Extracapsular dissection in the parapharyngeal space: benefits and potential pitfalls

Mantsopoulos, Konstantinos; Müller, Sarina; Agaimy, Abbas; Goncalves, Miguel; Koch, Michael; Wüst, Wolfgang; Bohr, Christopher; Iro, Heinrich

doi:10.1016/j.bjoms.2017.05.013

Cited by 22 publications

(8 citation statements)

References 20 publications

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“…Our analysis demonstrated that facial nerve‐dissecting modalities, in absolute numbers, remained relatively stable over the 19 years of our study: the number of PSPs increased from six to 16 cases, LP cases decreased slightly (from 15 to 10), and the number of CPs remained mostly the same (from 40 to 44). This observation points to the fact that dissection of the facial nerve retains its position and is strongly indicated in parotid surgery (diffuse unilateral multilocular cystadenolymphomas, lesions of the deep lobe, parapharyngeal lesions with broad contact to the facial nerve). It could also be seen that the rapid increase in the total number of parotidectomies (from 70 to 252) could be almost directly attributed to the increase in the number of extracapsular dissections (from 9 to 182).…”

Section: Discussionmentioning

confidence: 91%

“…According to the philosophy of our department, minimal invasive surgery in the form of an extracapsular dissection (ECD) was indicated in cases of a single and mobile lesion with preoperative clinical and imaging signs of a benign tumor and located within the lateral lobe of the parotid gland as well as in cases of conglomerates of cystadenolymphomas in the caudal pole of the parotid gland. Furthermore, it was performed via an extended submandibular incision in rare cases of tumors arising from the pharyngeal prolongation of the parotid gland, located within the deep parapharyngeal space and without broad contact to the lateral parotid flap, after sectioning of the posterior belly of the digastric muscle and the styloid process in most cases . Interestingly, a significant number of former literature reports, in particular, use the term “enucleation” in order to describe what could be regarded as a form of extracapsular dissection .…”

Section: Introductionmentioning

confidence: 99%

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Paradigm shift in surgery for benign parotid tumors: 19 years of experience with almost 3000 cases

2019

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Objectives The aim of this study was to explore the changes in philosophy in the surgical therapy of benign parotid tumors over a period of 19 years. Methods The records of all patients treated for benign parotid tumors between 2000 and 2018 were evaluated. Data were analyzed with respect to the number of procedures carried out per year of the study according to each of the different surgical modalities and the incidence of postoperative complications. Statistical analysis was performed using the x2 test. A P value of <.05 was considered statistically significant. Results A total of 2988 patients were included in this study. Our analysis showed that the increasing performance of extracapsular dissection was associated with a progressive reduction in the incidence of temporary facial nerve palsy and Frey's syndrome, while the rate of permanent facial nerve palsy remained consistently low. Conclusion One of the most controversial issues in head and neck surgery is which therapeutic approach is best in patients with benign parotid tumors. Our analysis demonstrated that a change of strategy towards reducing invasiveness was possible, with exceptional functional results. Avoidance of facial nerve dissection is feasible in more than two‐thirds of cases with benign tumors. Level of Evidence 4b Laryngoscope, 130: 1941–1946, 2020

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Section: Discussionmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 99%

Paradigm shift in surgery for benign parotid tumors: 19 years of experience with almost 3000 cases

2019

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“…Surgery must fulfill two criteria: complete tumor excision under good visualization and minimal functional and cosmetic adverse effects. 1–4,6,7,9–20 The transoral approach remains the most controversial, and historically, it was rather poorly applied. Its limitations include a poor view, rendering exposure of major neurovascular structures difficult; possible capsule disruption and tumor spillage; incomplete tumor removal; uncontrollable blood leakage from great vessels; and facial nerve injury.…”

Section: Discussionmentioning

confidence: 99%

Excision of tumors in the parapharyngeal space using an endoscopically assisted transoral approach: a case series and literature review

