Lee et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:10 https://doi.org/10.1186/s40463-020-00484-9 ORIGINAL RESEARCH ARTICLE Open Access Outpatient versus inpatient superficial parotidectomy: clinical and pathological characteristics Daniel J. Lee1†, David Forner1,2†, Christopher End3, Christopher M. K. L. Yao1, Shireen Samargandy1, Eric Monteiro1,4, Ian J. Witterick1,4 and Jeremy L. Freeman1,4* Abstract Background: Superficial parotidectomy has a potential to be performed as an outpatient procedure. The objective of the study is to evaluate the safety and selection profile of outpatient superficial parotidectomy compared to inpatient parotidectomy. Methods: A retrospective review of individuals who underwent superficial parotidectomy between 2006 and 2016 at a tertiary care center was conducted. Primary outcomes included surgical complications, including transient/ permanent facial nerve palsy, wound infection, hematoma, seroma, and fistula formation, as well as medical complications in the postoperative period. Secondary outcome measures included unplanned emergency room visits and readmissions within 30 days of operation due to postoperative complications. Results: There were 238 patients included (124 in outpatient and 114 in inpatient group). There was no significant difference between the groups in terms of gender, co-morbidities, tumor pathology or tumor size. There was a trend towards longer distance to the hospital from home address (111 Km in inpatient vs. 27 in outpatient, mean difference 83 km [95% CI,- 1 to 162 km], p = 0.053). The overall complication rates were comparable between the groups (24.2% in outpatient group vs. 21.1% in inpatient, p = 0.56). There was no difference in the rate of return to the emergency department (3.5% vs 5.6%, p = 0.433) or readmission within 30 days (0.9% vs 0.8%, p = 0.952). Conclusion: Superficial parotidectomy can be performed safely as an outpatient procedure without elevated risk of complications. Keywords: Parotidectomy, Outpatient surgery, Ambulatory surgery Introduction surgical technology, allowing for safe perioperative pa- Outpatient surgeries have gained popularity in modern tient care on an outpatient basis [1–3]. In fact, many healthcare with potential for improving overall efficiency “low” to “moderate” risk surgical procedures such as in healthcare resource utilization [1–3]. This trend has arthroscopy, cholecystectomy and hernia repair are rou- been accompanied by advances in anesthetic and tinely performed in ambulatory surgical centres [1, 2, 4– 6]. In the realm of head and neck surgery, thyroidectomy * Correspondence: [email protected] has emerged as a viable candidate for outpatient surgery †Daniel J. Lee and David Forner are co-first authors. with an acceptable safety profile [7]. Common criteria 1 – Department of Otolaryngology Head & Neck Surgery, University of for determining candidacy for outpatient procedures in- Toronto, Toronto, ON, Canada 4Department of Otolaryngology – Head & Neck Surgery, Sinai Health System, clude lack of significant co-morbidities, close proximity 600 University Avenue, Suite 401, Toronto, ON M5G 1X5, Canada Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Lee et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:10 Page 2 of 6 to a hospital, and availability of adequate social support selected for outpatient parotidectomy are free from sig- [7, 8]. nificant comorbidities, have adequate home assistance, Parotidectomy is performed to treat primary and ma- are reliable in their own care, and live relatively close to lignant tumors and to manage non-neoplastic condi- hospital. Length of follow-up was defined as the time be- tions, such as chronic sialadenitis. In the modern era, it tween the date of surgery and the last visit Otolaryngol- can be classified as extracapsular dissection, superficial ogy clinic visit. Drains were placed at the discretion of or total parotidectomy based on the extent of resection. the attending surgeons and removed if the drain output Although historically considered to be an inpatient pro- was less than 30 cc in 24 h. Patients were discharged cedure, this decision may be largely borne out of prac- home with home care if they underwent ambulatory sur- tice norms rather than evidence-based medicine. In fact, gery or if the drain output was more than the pre- the feasibility of ambulatory parotidectomy has been defined output during the inpatient stay. demonstrated in a number of retrospective reports [9– 15]. However, some of these studies were limited by Outcome measurements and data collection small sample sizes [10, 12, 15] while others had hetero- The data were extracted from electronic and scanned geneous comparison groups with different extent and medical chart reviews reviews using a standardized data duration of the operation [11, 13, 14]. Therefore, the extraction form by CE and verified by DJL and DF. Dis- aim of this study was to evaluate the safety profile and crepancies were reviewed and resolved by the senior au- feasibility of outpatient superficial parotidectomy com- thor. Demographic characteristics were collected and pared to inpatient superficial parotidectomy at a tertiary included age, gender and geographic proximity to the academic centre. hospital. Geographic proximity was calculated using Google Maps (Google LLC) and the patient’s most re- Methods cent postal code on record. The driving distance and Study design and patient population travel time were recorded based on the minimum Research approval was granted by the Research Ethics amount of time estimated by Google Maps travelling Board at Sinai Health System. A retrospective review of from Mount Sinai Hospital to the patient’s address at adult patients who underwent superficial parotidectomy 10:00 am the same day as their operation to control for with preservation of the facial nerve at Mount Sinai anticipated traffic variations. Medical co-morbidities at Hospital in Toronto, Ontario between 2006 and 2016 the time of surgery were recorded from chart reviews in- was performed. Patients were identified from an institu- cluding consultation notes and anesthesia records. We tional pathology database. The extent of the surgery was utilized the Charlson Co-morbidity Index (CCI) to score determined from the operative note. Patients were ex- the noted medical co-morbidities [16, 17]. Inpatient re- cluded if they had total parotidectomy, resection of a cords, including operative notes, were reviewed for sur- deep lobe tumor, free flap reconstruction, history of ra- gical indication, drain management, and length of in- diation or previous resection at the surgical site, pre- hospital stay. Pathology reports were reviewed for max- operative diagnosis of malignant tumors, or incomplete imum dimension, volume (length x width x height as documentation. Malignancy was excluded due to the an- provided in the pathology report) and the pathological ticipated extent of resection required and the necessity diagnosis of the tumor. Measurements are representative of inpatient monitoring. We included those who under- of a combination of tumor and specimen sizes. went limited neck dissection for lymph node biopsy at The primary outcome was the number of postopera- the time of parotidectomy, and these procedures were tive complications, including hematoma, seroma, transi- evenly performed in the inpatient and outpatient groups ent/permanent facial nerve palsy, wound infection and (42.1% vs 42.7%, p = 0.921). fistula formation as well as any medical complications in the immediate postoperative period. Secondary outcome Definitions: “outpatient” vs. “inpatient” measures included the number of emergency room visits For the purpose of this investigation, two groups were and unplanned admissions within first 30 days of oper- created based on the length of stay. The outpatient ation due to postoperative complications. group consisted of patients who were discharged home the same day from the post-anesthesia care unit after Statistical analysis the surgery. The inpatient group included those who All statistical analysis and database maintenance was stayed at least one night following the surgery. At our performed using SPSS Statistics (IBM SPSS Statistics for institution, there is no predefined criteria for performing Windows, version 21 (IBM Corp., Armonk, N.Y., USA) outpatient vs inpatient parotidectomy, and therefore the