Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 1  |  Page : 24-26

Parotidectomy with local anesthetics: a viable option in medical outreach in a resource poor setting


1 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
2 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital; Department of Surgery, Ebonyi State University, Abakaliki, Nigeria
3 Division of Paediatric Surgery, Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
4 Department of plastic surgery, National Orthopaedic Hospital, Enugu, Nigeria

Date of Submission18-Jan-2020
Date of Acceptance29-Jun-2020
Date of Web Publication17-Sep-2020

Correspondence Address:
MBBS, FWACS Charles Chidiebele Maduba
Department of Surgery, Alex Ekwueme University Teaching Hospital, Abakaliki P.M.B 102, Ebonyi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_1_20

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  Abstract 

Background: Parotidectomy has been traditionally done with general endotracheal anaesthesia mostly in tertiary institutions where there is adequate anaesthetic manpower. A lot of patients with parotid masses presents to other cheaper healthcare providers including medical outreaches where there is paucity of both anaesthetic manpower and gadgets. Aim: To share our experience in parotidectomy using local anaesthetics in medical outreaches where there is inadequate support of anaesthetic personnel and gadgets. Method: Patients counseled for parotidectomy had local anesthetic infiltration and nerve block with 1% ligdocaine in 1:100,000 adrenaline. Lazy-S incision was used starting pre-tragally down to the angle of the mandible. Branches of the facial nerve were gently separated from the mass which is delivered to the wound and shelled out. Wounds were closed in layers without drain. Conclusion: Parotidectomy with local anaesthetic agents is a safe option especially in settings of medical outreaches in resource poor countries with limited anaesthetic manpower and gadgets. The safety of surgery on day case basis and avoidance of use of hardly available nerve stimulator all the more make it an appealing alternative.

Keywords: Adrenaline, facial nerve, local anaesthetics, nerve block, parotidectomy


How to cite this article:
Maduba CC, Nnadozie UU, Modekwe VI, Onah II. Parotidectomy with local anesthetics: a viable option in medical outreach in a resource poor setting. Nigerian J Plast Surg 2020;16:24-6

How to cite this URL:
Maduba CC, Nnadozie UU, Modekwe VI, Onah II. Parotidectomy with local anesthetics: a viable option in medical outreach in a resource poor setting. Nigerian J Plast Surg [serial online] 2020 [cited 2020 Nov 1];16:24-6. Available from: https://www.njps.org/text.asp?2020/16/1/24/295251


  Introduction Top


Parotidectomy is usually done under general anaesthesia without myo-relaxants or with short acting myo-relaxants to enhance the effect of nerve stimulators.[1] The use of short acting myorelaxants facilitates endotracheal intubation.[2] General anesthesia with endotracheal intubation is preferred for parotid surgery because of proximity of the airway to the surgical field and secondly to ensure absolute immobility during the delicate part of the surgery.[2] It is usually done in hospitals with adequate support of anaesthetists and gadgets. The use of local anaesthetists have been attempted in patients who were not suitable for general anaesthesia in different published reports.[3],[4] Both superficial and total parotidectomy has been done successfully in those patients who were not suitable for general anaesthesia using local anaesthetics. In the setting of medical missions however where anaesthetic personnel and facility support is not sufficient, we found it necessary to resort to use of local anaesthetic agents with satisfactory outcome. This lack of anaesthetic support, nerve stimulators and sufficient post operative admission facilities, as well as the desire to offer day case surgery was our major indication for using local anaesthesia. Generally however the indication for surgery in all the patients was cosmetic as all the seven patients were asymptomatic. We therefore present this series to encourage surgical practitioners who are involved in medical outreaches to enhance their experience in use of local anaesthetic agents in parotidectomy.

