Robert L Witt

Pleomorphic adenoma of the parotid: formal parotidectomy or limited surgery?

BACKGROUND Optimal surgery for pleomorphic adenoma of the parotid is controversial. In the present review, we discuss the advantages and disadvantages of the various approaches after addressing the surgical pathology of the parotid pleomorphic adenoma capsule and its influence on surgery. DATA SOURCES PubMed literature searches were performed to identify original studies. CONCLUSIONS Almost all pleomorphic adenomas can be effectively treated by formal parotidectomy, but the procedure is not mandatory. Extracapsular dissection is a minimal margin surgery; therefore, in the hands of a novice or occasional parotid surgeon, it may result in higher rates of recurrence. Partial superficial parotidectomy may be a good compromise. The tumor is removed with a greater cuff of healthy parotid tissue than in extracapsular dissection. This may minimize the recurrence rate. On the other hand, the removal of healthy parotid tissue compared with formal parotidectomy is limited, thus minimizing complications such as facial nerve dysfunction and Frey syndrome.

Minimally invasive options for salivary calculi

The aim of this study was to review the advantages, limitations, and international interdisciplinary expert perspectives and contrasts of salivary gland endoscopy and transoral techniques in the diagnosis and management of salivary gland calculi and their adaptation in North America. The transition from transcervical approaches to strictly sialendoscopic approaches is a broad chasm and often not feasible. Sialendoscopy, sialendoscopy‐assisted, intraoral, and transcervical approaches all have surgical value. Diagnostic sialendoscopy, interventional sialendoscopy, sialendoscopy‐assisted, and transoral techniques have been a major step forward, not only in providing an accurate means of diagnosing and locating intraductal obstructions, but also in permitting minimally invasive surgical treatment that can successfully manage blockages precluding sialoadenectomy in most cases. A flexible methodology is required. Multiple or combined measured may prove effective.

Etiology and management of recurrent parotid pleomorphic adenoma

The objective of this review study was to encompass the relevant literature and current best practice options for this challenging, sometimes incurable problem. The source of the data was Ovid MEDLINE from 1946 to 2014. Review methods consisted of articles with clinical correlates. The most important cause of recurrence is enucleation with rupture and incomplete tumor excision at operation. Incomplete pseudocapsule, extracapsular extension, pseudopods of pleomorphic adenoma tissue, and satellite pleomorphic beyond the pseudocapsule are also likely linked to recurrent pleomorphic adenoma. Most recurrent pleomorphic adenoma are multinodular. Magnetic resonance imaging is the imaging study of choice for recurrent pleomorphic adenoma. Nerve integrity monitoring may reduce morbidity for recurrent pleomorphic adenoma. Treatment of recurrent pleomorphic adenoma must be individualized. Total parotidectomy, given the multicentricity of recurrent pleomorphic adenoma, is appropriate in many patients, but may be inadequate to control recurrent pleomorphic. There is accumulating evidence from retrospective series that postoperative radiation therapy results in significantly better local control. Laryngoscope, 125:888–893, 2015

Diagnosis and management of differentiated thyroid cancer using molecular biology

To define molecular biology in clinical practice for diagnosis, surgical management, and prognostication of differentiated thyroid cancer.

Acute bilateral sequential vestibular neuritis

Two cases of bilateral sequential vestibular neuritis demonstrate the significant persistent disequilibrium that follows involvement of the second ear. The etiology for the loss of vestibular function is postulated to be a viral neuritis. Vestibular suppressant drugs are helpful in relieving nausea and vomiting in the acute phase of the disease; however, they are of no therapeutic value for the protracted disequilibrium following involvement of the second ear. An awareness of this disorder as a disease entity will minimize diagnostic and therapeutic frustration on the part of the physician and provide a realistic prognosis for the patient. Unfortunately, the prognosis is for permanent but somewhat lessening disequilibrium with the passage of time and depends in great part on the subjects age.

