ORIGINAL ARTICLE Quality of Life After Great Auricular Nerve Sacrifice During Parotidectomy

Nilesh Patel, MD; Gady Har-El, MD; Richard Rosenfeld, MD, MPH

Objective: To determine the impact of great auricular Even among patients experiencing symptoms, 23 (77%) nerve (GAN) sacrifice during parotidectomy on pa- reported only a little or no bother caused by the symp- tients’ quality of life. toms, and 27 (90%) reported no interference or almost none with their daily activities. The degree of bother or Design: Historical cohort survey of patients who had interference reported had a moderate positive correla- undergone GAN sacrifice during parotidectomy. tion with the number of abnormal sensations reported.

Setting: Tertiary academic otolaryngologic practice. Conclusions: The results suggest that, while many pa- tients experienced sensory deficits, the overall quality of Patients and Methods: Fifty-three patients who had life was not significantly affected after GAN sacrifice dur- undergone GAN sacrifice during parotidectomy com- ing parotidectomy. Patients who report multiple abnor- pleted an 8-item quality-of-life survey with a 7-point re- mal sensations, however, would benefit from additional sponse scale designed to measure outcome after GAN sac- counseling and from reassurance that the number of sen- rifice during parotidectomy. sations will diminish with time. Further study evaluat- ing the effect of preservation of the posterior branch of Results: Thirty patients (57%) reported experiencing at the GAN during parotidectomy on patients’ quality of life least 1 abnormal symptom, but the mean number of symp- is needed. toms decreased significantly with time, from a mean of 2.3 during the first year to 0.2 after 5 years (PϽ.001). Arch Otolaryngol Head Neck Surg. 2001;127:884-888

AROTIDECTOMY IS a rela- the mandible, while the posterior branch tively common surgical pro- innervates the skin over the mastoid, the cedure for treatment of pa- posteroinferior surface of the auricle, the rotid and is lobule, and the concha. occasionally performed for Although clinical experience and an- Pinflammatory and autoimmune condi- ecdotal reports clearly identify morbidity tions. Potential complications include associated with GAN sacrifice during pa- hemorrhage, infection, seroma forma- rotidectomy, no study has systematically tion, salivary fistula, keloid formation, fa- evaluated the short- and long-term con- cial nerve paralysis or paresis, auriculo- sequences on patients’ quality of life. In ad- temporal syndrome (gustatory sweating or dition, there has been some interest in the Frey syndrome), and great auricular nerve preservation of the posterior branch of the (GAN) anesthesia.1-3 While much atten- GAN, when feasible, to decrease surgical tion and discussion is focused on facial morbidity.4-6 The purpose of this cohort nerve injury and Frey syndrome, conse- study was to evaluate the quality of life af- quences of GAN sacrifice have not been ter GAN sacrifice during parotidectomy well studied. and thereby provide a basis of compari- The GAN is a sensory nerve arising son for future studies with preservation of from fibers of the second and third cervi- the posterior branch of the GAN. cal rami. As it ascends across the sterno- cleidomastoid muscle toward the parotid RESULTS From the Department of gland, it divides into anterior and poste- Otolaryngology, State rior branches. The anterior branch pro- The study sample consisted of 53 pa- University of New York Health vides sensory innervation to the skin over- tients who underwent GAN sacrifice dur- Science Center at Brooklyn. lying the and at the angle of ing parotidectomy between June 16, 1993,