Parotid masses are usually benign in 80% of cases.[5] These benign cases could be clinically diagnosed in most cases. They could benefit from use of local anaesthetic agents in their surgical removal. The goal is to remove the superficial parotid gland along with disease and avoid injury to the facial nerve branches. This is usually achieved with a nerve monitor intra-operatively. However, with local anaesthetic agents, there may be no need for nerve stimulator.[6]


  Patients and method Top


Patient selection

Patients who were clinically adjudged to have benign lesions were selected and worked up for the surgery. No cases of suspicious malignant lesions were seen in the period however. Facial nerve examination was done pre-operatively. Basic laboratory investigations for assessment of fitness, such as packed cell volume, urinalysis, fasting blood sugar and serum electrolytes, blood urea and creatinine, were done. Fine needle aspiration cytology was not done for the patients. Informed consent was obtained for all the patients. The medical outreach lasted about 2 weeks in each of the three phases.

Operative technique

Aseptic cleaning and draping were employed for all the patients. Routine prophylactic antibiotics were not given. Great auricular and auriculo-temporal nerves were blocked with about 2ml of 1% lignocaine in 1:100,000 adrenaline. Incision line infiltration and peritumor infiltrations were made limiting total lignocaine infiltration to about 10–20 ml. Parenteral analgesic (pentazocine) was used in only a patient midway in the procedure to control pain. About 10 minutes were allowed for the vaso-constrictive effect of adrenaline to be achieved. This duration of 10 minutes was employed instead of the usual 7 minutes for certainty. Lazy-S incision was made from the anterior border of the tragus down to the lobule and then to the angle of the mandible. The flaps were raised and dissection made gently down to the tumor. The superficial parotid gland was removed with gentle separation of the gland from the facial nerve. Hemostasis was ensured and the wound closed in two layers without drain. Skin closure was done with interrupted dermal buried suturing technique using size 2/0 polyglactin-90 sutures. Facial nerve was assessed in the post-operative period. Follow-up was individualized ranging from two weeks to not more than six months depending on accessibility to the patients. No obvious complications were noted during follow-up visits scheduled at patients’ instance.


  Results Top


Three medical outreaches were done in 2017, 2018 and 2019 respectively. A total of seven cases were operated on during the outreaches. A case was done in 2017, two cases in 2018 and four 2019. Six out of the seven were females with average age of 44.29 years and the median age of 48 years. The average surgery time was 76 minutes. Patients were discharged home same day except for the case of bilateral parotid cysts that stayed for observation for 24 hours. There were no facial nerve injuries and no wound sepsis.[Table 1]
Table 1 Patient characteristics

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  Discussion Top


Parotidectomy is ideally done under general anaesthesia except for a few patients who are unfit for general anaesthetic exposure.[1],[7] In such cases, local anaesthetic agents have been used. Partial parotidectomy in which only part of the superficial lobe was removed has been shown in published reports to be successfully done with local anaesthetic agents.[8]

Superficial parotidectomy is usually done for histo-pathologic diagnosis of a parotid mass. The parotid masses are mostly benign with an incidence of 2.4 per 100,000.[7] Parotidectomy under general anaesthesia poses a significant iatrogenic injury risk to facial nerve and its branches. About 30–65% suffers transient facial nerve palsy while about 3–6% develops permanent nerve dysfunction after superficial parotidectomy.[7] This could be reduced with use of nerve stimulators and meticulous tissue handling in skilled hands. With local anaesthetic agents, patient complains of pain and discomfort when dissection affects the facial nerve sheaths or its branches enhancing identification and prevention of iatrogenic nerve injuries. This is another advantage of using local anaesthetic agents. This adds to day case concept and avoidance of local anaesthtetic overdose as usually not more than 25ml of 0.5% bupivacaine or 1% lidocaine is needed as summarized in Sethna’s enumeration of advantages of local anaesthetic agents in parotidectomy.[3] Avoidance of complications of general anaesthesia cannot be overemphasized.[8],[9]

