who underwent outpatient parotidectomy. On average at the authors' institution, the direct outpatient parotidectomy cost was $1,200 less than the inpatient equivalent., Conclusion: Outpatient parotidectomy can be performed safely and cost effectively with no increased risk of complications., (Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. All rights reserved.)

Background: Frey syndrome is one of the important complications of parotid surgery. Placing a barrier between the parotid gland and the skin flap is considered to be effective for preventing this syndrome by blocking misdirected regeneration of nerve fibers. Neoveil is nonwoven polyglycolic acid (PGA) felt that is used as absorbable reinforcing material. The present study evaluated the effectiveness of this PGA felt as a barrier for preventing Frey syndrome., Methods: A total of 19 patients who underwent superficial parotidectomy from 2012 to 2017 were retrospectively reviewed. Application of PGA felt (n = 9) or sternocleidomastoid flap (SCMF) transfer (n = 10) was performed to prevent Frey syndrome. The total operating time, intraoperative blood loss, operating time after parotidectomy, and postoperative drainage volume were compared between the 2 groups., Results: The operating time after parotidectomy was significantly shorter in the PGA felt group than in the SCMF group (43.7 ± 10.7 vs 57.8 ± 15.7 minutes). The total operative time was shorter and the drainage volume was smaller in the PGA felt group than those in the SCMF group without statistical significance (210.1 ± 43.4 vs 234.3 ± 52.7 minutes and 80.6 ± 36.8 vs 118.8 ± 83.9 mL). Neither Frey syndrome nor other major complications occurred in either group., Conclusions: Use of PGA felt successfully prevented Frey syndrome, while being technically simpler and more rapid compared with SCMF transfer.

Parotid gland lesions in children can be divided into benign or malignant. The age of the patient helps narrow the differential diagnosis, with vascular and congenital lesions being more frequent in the 1st year of life, while solid tumors are more frequent in older children. Inflammatory disease usually has rapid onset in comparison with that of neoplastic or congenital processes, which have more gradual clinical evolution. Currently, multiple imaging techniques are available to study the parotid region, such as US, CT, and MRI. However, it is still a challenge to distinguish nonmalignant lesions from malignant ones. US is the first-line diagnostic approach in children to characterize the morphology and vascularity of these lesions. CT in children may be indicated for evaluation of abscesses or sialolithiasis. MRI is the imaging modality of choice for investigating the nature of the lesion and its extent. In addition to complete and detailed clinical information, knowledge of parotid gland anatomy and characteristic radiologic features of parotid disorders is essential for optimal radiologic evaluation and avoiding unnecessary interventional diagnostic procedures or treatment. This article illustrates a variety of entities (congenital, inflammatory, vascular, neoplastic) that can occur in the parotid gland, highlighting the most frequent radiologic patterns of manifestation and correlating them with clinical, surgical, and pathologic findings. © RSNA, 2018.

Amyloidosis in the parotid gland is rare and is usually associated with systemic amyloidosis. Localized amyloidosis in the parotid gland is extremely rare. We present a case of localized light chain amyloidosis of the parotid gland without systemic involvement. A 70-year-old woman presented with an asymptomatic swelling of the right parotid region. The findings of a physical examination, hematologic and biochemical investigations, imaging, and cytology were inconclusive. The patient underwent an extracapsular dissection of the right parotid gland. Histologic analysis showed that the tissue of the right parotid gland mostly consisted of amyloid deposition. The amyloid stained with antibodies to lambda light chains. Additional investigations showed no systemic involvement. The patient is asymptomatic 5 months after surgery. Clinicians should be aware of the possibility of localized amyloid light chain amyloidosis in the parotid gland, especially if magnetic resonance imaging, computed tomography imaging, and ultrasound findings are inconclusive, and they should recognize, evaluate, and treat it accordingly., (Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. All rights reserved.)