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Thank you for taking the time to answer the following questions regarding PATIENTS AND METHODS your parotid surgery. Please answer as accurately as possible. 1) Please check any of the following sensations you may be experiencing around your ear or neck since your surgery. The cohort for the study consisted of 75 patients ❏ Stinging who had undergone GAN sacrifice during paroti- ❏ Abnormal sensation dectomy at the State University of New York Health ❏ Burning ❏ Science Center at Brooklyn and its affiliated hospi- Lack of feeling ❏ Pain tals. Subjects were identified through review of ❏ Lack of sensitivity medical records. Exclusion criteria included pa- ❏ Discomfort tients who had undergone a second surgical proce- ❏ Hypersensitivity dure at the time of parotidectomy, such as a neck If you did not check any of the above, you may stop here. dissection, and patients who could not be contacted Otherwise, please complete the remainder of the survey. for participation in the study, because of change of 2) How often have you experienced any of the above sensations within the address or death. Inclusion criteria included a mini- past month? mum of 3 months’ follow-up, age older than 18, and 1- Never English literacy. Data obtained from the remaining 2- Almost none of the time 53 patients’ medical charts included age, sex, time 3- A little bit of the time 4- Some of the time since surgery, surgical procedure, and final surgical 5- A good bit of the time pathologic findings. 6- Most of the time A quality-of-life survey consisting of 8 ques- 7- Always tions was designed to measure outcome after GAN 3) How long does it last? sacrifice during parotidectomy (Figure). Face va- 1- Up to 1 minute lidity was ensured through targeted discussion with 2- Up to 10 minutes other otolaryngologists and head and neck sur- 3- Up to 30 minutes geons and by discussion with patients. In designing 4- Up to 60 minutes 5- Up to 12 hours the survey, a 7-point ordinal response scale was 6- More than 1 day used for most questions to increase reliability. Sur- 7- All the time vey research suggests that the minimum number of 4) How much does it bother you? categories used by raters should be 5 to 7.7 In addi- 1- Not at all tion, the 7-point responses for the questions assess- 2- Almost none ing frequency, severity, and degree of interference 3- A little were adapted from previously validated health-re- 4- Somewhat lated quality-of-life surveys.8 The survey was ad- 5- A good amount 6- A lot ministered to and completed by the patients 3 to 69 7- A tremendous amount months after surgery. 5) How large is the affected area? Statistical analyses of the data were performed using commercially available software9 for medical 1- Smaller than the size of a penny 2- About the size of a penny statistics. Differences were considered significant at 3- About the size of a quarter PϽ.05 (2-tailed). Relationships between survey 4- About the size of a half-dollar question responses were assessed using correlation 5- Larger than the size of a half-dollar coefficients based on a priori hypothesis. Spearman 6) How much does it interfere with your daily activities? rank correlation was used, which is a distribution- 1- Not at all free method suitable for the modest sample size in 2- Almost none this study. 3- A little 4- Somewhat 5- A good amount 6- A lot 7- A tremendous amount 7) How does it interfere with your daily activities? (shaving, combing your and December 30, 1998. The mean±SD age was 54±16 hair, etc) years (range, 20-84 years). Twenty-eight (53%) of the pa- 8) How often are you worried or concerned about any of the above tients were men. Surveys were completed a median of 22 sensations? months after surgery (range, 3-69 months). At least 15 1- Never months of follow-up data were available for 40 (75%) pa- 2- Almost never tients studied. Forty-six patients underwent a superfi- 3- A little bit of the time 4- Some of the time cial parotidectomy; 1 patient, a subtotal parotidectomy; 5- A good bit of the time and 6 patients, a total parotidectomy. The most com- 6- Most of the time mon surgical pathologic finding was pleomorphic ad- 7- All of the time enoma, followed by Warthin tumor, benign lympho- epithelial lesion, chronic sialadenitis, and low-grade Qualify-of-life survey following parotidectomy. (Table 1). Thirty patients (57%) reported experiencing at lack of sensitivity in 13 (25%), or other abnormal sen- least 1 or more abnormal sensations in the ear or neck sation in 8 (15%). Only 1 abnormal sensation was noted region after surgery, including pain in 5 (9%), burning by 12 (23%), but 10 (19%) had 2, 5 (9%) had 3, and in 1 (2%), stinging in 2 (4%), discomfort in 5 (9%), hy- 3 (6%) complained of having at least 4. The number of persensitivity in 4 (8%), lack of feeling in 24 (45%), abnormal sensations reported had a moderate inverse

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 1. Distribution by Surgical Pathologic Finding* Table 4. Symptom Duration for 30 Patients Reporting Abnormal Sensations Surgical Pathologic Finding No. (%) Duration No. (%) 22 (42) Warthin tumor 9 (17) Up to 1 min 5 (17) Benign lymphoepithelial lesion 7 (13) Up to 10 min 4 (13) Chronic sialadenitis 4 (8) Up to 30 min 0 Low-grade mucoepidermoid carcinoma 3 (6) Up to 60 min 0 Parotid cyst 2 (4) Up to 12 h 0 Monomorphic adenoma 1 (2) Ͼ1 d 3 (10) Lymphoma 1 (2) Always 18 (60) Other 4 (8)

*Percentages do not sum to 100 because of rounding.

Table 5. Degree of Bother Caused by Abnormal Sensations Table 2. Relationship of Symptom Prevalence for 30 Patients to Time Since Surgery Degree of Bother No. (%) Time Since Surgery, mo No. of Patients Mean No. of Symptoms None at all 12 (40) 0-11 8 2.3 Almost none 5 (17) 12-23 19 1.7 A little 6 (20) 24-35 10 0.5 Somewhat 3 (10) 36-47 8 0.7 A good amount 3 (10) 48-59 3 0.3 A lot 0 60-71 5 0.2 A tremendous amount 1 (3)

Table 3. Frequency of Symptom Occurrence During the Past Table 6. Size of the Affected Area for 30 Patients Month for 30 Patients Reporting Abnormal Sensations Reporting Abnormal Sensations