Comparing capsule exposure using extracapsular dissection with partial superficial parotidectomy for pleomorphic adenoma

UNLABELLED The aim of this study was to compare capsule exposure using extracapsular dissection (ECD) with partial superficial parotidectomy (PSP) for pleomorphic adenoma. PURPOSE Long-term favorable results for recurrence and facial nerve function have been reported for ECD and PSP for parotid pleomorphic adenoma. Extracapsular dissection is distinguished from PSP in that the facial nerve is dissected in PSP but not in ECD. This article attempts to answer the following hypothesis: the margin of normal parotid tissue surrounding a parotid pleomorphic adenoma is less for ECD compared with PSP. MATERIAL AND METHODS This is a retrospective individual case-control study. Twelve consecutive parotidectomy procedures with a final pathology report of pleomorphic adenoma were retrospectively measured for margin (the percent of capsule exposure around the tumor). In 8 highly selected patients, ECD was performed. Four parotid surgical procedures not meeting strict criteria underwent PSP and served as controls. RESULTS The eight patients with ECD had a mean of 80% (71%-99%) of the capsule exposed. The 4 PSP procedures had 21% (4%-50%) of the capsule exposed (P < .05). CONCLUSIONS Extracapsular dissection results in higher capsule exposure.

Suppressed sneezing as a cause of hearing loss and vertigo

Two cases of inner ear injury caused by suppressed sneezing are described. One patient experienced vestibular symptoms in the form of reflexogenic vertigo that was relieved by surgical section of the tensor tympani tendon. The other patient had a sudden severe permanent sensorineural hearing loss. It is proposed that the aerodynamic pressure increase associated with suppressed sneezing is transmitted via the eustachian tube to cause an implosive fistula of either the round or oval window with injury to the membranous labyrinth.

How can Frey's syndrome be prevented or treated following parotid surgery?

BACKGROUND After parotid surgery, traumatized auriculotemporal, postganglionic, parasympathetic nerve fibers reinnervate the sweat glands and subcutaneous vessels resulting in gustatory sweating and facial flushing. Because Frey’s syndrome (FS) does not spontaneously resolve, multiple prevention and treatment strategies have been proposed. The literature supports evidencebased best practices for procedures in selected patients directed at the prevention and treatment of FS who are likely to have improved long-term quality of life after parotidectomy.

Recurrent Benign Salivary Gland Neoplasms.

The most important causes of recurrence of benign pleomorphic adenoma are enucleation with intraoperative spillage and incomplete tumor excision in association with characteristic histologic findings for the lesion (incomplete pseudocapsule and the presence of pseudopodia). Most recurrent pleomorphic adenomas (RPAs) are multinodular. MRI is the imaging method of choice for their assessment. Nerve integrity monitoring may reduce morbidity of RPA surgery. Although treatment of RPA must be individualized, total parotidectomy is generally recommended given the multicentricity of the lesions. However, surgery alone may be inadequate for controlling RPA over the long term. There is growing evidence from retrospective series that postoperative radiotherapy results in significantly better local control. A high percentage of RPAs are incurable. All patients should therefore be informed about the possibility of needing multiple treatment procedures, with possible impairment of facial nerve function, and radiation therapy for RPA. Reappearance of Warthin tumor is a metachronous occurrence of a new focus or residual incomplete excision of all primary multicentric foci of Warthin tumor. Selected cases can be observed. Conservative surgical management can include partial superficial parotidectomy or extracapsular dissection. Not uncommonly, other major and minor salivary gland neoplasms, including myoepithelioma, basal cell adenoma, oncocytoma, canalicular adenoma, cystadenoma, and ductal papilloma, follow an indolent course after surgical resection, with rare cases of recurrence.

What is the treatment of the lateral neck in clinically localized sporadic medullary thyroid cancer

BACKGROUND Sporadic medullary thyroid cancer has a high rate of regional and distant metastasis. Medullary thyroid cancer (MTC) is sporadic in 75% of cases, with the remainder being hereditary. Disease-free survival is 75% to 85% at 5 and 10 years. The treatment of clinically or imaging-positive lateral metastasis, without distant metastasis, is lateral neck (levels IIA, III, IV, and V) dissection. The treatment of the N0 neck has historically included advocates for central (level VI), ipsilateral, and/or bilateral neck dissection. In the era of high-resolution neck imaging, can prophylactic lateral neck dissection be withheld for patients with negative preoperative imaging? Can lateral neck dissection be withheld if imaging of the lateral neck is negative and there are positive central lymph nodes? The American Thyroid Association (ATA) published guidelines for the management of differentiated thyroid cancer in 2006 and published an update in 2009. MTCATA guidelines were first published in 2009. This review will summarize these guidelines and the current relevant literature.