Applicability of shear wave elastography of the major salivary glands: values in healthy patients and effects of gender, smoking and pre-compression.

Our aim in this study was to determine normal shear wave elastography (SWE) values for the parenchyma of the major salivary glands and to evaluate the influences of gender, smoking, side and type of gland and varying amounts of ultrasound probe pressure on SWE values. Twenty-five consecutive healthy patients were examined with ultrasound. SWE velocities were measured with acoustic radiation force imaging in the hilum and central region of both glands with "normal" and very low pressure. Mean SWE velocities were 1.854 m/s for the parotid gland and 1.932 m/s for the submandibular gland. No statistically significant differences were detected between males and females, smokers and non-smokers, parotid and submandibular gland and left and right sides. Greater pre-compression with the ultrasound probe resulted in a statistically significant increase in the SWE values of both salivary glands (p < 0.000). The degree of pre-compression by the ultrasound transducer should be standardized, so that the reliability and reproducibility of this innovative method can be improved.

Evolution and changing trends in surgery for benign parotid tumors.

OBJECTIVE/HYPOTHESIS: The ideal extent of surgical intervention for benign parotid tumors remains a matter of controversy. The aim of the study was to trace the development of surgical therapy in a large cohort, explore its changes in a single institution specializing in salivary gland pathologies over the last 12 years, and determine the extent to which a possible shift in the surgical therapy of parotid benign tumors toward less radical methods was correlated with a change in the incidence of facial palsy and Frey's syndrome. STUDY DESIGN: Retrospective clinical study. METHODS: A retrospective evaluation of the records for all patients treated for benign parotid tumors between 2000 and 2012 at a tertiary referral center was carried out. Surgical methods were classified into four groups: extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy, and complete parotidectomy. RESULTS: A total of 1,624 patients were included in the study. Our analysis demonstrated an increase in the total number of parotidectomies for benign lesions from 71 (2000) to 184 (2012), mostly due to the increase in extracapsular dissections (from 9 to 123). Increased performance of less radical surgery was associated with a significantly decreased incidence of temporary and permanent facial palsies (from 22.8% to 9% and 9.8% to 5.9%, respectively) and Frey's syndrome (from 11.3% to 1.6%). CONCLUSIONS: One of the most controversial issues in the treatment of benign parotid tumors is the best therapeutic approach to be taken in such patients. Our study showed that increased performance of less radical surgery was associated with better functional outcomes.

Elective neck dissection vs observation in transorally treated early head and neck carcinomas with cN0 neck.

CONCLUSION: This study showed that elective neck dissection (ND) resulted in reduced regional recurrences in a selected group of surgically treated patients with pT1-2 carcinomas but did not show any benefit for disease-specific survival (DSS). Furthermore, the importance of pN classification was also verified for this patient group. OBJECTIVES: The aim of this study was to determine whether the use of elective ND in patients with early head and neck carcinomas and cN0 neck that have undergone a transoral removal of the primary tumor can reduce the incidence of regional recurrence and improve survival. METHODS: Between 1980 and 2010, 224 patients that underwent transoral resection of a pT1-2 carcinoma and had a cN0 neck were included in the study; 101 patients received an elective ND and 123 did not. RESULTS: The group that underwent elective ND showed a tendency toward better regional control (RC) (96.0% vs 90.3%, p = 0.07) but similar DSS (85.7% vs 85.4%, p = 0.984). Cases with pN0 classification had a better overall survival (74.6% vs 46.9%, p = 0.07), DSS (88.4% vs 53.6%, p = 0.44), and RC (98.6% vs 62.5%, p < 0.001) compared with pN+ patients.

Follow-up of parotid pleomorphic adenomas treated by extracapsular dissection.

BACKGROUND: This study was carried out to evaluate tumor recurrence following extracapsular dissection of pleomorphic adenomas of the parotid gland. METHODS: We conducted a retrospective evaluation and clinical follow-up of the patients who underwent extracapsular dissection of a pleomorphic adenoma as primary surgery in the otolaryngologic department of the Erlangen University Clinics during the period from 2000 to 2005. RESULTS: In all, 601 surgical interventions on benign parotid tumors were carried out from 2000 to 2005, 219 of which were primary operations for removal of a pleomorphic adenoma. In 76 patients (34.7%), extracapsular dissection of a primary pleomorphic adenoma was carried out. Tumor recurrence has not been observed in any of these patients to date after an average monitoring period of 7.38 years (range, 5.05-10.52 years). CONCLUSIONS: Extracapsular dissection is a conservative and safe surgical procedure for extirpation of pleomorphic adenomas that should be firmly established in the repertoire of parotid gland surgery.

Results of minimally invasive gland-preserving treatment in different types of parotid duct stenosis.