Frequency No. (%) Size of Affected Area No. (%) Never 1 (3) Smaller than the size of a penny 1 (3) Almost never 3 (10) About the size of a penny 3 (10) A little bit of the time 2 (7) About the size of a quarter 11 (37) Some of the time 6 (20) About the size of a half-dollar 5 (17) A good bit of the time 3 (10) Larger than the size of a half-dollar 10 (33) Most of the time 4 (13) Always 11 (37)

correlation with time since surgery (r=−.50, PϽ.001), gree of bother had a moderate correlation with the suggesting gradual symptom resolution. As shown in number of sensations reported (r=.54, P=.002) and Table 2, 8 patients reported a mean of 2.3 symptoms showed a trend toward reduced levels as time passed af- during the first year after surgery, but 5 patients who ter surgery (r=−.32, P=.09). The degree of bother did were surveyed 5 or more years after surgery had a mean not correlate significantly with the frequency or dura- of only 0.2 symptoms. Conversely, the number of tion of abnormal sensation (Tables 3 and 4) and symptoms reported did not correlate with patient age showed no relationship to the reported size of the af- (r=−.05, P=.75). fected area (Table 6). Among the 30 patients reporting at least 1 abnor- Three patients (10%) thought that their abnormal mal sensation, the problem was present most or all of the sensations interfered significantly with performance of time in 15 (50%) (Table 3). Duration showed a bimo- their daily activities (Table 7). The degree of interfer- dal distribution (Table 4), with 9 patients (30%) hav- ence had a moderate correlation with the number of sen- ing symptoms lasting 10 minutes or less and 21 (70%) sations reported (r=.53, P=.003) but had no relation- having them last longer than 1 day. Eighteen patients ship to the passage of time. Eight patients (27%) reported (60%) reported continuous problems. having at least some worry or concern because of their The degree of bother caused by the abnormal sen- symptoms, and 2 (7%) reported being worried or con- sations was generally mild (Table 5). Seventeen pa- cerned most or all of the time (Table 8). The degree of tients (57%) reported the symptoms to be trivial (ie, no worry or concern had a small correlation with the num- bother or almost no bother), and only 1 patient (3%) ber of sensations reported (r=.38, P=.04) but had no re- considered the sensations a tremendous bother. The de- lationship to the passage of time.

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 7. Degree of Interference With Daily Activities Table 8. Frequency of Worry or Concern Caused by for 30 Patients Reporting Abnormal Sensations Abnormal Sensations for 30 Patients

Degree of Interference No. (%)* Frequency of Worry/Concern No. (%)* None at all 23 (77) Never 15 (50) Almost none 4 (13) Almost never 4 (13) A little 1 (3) A little bit of the time 3 (10) Somewhat 1 (3) Some of the time 6 (20) A good amount 0 A good bit of the time 0 A lot 0 Most of the time 1 (3) A tremendous amount 1 (3) Always 1 (3)

*Percentages do not sum to 100 because of rounding. *Percentages do not sum to 100 because of rounding.

