Superficial parotidectomy under local anaesthesia

Introduction
Superficial parotidectomy with presentation of the facial nerve is the treatment of choice for benign parotid tumors, however even in expert hands there is a significant risk of damage of the facial nerve. The incidence of facial nerve weakness, both temporary and permanent, after superficial parotidectomy, ranges between 36-41% and 3-5% respectively (1).
In an attempt to minimize this risk we have performed, since 1985, a series of superficial parotidectomies under local anesthesia with the patient able to move his face on command thus providing reliable facial nerve monitoring. A series of 16 patients is presented but the target is not to dispute general anesthesia but mostly to describe the satisfactory results obtained.

Patients and Methods
Between January 1985 and December 2004, 16 patients, 9 males and 7 females, ranging in age from 17 to 76 years, suffering from benign parotid lesions, underwent superficial parotidectomy under local anesthesia. The parotid lesions included 11 cases of patients with pleomorphic adenoma, 2 cases of patients with lipoma, 1 case of parotid abscess, 1 case of echinococcal cyst (2) and 1 case of chondroma.
The preoperative diagnosis was based on fine - needle aspiration cytology and the cytological diagnoses compared with the final histopathological diagnoses were identical. The patient with echinococcal cyst had not been subjected to a preoperative cytological examination. In order to achieve local anesthesia in the first 7 patients, lignocaine 2% and adrenaline 1:200000 were used, while for the next 9 patients bupivacaine 0,5 and adrenaline 1:200000 were used. The region along the incision site was infiltrated. In the majority of cases, a formal exposure of the facial nerve was made before proceeding to excision. The duration of the operation ranged from 87 to 118 minutes. In all the operative procedures no capsular rupture occurred. In all the cases the patients were able to make a gesture on their face on command, providing reliable facial nerve monitoring.

Results
Postoperatively: two patients presented a temporary weakness of the lower lip, which was restored in both cases after 3 weeks; 3 patients developed Frey's syndrome of gustatory salivation which was mild in all cases and the patient was informed that it was of no concern; one patient experienced a salivary fistula which developed on the 3rd postoperative day and healed spontaneously after 2 weeks; finally 2 patients developed keloid scars.

Follow-up
The duration of follow - up in these patients, without any recurrence ranged from 19 months to 10 years.

Discussion
Approximately 80% of salivary gland tumors occur in the parotid gland of hich 75-80% are benign (3). All benign parotid tumors in the superficial lobe present as a lump and, unless there are clinical signs sugesting malignancy, accurate preoperative diagnosis of the lesion is not possible. Clinical signs suggesting the benign nature of parotid swelling are: a long history, lack of pain (except for inflammatory masses), normal function of the facial nerve and, the well defined borders of the mass which is not hard and has a good mobility. In order to evaluate parotid gland masses to document the accurate diagnosis and apply the therapeutic planning, fine needle aspiration cytology is indicated (4). These benign masses are treated with complete surgical excision with uninvolved margins (5). The rule is that superficial parotidectomy with facial nerve preservation is adequate.
However, even in expert hands there is a significant risk of damage of the facial nerve; in addition most parotid tumors occur during the sixth and seventh decade of life. Thus, many of the patients belong to this group of people with cardio-pulmonary compromise where the use of general anesthesia carries some risk? thus for these two reasons a simple question has resulted: Is it feasible to perform superficial parotidec-tomy under local anesthesia? The truth is that this idea has not been widely entertained. The first report in 1987 by Fujimura et al, described a lumpectomy under local anesthesia in an elderly lady suffering from parotid cancer, which was not a superficial parotidectomy (6).
In 1990 we reported 7 cases of superficial parotidectomy for benign tumors (7) in the Greek literature. In 2000 Reece reported in the English literature the first case of superficial parotidectomy under local anesthesia in a 47-year-old man suffering from a mucoepidermoid carcinoma (8). Since 1990 we have performed 9 more superficial parotidectomies under local anesthesia with encouraging results which are reported in this paper.
This piece of experience shows that superficial parotidectomy may be carried out under local anesthesia. The gland is located proximally to the skin and recognition of the facial nerve will uniquely rely on the knowledge of surgical anatomy, since no nerve stimulation can be used, given that it is very painful. Thus, such an operation could be feasible in the hands of an experienced surgeon who is familiar with the region.
In conclusion, superficial parotidectomy under local anesthesia is a challenging and promising technique awaiting for experienced and dareful surgeons to apply it. If it becomes a routine procedure for benign tumors, at least in patients who can poorly tolerate general anesthesia, this will contribute in reducing morbidity, hospital stay and cost effectiveness.

References
1. Woods, J.E. - Parotidectomy versus limited resection for benign parotid masses. Am. J. Surg., 1985, 149:749.
2. Safioleas, M., Giannopoulos, A., Manti, C., Stamatakos, M., Safioleas, K., Stavrou, E. - Hydatid disease of the parotid gland: A rare case report. Parasitol Int., 2007, 6: [Epub ahead of print]
3. Webb, A.J., Eveson, J.W. - Pleomorphic adenomas of the major salivary glands: a study of the capsular form in relation to surgical management. Clin. Otolaryngol., 2001, 26:134.
4. Zbaren, P., Schar, C., Hotz, M., Loosli, H. - Value of Fine - Needle Aspiration Cytology of Parotid Gland Masses. The Laryngoscope, 2001, 111:1989.
5. Peterson - Book on Principles of oral and maxillofacial surgery, 2nd edition, DC Decker editions. 2004.
6. Fujimura, T., Yonemura, Y., Kamata, T., Takegawa, S., Sugiyama, K., Nishimura, G., MIYATA, R., YAMAGUCHI, A., MIYAZAKI, I., NAKAJIMA, K. - A case of parotid tumor showing remarkable regression following hyperthermochemo-radiotherapy. Jpn. J. Cancer Chemother., 1987, 14:723.
7. Safioleas, M., Paikos, S., Constantis, T.H., Farantzos, E. - Superficial parotidectomy with local anaesthesia. Medical Annals, 1990, 44:95.
8. Reece, P.H., Papesch, M.E., Tolley, N.S. - Superficial parotidectomy under local anaesthesia. The Journal of Laryngology and Otology, 2000, 114:983.

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