OBJECTIVE: To assess differences in minimally invasive treatment in various types of Stensen duct stenoses, because sparse data have been published concerning this. DESIGN: Retrospective study. SETTING: Tertiary reference center, level of evidence: 2b. PATIENTS: Ninety-three patients with stenoses. METHODS: Treatment of 111 parotid duct stenoses was evaluated with particular attention to which treatment strategies were successful in various types of stenoses (type 1, inflammatory; type 2, web-associated fibrous; and type 3, fibrous). Minimally invasive treatment consisted of sialendoscopy-guided rinsing with cortisone (all cases) and interventional sialendoscopy with instrumental dilation alone or combined with transoral ductal surgery. RESULTS: Sialendoscopy-guided rinsing with cortisone was sufficient in 73.0% of cases of type 1 stenosis (21.5% of all cases). Interventional sialendoscopy with instrumental dilation was successful in 47.1% of cases of type 2 stenosis and 70.5% of cases of type 3 stenosis (59.2% of all patients). Interventional sialendoscopy combined with transoral duct surgery was successful in 72.7% of cases of type 3 stenosis (8.6% of all cases). Glands could be preserved in 96.4% of cases. CONCLUSIONS: Stenoses that can be differentiated using sialendoscopy seem to require different minimally invasive treatment. Sialendoscopy-guided rinsing with cortisone is an important basic anti-inflammatory treatment, particularly in inflammatory stenoses. Interventional sialendoscopy with instrumental dilation, transoral ductal surgery or a combination of both are the first choice in fibrous stenoses.

Sialendoscopy in the diagnosis and treatment of sialolithiasis: a study on more than 1000 patients.

OBJECTIVE: Sialendoscopy and other gland-preserving techniques such as extracorporeal shockwave lithotripsy (ESWL), transoral stone removal, and combinations of these methods have fundamentally changed the therapeutic approach to salivary stones. Since 2003, all patients presenting with sialolithiasis have been diagnosed and treated with the same algorithm and routine salivary gland endoscopy (SGE). STUDY DESIGN: Case series with chart review of patients with sialolithiasis treated between 2003 and 2008 using an algorithm for gland preservation. SETTING: Tertiary referral academic medical center. SUBJECTS AND METHODS: A total of 1154 patients with suspected sialolithiasis were identified and reviewed. Factors analyzed included stone location, size, surgical method, rate of stone clearance, complications, and rate of short- and long-term symptom resolution. Successful treatment was defined as freedom from symptoms at follow-up. RESULTS: Diagnostic sialendoscopy confirmed 221 parotid stones and 812 submandibular stones, of which 206 and 736, respectively, were treated. Transoral stone removal was the most frequently used method to remove submandibular stones (92%), with a smaller percentage able to be removed by SGE alone (5%) with long-term success rates ≥90%. Only 4% (29/736) required submandibular gland removal. Parotid stones were removed by SGE (22%), combined SGE and incisional technique (26%), or ESWL (52%), with long-term success rates of 98%, 89%, and 79%, respectively. Only 8 of 206 (4%) patients eventually required parotidectomy. CONCLUSION: Salivary gland endoscopy is an important diagnostic and therapeutic tool in the management of sialolithiasis but must be combined with additional techniques to ensure a high rate of stone clearance, symptom resolution, and gland preservation.

Sonoelastography of parotid gland tumours: initial experience and identification of characteristic patterns.

OBJECTIVES: The aim of this study was to investigate B-mode and elastographical ultrasound criteria capable of differentiating between benign and malignant parotid tumours and to define characteristic elastographical patterns for pleomorphic adenomas and Warthin's tumours. METHODS: Fifty-seven patients with parotid gland tumours were examined using a combination of B-mode and elastographic ultrasounds. The data acquired were analysed retrospectively by two experienced ultrasound operators to identify specific sonographical features of benign and malignant lesions. Additionally, elastographical patterns were defined and analysed for their specificity. RESULTS: A blurred margin proved to be the only significant criterion in B-mode ultrasound capable of differentiating between malignant and benign tumours. The garland sign was defined as an elastographical pattern found significantly more frequently in malignant tumours, improving sonographical prediction of the benign or malignant nature of a parotid lesion. A logistic regression model was developed that achieved a correct prediction in 87.7% of cases. A "dense core" sign was also specifically defined for pleomorphic adenomas and a "half-half" sign for Warthin's tumours. CONCLUSIONS: Elastography is an innovative and powerful diagnostic tool that can improve the sonographical examination of parotid gland tumours by revealing easily recognised and characteristic patterns of tissue distribution. KEY POINTS: • Elastography can help differentiate benign from malignant parotid tumours during parotid ultrasound. • The elastographical "garland sign" is more frequent in malignant than benign parotid tumours. • Pleomorphic adenomas show an elastographical "dense core sign". • Warthin's tumours show an elastographical "half-half sign". • Parotid cysts show an elastographical "bull's-eye sign".

Computer aided diagnosis of parotid gland lesions using ultrasonic multi-feature tissue characterization.