The case series done are different as other published cases were mainly in unfit patients or for partial parotidectomy.[8] No one has considered the medical outreach angle especially in the developing countries where so many poor people cannot afford medical care but depend on medical outreaches for treatment. The increasing tendency to offer operative treatment in such outreaches increases attention to use of local anaesthetic agents to ensure optimal advantages with reduced possibility of facial nerve injury. Local anesthetics in addition to demanding less personnel are relatively cheaper and easier to manage post-operatively making it a desirable option in medical missions. The dependence on the physician anesthetist is so crucial that a case incidentally done with local anesthetist in Kano Northwest Nigeria was as a result of absence of a physician anesthetist in a case previously booked for parotidectomy under general anesthesia.[10]Furthermore, general anesthesia is associated with a lot of risks such that a published report reviewing the benefits of watchful waiting in management of pleomorphic adenoma of thyroid gland recommends avoidance of surgery in the elderly due to progressive cognitive impairment following the use of general anesthesia.[11] This is very important when considering patients managed in medical outreach where follow up is quite limited to few months in this report and perhaps in many similar outreaches. Development of progressive cognitive impairment will go undetected by the surgical team that performed the procedure. It is therefore needful to draw attention of medical outreach organizations to this simple and safe modality in performing parotidectomy.


  Conclusion Top


Parotidectomy with local anaesthetic agents is a safe option especially in settings of medical outreaches with limited anaesthetic manpower and gadgets. The safety of surgery on day case bases and avoidance of use of nerve stimulator all the more makes it an appealing alternative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kamran S et al. Total parotidectomy under local anaesthesia: a novel technique. JCPSP 2007;17:116-7  Back to cited text no. 1
    
2.
Mauricio P, Biao L, Daniel A. Anesthesia for parotid surgery. In Abdelmalak B, Doyle DJ (eds). Anesthesia for otolaryngologic surgery. Cambridge University press 2013;203-209  Back to cited text no. 2
    
3.
Sethna KS, Sengupta MA, Prabhakar S. Local anesthesia for parotidectomy − a new technique. Ambulatory Surgery 1996;4:93-94  Back to cited text no. 3
    
4.
Chow TL, Choi CY, Lam SH. Parotidectomy under local anesthesia: Report of seven cases. Am J Otolaryngol 2013;34:79-81  Back to cited text no. 4
    
5.
Ariyan S, Narayan D, Ariyan CE. Salivary gland tumors. In: Neligan PC (ed.). plastic surgery. (3rd ed), New York, PN Elsevier Saunders 2013;3:361-79.  Back to cited text no. 5
    
6.
Akil F, Yollu U, Turgut F, Ayral M et al. Total parotidectomy under local anesthesia. Two points of lidocaine injection: incision line and subperichondrial tragal cartilage. Otolaryngol Online Journal 2017;7:145  Back to cited text no. 6
    
7.
Ibrahim M. superficial parotidectomy under local anaesthesia, case report. Egypt J Anaesthesia 2017 http://dx.doi.org/10.1016/j.egja.2017.01.002.  Back to cited text no. 7
    
8.
Cheung SH, Kwan WYW, Tsui KW, Chow TL. Partial parotidectomy under local anesthesia for benign parotid tumors: an experience of 50 cases. Am J Otolaryngol 2018, https://doi.org/10.1016/jamjoto.2018.03.008.  Back to cited text no. 8
    
9.
Steckler RM. Outpatient parotidectomy. Am J Surg 1991;162:303-5  Back to cited text no. 9
    
10.
Osude OD, Bassey GO, Fomete B. Superficial parotidectomy under local anesthesia: a case report. Ibom Medical Journal 2018;11:99-101.  Back to cited text no. 10
    
11.
Malik V, Kay NL, Ramsay TM. Pleomorphic adenoma of parotid gland in the elderly: do we always need to operate? Archives of Clinical Experimental Surgery 2012;1:41-44.  Back to cited text no. 11
    



 
 
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Introduction
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