COMMENT patients included difficulty in wearing earrings, comb- ing hair, using the telephone, and shaving. The GAN is often sacrificed or accidentally injured dur- Eight patients (27%) with abnormal symptoms re- ing various surgical procedures, such as parotidectomy, ported being worried or concerned about their symp- , rhytidectomy, and excision of lateral neck toms at least some of the time. The level of concern or masses. Although morbidity following GAN section is worry had a mild correlation with the number of symp- clearly recognized, few studies have evaluated its effect toms reported and had no correlation with the passage on patients’ quality of life. of time. Schultz et al10 evaluated donor site morbidity in 29 Given the relationship between multiple symp- patients who underwent GAN graft procurement for re- toms reported and increased degree of bother, activity pair of lingual or inferior alveolar nerves. They reported interference, and level of worry or concern, it may be pru- symptomatic nerve injury in 46% of patients, with spon- dent for the surgeon to spend additional time investigat- taneous resolution in 54% of those. They conclude that, ing complaints and working to reduce anxiety in pa- while morbidity following GAN procurement for recon- tients reporting multiple symptoms. These patients should struction following ablative tumor surgery may be per- be informed that the number of symptoms experienced ceived as minor, nerve removal for repair of lingual or will decrease over time. A more thorough preoperative inferior alveolar nerve injuries following elective orthog- discussion explaining potential symptoms would likely nathic or dentoalveolar surgery may assume greater be of benefit as well. significance. Preservation of the posterior branch of the GAN dur- Our study indicates that abnormal sensations fol- ing parotidectomy and other surgical procedures is not a lowing GAN sacrifice during parotidectomy are com- new concept and has been discussed in the literature by mon, occurring in 30 patients (57%). While 12 (23%) several authors.2,4-6,11 Brown and Ord4 showed significantly reported 1 abnormal sensation, 10 (19%) reported 2, less sensory loss to the skin of the ear and the angle of the and 8 (15%) reported 3 or more. The most commonly mandible in 6 patients in whom the posterior branch was reported problems included lack of feeling and lack of preserved, compared with 6 patients in whom it was sac- sensation. However, with the passage of time, there was rificed. They noted an additional operating time of 10 to a significant decrease in the number of reported symp- 15 minutes required to identify and preserve the poste- toms. Out of 8 possible abnormal symptoms, patients rior division initially, which may decrease as the surgeon reported a mean of 2.3 symptoms during the first year becomes more experienced with the procedure. after surgery, 0.5 symptoms between the second and Christensen and Jacobsen6 evaluated 95 patients who third postoperative years, and only 0.2 symptoms 5 or underwent superficial parotidectomy. In their study, the more years following surgery. This is likely the result of posterior division of the GAN was able to be dissected several factors, including partial regeneration of cuta- free and preserved in 67 patients (70.5%). They noted a neous sensory nerve fibers, collateral innervation from significantly higher percentage of patients with subjec- the lesser occipital nerve posteriorly and the transverse tive sequelae in the group in which the posterior branch cutaneous nerve anteriorly, and patients’ acclimation to was not preserved. However, they did not stratify pa- any deficits. tients based on time elapsed since surgery and did not Even among patients who perceived abnormal symp- specifically evaluate the effect of the subjective sequelae toms following surgery, only 4 (13%) were bothered a on patients’ quality of life. good or tremendous amount by the symptoms. Like- Although not reported by any of the patients in our wise, 27 (90%) of these patients reported almost no or study, anecdotal stories and a case reported by Brown and no interference with daily activities. These findings in- Wake5 note that skin burns may also result as a conse- dicate that the quality of life of most patients was not sig- quence of GAN anesthesia. nificantly affected after GAN sacrifice during parotidec- Our study identified that the effect of GAN sacri- tomy. The number of abnormal symptoms experienced fice was greatest in the first year and did not have a sig- by the patients correlated with the degree of bother and nificant long-term effect on patients’ quality of life. It activity interference. Problem areas identified by some provides a basis of comparison for future studies evalu-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 ating the short- and long-term effects of preservation of Science Center at Brooklyn, 340 Henry St, Brooklyn, NY the posterior branch of the GAN. 11201 (e-mail: [email protected]).

CONCLUSIONS REFERENCES

Although a large number of patients experienced some 1. Powell ME, Clairmont AA. Complications of parotidectomy. South Med J. 1983; abnormal sensation after GAN sacrifice during paroti- 76:1109-1111. dectomy, it decreased significantly with time. Even among 2. Leverstein H, van der Wal JE, Tiwari RM, et al. Surgical management of 246 pre- patients who experienced abnormal symptoms, most did viously untreated pleomorphic adenomas of the parotid gland. Br J Surg. 1997; 84:399-403. not report any significant degree of bother, concern, or 3. Owen ER, Banerjee AK, Kissin M, et al. Complications of parotid surgery: the need worry or interference with their daily activities. This in- for selectivity. Br J Surg. 1990;77:1034-1035. dicates that the overall quality of life does not appear to 4. Brown JS, Ord RA. Preserving the great auricular nerve in parotid surgery. Br J be significantly affected after GAN sacrifice during pa- Oral Maxillofac Surg. 1989;27:459-466. rotidectomy. While preservation of the posterior branch 5. Brown AM, Wake MJ. Accidental full thickness burn of the ear lobe following division of the great auricular nerve at parotidectomy. Br J Oral Maxillofac Surg. of the GAN appears logical in patients in whom surgical 1990;28:178-179. or oncologic results would not be compromised, fur- 6. Christensen NR, Jacobsen SD. Parotidectomy: preserving the posterior branch ther outcomes study of preservation of the posterior of the great auricular nerve. J Laryngol Otol. 1997;111:556-559. branch during parotidectomy would help elucidate its ef- 7. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 2nd ed. Oxford, England: Oxford University Press Inc; 1995: fect on patients’ quality of life. 35-36. 8. Juniper EF, Guyatt GH, Willan A, Griffith LE. Determining a minimal important change Accepted for publication March 17, 2001. in a -specific Quality of Life Questionnaire. J Clin Epidemiol. 1994;47:81-87. Presented at the annual meeting of the American Head 9. Gustafson TL. True Epistat Reference Manual. 5th ed. Richardson, Tex: Epistat and Neck Society, Fifth International Conference on Head and Services; 1994. 10. Schultz JD, Dodson TB, Meyer RA. Donor site morbidity of greater auricular nerve Neck Cancer, San Francisco, Calif, July 29-August 2, 2000. graft harvesting. J Oral Maxillofac Surg. 1992;50:803-805. Corresponding author: Nilesh Patel, MD, Depart- 11. Converse JM. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, Pa: WB Saun- ment of Otolaryngology, State University of New York Health ders Co; 1997:2534.

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