In this article, an ultrasound based system for computer aided characterization of biologic tissue and its application to differential diagnosis of parotid gland lesions is proposed. Aiming at an automated differentiation between malignant and benign cases, the system is based on a supervised classification using tissue-describing features derived from ultrasound radio-frequency (RF) echo signals and image data. Standard diagnostic ultrasound equipment was employed to acquire ultrasound RF echo data from parotid glands of 138 patients. Lesions were manually demarcated as regions-of-interest (ROIs) in the B-mode images. Spectral ultrasound backscatter and attenuation parameters are estimated from diffraction corrected RF data, yielding spatially resolved parameter images. Histogram based statistical measures derived from the parameters distributions inside the ROI are used as tissue describing features. In addition, texture features and shape descriptors are extracted from demodulated ultrasound image data. The features are processed by a maximum likelihood classifier. An optimal set of 10 features was chosen by a sequential forward selection algorithm. The classifier's performance is evaluated using total cross validation and receiver operating characteristic (ROC) analysis. As a reference method, postoperative pathohistologic analysis was conducted and proved malignancy or prospective malignancy in 51 patients. The classification using the proposed system yielded an area under the ROC curve of 0.91, proving significant potential for differentiating between malignant and benign parotid gland lesions.

Postoperative complications after extracapsular dissection of benign parotid lesions with particular reference to facial nerve function.

OBJECTIVES/HYPOTHESIS: The desirable extent of surgical intervention for benign parotid tumors remains a matter of controversy. Superficial or total parotidectomy as a standard procedure is often said to be the gold standard; however, with it the risk of intraoperative damage to the facial nerve cannot be ignored. For some time now, extracapsular dissection without exposure of the main trunk of the facial nerve has been favored as an alternative for the treatment of discrete parotid tumors. Data on the incidence of facial nerve lesions and other acute postoperative complications of extracapsular dissection have been lacking until now. STUDY DESIGN: Retrospective analysis. METHODS: We performed a retrospective analysis of the data from patients in whom extracapsular dissection of a benign parotid tumor had been performed under facial nerve monitoring and as a primary intervention in our department between 2000 and 2008. RESULTS: A total of 934 patients were operated on for a newly diagnosed benign tumor of the parotid gland. Three hundred seventy-seven patients (40%) underwent extracapsular dissection as a primary intervention. The most common postoperative complication was hypoesthesia of the cheek or the earlobe, as reported by 38 patients (10%). Eighteen patients (5%) developed a seroma and 13 patients (3%) a hematoma. A salivary fistula formed in eight patients (2%). Secondary bleeding occurred in three patients (0.8%). In 346 patients (92%) facial nerve function was normal (House-Brackmann grade I) in the immediate postoperative period, whereas 23 patients (6%) showed temporary facial nerve paresis (House-Brackmann grade II or III) and eight patients (2%) developed permanent facial nerve paresis (seven patients House-Brackmann grade II, one patient House-Brackmann grade III). CONCLUSIONS: Extracapsular dissection of benign parotid tumors is associated with a low rate of postoperative complications, a fact that is confirmed by the available literature. We therefore recommend that use of this technique always be considered as a means of treating benign parotid tumors as conservatively, that is, as uninvasively, as possible.

Diagnostic imaging in sialadenitis.

This article presents a survey of the imaging procedures in inflammatory changes of the salivary glands. State-of-the-art procedures are described along with a perspective on recent innovations. Various imaging procedures are discussed, including ultrasound, computed tomography, and magnetic resonance imaging. Then, imaging options in different forms of acute and chronic sialadenitis are considered. The choice of method is guided by consideration of the reliability, the side effects, the accessibility, and, ultimately, the costs. The focus is mainly on diagnostic ultrasound and resonance methods because, with their aid, the investigation of almost all the inflammatory diseases of the large salivary glands can be performed with accurate results, without exposing the patient to radiation.

RGS protein specificity towards Gq- and Gi/o-mediated ERK 1/2 and Akt activation, in vitro.

Extracellular Regulated Kinases (ERK) and Protein Kinase B (Akt) are intermediaries in relaying extracellular growth signals to intracellular targets. Each pathway can become activated upon stimulation of G protein-coupled receptors mediated by G(q) and G(i/o) proteins subjected to regulation by RGS proteins. The goal of the study was to delineate the specificity in which cardiac RGS proteins modulate G(q)and G(i/o)-induced ERK and Akt phosphorylation. To isolate G(q)- and G(i/o)-mediated effects, we exclusively expressed muscarinic M(2) or M(3) receptors in COS-7 cells. Western blot analyses demonstrated increase of phosphorylation of ERK 1.7-/3.3-fold and Akt 2.4-/6-fold in M(2)-/M(3)- expressing cells through carbachol stimulation. In co-expressions, M(3)/G(q)-induced activation of Akt was exclusively blunted through RGS3s/RGS3, whereas activation of ERK was inhibited additionally through RGS2/RGS5. M(2)/G(i/o) induced Akt activation was inhibited by all RGS proteins tested. RGS2 had no effect on M(2)/G(i/o)-induced ERK activation. The high degree of specificity in RGS proteins-depending modulation of G(q)- and G(i/o)-mediated ERK and Akt activation in the muscarinic network cannot merely be attributed exclusively to RGS protein selectivity towards G(q) or G(i/o) proteins. Counter-regulatory mechanisms and inter-signaling cross-talk may alter the sensitivity of GPCR-induced ERK and Akt activation to RGS protein regulation.