Chen¹,

Chen²,

Yu³

et al. 2018

J Int Med Res

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Objective Magnetic resonance imaging (MRI) provides important information regarding tumors in the parapharyngeal space (PPS), revealing their origin, whether they are benign or malignant, and their relationships with surrounding structures. Methods Twelve tumors in the PPS were completely excised using an endoscopically assisted transoral approach (EATA). The MRI features were analyzed. Results Ten pleomorphic adenomas confirmed on postoperative pathological examination had the parotid pedicle sign. A fat space between the tumor and parotid gland may distinguish such a tumor from a tumor arising from a minor salivary gland in the prestyloid space and a tumor arising from the deep lobe of the parotid gland. Both the jugular vein and carotid artery were displaced posteriorly in all 10 cases of pleomorphic adenomas. The principal features of the two schwannomas confirmed on postoperative pathological examination were separation of the internal carotid artery and internal jugular vein and anteromedial displacement of the internal carotid artery, suggesting that the tumors originated in the poststyloid space. In this review, 95 tumors were excised by the EATA in the English-language literature. Conclusions MRI renders differential diagnosis possible. PPS tumors may be completely excised via an EATA guided by tumor features evident on preoperative MRI.

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“…Every effort towards reducing surgical invasiveness, e.g., avoiding nerve exposure and surgical dissection around the tumor with preservation of a cuff of healthy tissue around it (“extracapsular dissection”, Figure 2 ), was not received with open arms and encountered skepticism among several working groups [ 1 , 17 , 18 ]. Remarkably, this otherwise highly controversial surgical modality is accepted as one of the most common and undoubtedly least invasive ways of managing the same lesions in the parapharyngeal space [ 15 , 19 , 20 , 21 , 22 ]. In fact, extracapsular dissection in the parapharyngeal space tends to take the form of capsular dissection (or extracapsular enucleation [ 23 ]) around a large amount of surface of the PA.…”

Section: Discussionmentioning

confidence: 99%

“…Despite the fact that numerous literature reports propose strict adherence to the surgical rule “avoid seeing the tumor capsule wherever possible” in PAs of the PG 6 , the most common approach in the management of PAs in the parapharyngeal space traditionally consists in a transcervical rather blunt dissection along the capsule of the lesion, which is equal to the so-called enucleation in the PG. Remarkably, two diametrically opposing surgical philosophies for the same histopathologic entity seem to share comparable oncologic outcomes [ 12 , 13 , 14 , 15 , 16 ]. This realization gave rise to several questions that are hidden behind the somewhat provocative title of this article: Do PAs of the PG and PS really belong to the same histologic entity?…”

Section: Introductionmentioning

confidence: 99%

Pleomorphic Adenoma of the Parotid Gland and the Parapharyngeal Space: Two Diametrically Opposing Surgical Philosophies for the Same Histopathologic Entity?

Hornung

Constantinidis

Thimsen

et al. 2021

JCM

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Background: The aim of this study was to investigate the histopathologic findings in parotid and parapharyngeal pleomorphic adenomas and draw conclusions concerning the surgical strategy. Methods: Retrospective study of medical charts of patients with resected pleomorphic adenomas (PA) between 2005 and 2020 at two tertiary medical referral centers. Histologic specimens were reexamined by an experienced head and neck pathologist. Patients with insufficient/incomplete data were excluded from our study sample. Results: A total of 844 patients formed our study sample (291 men, 553 women, average age 48.9 years); 786 cases had a PA in the parotid gland (PG) (93.1%), and the remaining 58 cases had a PA in the parapharyngeal space (PS) (6.9%). Recurrences were detected in 8/844 cases (7/786 in the PG, 1/58 in the PS, 0.94% in total) with a mean follow-up time of 86.7 months (10–189 months) with no statistically significant differences between the study groups (p = 0.527). Our analysis showed that parapharyngeal pleomorphic adenomas are characterized by a lower incidence of an intact anatomical capsule (71.4% vs. 82.6%, p = 0.035) and a remarkably more frequent occurrence of satellite nodules (20.7% vs. 7.5%, p < 0.001). Conclusions: The more challenging histopathologic profile of parapharyngeal pleomorphic adenomas points towards the fact that parapharyngeal surgery should remain in the hands of experienced surgeons at high-volume centers.

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Extracapsular dissection in the parapharyngeal space: benefits and potential pitfalls

Cited by 22 publications

References 20 publications

Paradigm shift in surgery for benign parotid tumors: 19 years of experience with almost 3000 cases

Paradigm shift in surgery for benign parotid tumors: 19 years of experience with almost 3000 cases

Excision of tumors in the parapharyngeal space using an endoscopically assisted transoral approach: a case series and literature review

Pleomorphic Adenoma of the Parotid Gland and the Parapharyngeal Space: Two Diametrically Opposing Surgical Philosophies for the Same Histopathologic Entity?

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