Abstract
Objective
Parotidectomy is usually carried out under general anesthesia. We reported our early experience of performing parotidectomy under local anesthesia.
Study design
Case series reviewed.
Setting
Head and neck services of a regional hospital.
Patients, intervention, and results
Seven patients underwent parotidectomy under local anesthesia. The indications were high risk for general anesthesia due to co-morbidity in 2 patients and personal preference for the rest. The operations were performed by retrograde facial nerve dissection after superficial cervical plexus block and incision wound infiltration with local anesthetics. There was no conversion to general anesthesia. Six operations were carried out in the setting of ambulatory procedure and were discharged on the same day. Transient mild facial paresis occurred in 2 patients.
Conclusion
Parotidectomy under local anesthesia can be conducted successfully and avoid the adverse effect of general anesthesia.
1
Introduction
In the past 2 decades, some of the head and neck operations have been increasingly conducted under local anesthesia (LA) . This form of minimally invasive anesthesia not only eliminates the inherent risk of the general anesthesia(GA), but also accelerates immediate patient recovery at the observation room and so facilitates day-case surgery.
In our centre, most of the submandibular sialoadenectomy are performed under LA for clinically benign submandibular masses . The feasibility is due to the relative superficial location of the submandibular gland. Likewise, we had reported that thyroidectomy under LA is also feasible for selected thyroid nodules .
Parotidectomy is a highly effective treatment for parotid tumors. Classically, parotidectomy is performed by the antegrade facial nerve dissection technique — the facial nerve trunk is first identified and safeguarded during the initial part of the operation. The nerve is subsequently followed and traced towards the periphery of the parotid gland. The tumor superficial to it is then removed by meticulous dissection while the branches of the facial nerve are preserved. Recently, partial parotidectomy, in which only part of the superficial lobe is excised with a cuff of normal salivary tissue surrounding the tumor, has been advocated as a safe alternative to formal superficial parotidectomy . From our experience, partial parotidectomy by retrograde nerve dissection is technically simple and has advantages over the antegrade parotidectomy . During retrograde parotidectomy, the main facial nerve trunk, which is quite deep-seated, can be spared from dissection. Being inspired by the success of LA thyroidectomy and submandibular sialoadenectomy, we stride one step further to perform LA parotidectomy since July 2010. Hereby we report the technique and briefly discuss the benefits of such procedure.
2
Surgical technique
The selection criteria were clinically benign tumor without evidence of fixity and the preoperative fine-needle aspiration cytology examination was not suggestive of malignancy. Informed consents were obtained from all the patients prior to surgery. Review board approval is not mandatory for retrospective study in our locality.
The patient was in supine position with the neck extended and rotated to the opposite side. All the LA parotidectomies were performed by retrograde nerve dissection. Superficial cervical plexus block was initially administered with 1% lignocaine with 1:400,000 adrenaline solution. The landmark for the block is the posterior border of sternomastoid muscle at midpoint between the mastoid process and sternal head of clavicle. The incision wound was then infiltrated with the same LA solution. Intravenous sedation with diazepam and pethidine was also given at the outset of surgery. Bipolar diathermy was liberally utilized throughout the operation to avoid the excessive heat production and thus reduce the thermal pain as well as the risk of facial nerve injury.
After the “lazy S” incision was made, subplatysmal flap was elevated. The great auricular nerve was preserved whenever possible . For anterior tumors, the great auricular nerve might not be encountered as it resided beyond the field of retrograde nerve dissection . At this juncture, more LA was infiltrated just beneath the parotid gland capsule. This will render the opening of the thick gland capsule painless. We did not attempt to identify the main facial nerve trunk. Conversely, its branches (mostly buccal and marginal branches) were identified at the periphery of the parotid gland. These branches, which appeared as white and shinny small bundles, were usually sizable enough to be recognized by meticulous dissection of the normal parotid parenchyma without undue difficulty. The operation was then continued in centripetal manner while tracing and protecting the facial nerve branches. Useful landmarks for identification of facial nerve branches are: the marginal branch is superficial to the anterior facial vessel 1–2 cm within the lower border of mandible, the buccal branch is 1 cm below and parallel to the zygomatic arch just above the parotid duct, and the temporal branch crosses the junction of anterior one third and posterior two thirds of the zygomatic arch. Although continuous facial nerve monitoring was seldom necessary, nerve stimulator was helpful to confirm the peripheral facial nerve branches. The tumor was removed with about 1 cm lateral margin. Suction drainage was routinely practised before wound closure. For day cases, the drains were cared by community nurses and daily output was charted. If the daily output was less than 10 ml, the drain was removed.
2
Surgical technique
The selection criteria were clinically benign tumor without evidence of fixity and the preoperative fine-needle aspiration cytology examination was not suggestive of malignancy. Informed consents were obtained from all the patients prior to surgery. Review board approval is not mandatory for retrospective study in our locality.
The patient was in supine position with the neck extended and rotated to the opposite side. All the LA parotidectomies were performed by retrograde nerve dissection. Superficial cervical plexus block was initially administered with 1% lignocaine with 1:400,000 adrenaline solution. The landmark for the block is the posterior border of sternomastoid muscle at midpoint between the mastoid process and sternal head of clavicle. The incision wound was then infiltrated with the same LA solution. Intravenous sedation with diazepam and pethidine was also given at the outset of surgery. Bipolar diathermy was liberally utilized throughout the operation to avoid the excessive heat production and thus reduce the thermal pain as well as the risk of facial nerve injury.
After the “lazy S” incision was made, subplatysmal flap was elevated. The great auricular nerve was preserved whenever possible . For anterior tumors, the great auricular nerve might not be encountered as it resided beyond the field of retrograde nerve dissection . At this juncture, more LA was infiltrated just beneath the parotid gland capsule. This will render the opening of the thick gland capsule painless. We did not attempt to identify the main facial nerve trunk. Conversely, its branches (mostly buccal and marginal branches) were identified at the periphery of the parotid gland. These branches, which appeared as white and shinny small bundles, were usually sizable enough to be recognized by meticulous dissection of the normal parotid parenchyma without undue difficulty. The operation was then continued in centripetal manner while tracing and protecting the facial nerve branches. Useful landmarks for identification of facial nerve branches are: the marginal branch is superficial to the anterior facial vessel 1–2 cm within the lower border of mandible, the buccal branch is 1 cm below and parallel to the zygomatic arch just above the parotid duct, and the temporal branch crosses the junction of anterior one third and posterior two thirds of the zygomatic arch. Although continuous facial nerve monitoring was seldom necessary, nerve stimulator was helpful to confirm the peripheral facial nerve branches. The tumor was removed with about 1 cm lateral margin. Suction drainage was routinely practised before wound closure. For day cases, the drains were cared by community nurses and daily output was charted. If the daily output was less than 10 ml, the drain was removed.
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