Introduction
Quality of Life (QoL) can be defined as the “perceived discrepancy between the reality of what a person has and the concept of what the person wants, needs, or expects.” QoL is multidimensional, incorporating physical, psychological, social, emotional, and functional domains. It is subjective and must be based on self-reporting according to a patient’s own experiences. Thus, data from QoL questionnaires are becoming an important supplement to information pertaining to treatment outcome.
Quality of Life Outcomes From Surgery
Differences between surgery for benign versus malignant disease were found to be significant in a QoL study on parotidectomy. Regarding QoL and surgery, Beutner et al. reported no alterations in QoL 1 year after lateral or superficial parotidectomy. Fang et al. evaluated long-term QoL in child survivors of parotid tumor surgery and found that it had a limited negative impact. Breeze et al. prospectively studied QoL after treatment of cancer of the submandibular gland. QoL dropped at 6 months, but had resolved to >80% of the pretreatment value by a year, with the exception of the domains taste and saliva. Becker et al. concluded that “appearance”, “activity” and “anxiety” are the domains with the lowest scores. Radiation therapy has the highest impact on health-related QoL and seems to be the most substantial negative factor.
Reported QoL issues associated with the submandibular glands include drooling and relocation of the ducts. Min et al. studied the option of partial submandibular gland excision rather than removal of the whole gland in two patient groups. The extent of injury to the lingual nerve, together with deformities of the facial contour were significantly less in the group in which the gland was preserved. Postoperative salivary production and overall patients’ satisfaction were also better in that group. They recommend that gland-preserving techniques be deployed where feasible for management of benign submandibular tumors.
Hirota et al. found the youngest among all patients reported a significantly greater worsening of their physical well-being and emotional status after treatment as compared with others. Age of development of the neoplasm and type of disease had a greater effect on QoL than treatment modality. Al-Mamgani et al. reported parotid surgery and postoperative radiotherapy resulted in excellent outcomes with minimal side effects and preservation of good QoL scores.
Salivary Flow
The author’s group prospectively evaluated salivary flow rates and composition in patients undergoing parotidectomy, both preoperatively and postoperatively. Analysis of the individual results revealed three patterns of preoperative and postoperative response, compatible with either a preoperative or postoperative compensatory mechanism in the contralateral gland. None of the patients complained of xerostomia before or after surgery.
Xerostomia is a major concern in regard to QoL. The author looked into stimulated parotid salivary flow rate and clinical recordings of oral symptoms in 48 terminally ill cancer patients. A total of 68% reported a sensation of oral dryness; 33% had no saliva at the floor of the mouth, with candidiasis in almost all of this group ( Fig. 56.1 ). Analysis of individual salivary flow rates were stratified into three levels of secretion: 0, <0.2, and ≥ 0.2 mL/min. Symptoms were found to correlate with salivary flow rates. Xerostomia may also be induced by radioiodine treatment for thyroid cancer.
Prevention or reduction of xerostomia is unfortunately not satisfactorily assisted by intensity modulated radiation therapy (IMRT) radiation techniques. Amifostine is used as a gland protector; submandibular gland transfer to the submental area removing the gland from the radiation field; and salagen is used for enhancing postradiation salivary symptoms.
Sialorrhea or drooling is most commonly seen in neurologically or mentally impaired patients. It may uncommonly also be associated with cancer of the head and neck. Treatment options range from medication, radiation, and surgical therapy. Anticholinergic medications, such as glycopyrrolate and scopolamine are effective but their use may be limited by side effects. The injection of botulinum toxin into the parotid and submandibular glands is an effective yet temporary measure. In our experience, duct relocation is highly effective both for the patients when mindful of their situation and their caregivers as reported by other groups.
Pain and Sensation
Pain was noted by 50% of patients undergoing parotidectomy but improved over time. Similar to results reported by one group, pain was encountered significantly less in patients younger than 45 years of age, and no significant difference was noted in comparing complaints of pain between patients undergoing partial or total resection of the gland. Another aspect of pain noted following parotidectomy is “First bite syndrome”. A total of 33% underwent at least one type of treatment for symptomatic relief, albeit no treatment consistently provided effective symptomatic relief.
Decreased sensation was reported as the most common disturbing problem occurring in 90% of patients postparotidectomy after great auricular nerve (GAN) sacrifice. Despite this, Patel et al. stated overall QoL was not significantly affected. Yokoshima et al. attempted to preserve the posterior branch of the GAN in parotidectomy, succeeding in 65% of cases. The QoL was significantly better in the group of patients with GAN preservation. Ryan and Fee described QoL with GAN sacrifice as tolerable and improved during the first postoperative year. Lorenz et al. reported preservation was beneficial. George et al., in a systematic review of prospective and retrospective studies, found QoL does not seem to be adversely affected when the GAN is sacrificed. No evidence was found to support that overall QoL is affected when the GAN is sacrificed, in a report by Grammatica et al.
Frey Syndrome
Frey syndrome or gustatory sweating requires treatment in only a minority of patients. Hartl et al. assessed QoL before and after botulinum toxin A treatment in patients with Frey syndrome with significant improvement noted. Frey syndrome was identified in this study as the most serious self-perceived sequela and the resulting discomfort worsened with time.
The outcome of parotidectomy in benign disease had little impact on general QoL and global health status; however, hypoesthesia or dysesthesia, Frey syndrome, and cosmetic discontent were found to be quite common and may impair QoL. Frey syndrome had statistically significantly decreased scores related to social functions, economic difficulties, speech defects, reduced sexuality, and nutritional parameters.
Parotid Gland Incision
This classic incision was popularized by Blair in 1936, and since then a variety of incisions have been offered. A modified facelift incision resulted in improved patient satisfaction compared with the modified Blair incision. Facelift incision was suggested to improve the cosmetic outcome ( Fig. 56.2 ).
