International Journal of Pediatric Otorhinolaryngology 78 (2014) 235–237

Long term quality of life in pediatric patients surviving parotid tumors

Qi-Gen Fang a, Shuang Shi b, Xu Zhang a, Mengjie Li c, Fa-Yu Liu a, Chang-Fu Sun a,*a Department of Oromaxillofacial-Head and Neck Surgery, Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University,

No.117, Nanjing North Street, Heping District, Shenyang, Liaoning 110002, PR Chinab Department of Pediatric Dentistry, School of Stomatology, China Medical University, Shenyang, Liaoning, PR Chinac Department of endodontic, School of Stomatology, Jilin University, Changchun, PR China

A R T I C L E I N F O

Article history:

Received 28 June 2013

Received in revised form 11 November 2013

Accepted 14 November 2013

Available online 22 November 2013

Keywords:

Quality of life

Pediatric

Parotid tumor

Parotidectomy

A B S T R A C T S

Objective: To evaluate the long term quality of life in pediatric patients who have survived parotid

tumors.

Methods: A quality of life instrument, based on the principles of the University of Washington Quality of

Life questionnaire, was specifically created for this study and sent to pediatric patients who had

undergone a parotidectomy between 2000 and 2008.

Results: The mean general health score was 3.45, which was deemed good to very good. The highest

overall score in the group was 99.24. These results indicated that almost no patients complained of pain.

Initially, 10 patients had reported that sensation was affected, but six of these cases recovered. Three

(9.1%) patients reported a change in their appearance. Two patients (6.1%) reported surgical site

depression and a further two (6.1%) reported scarring depression. Six (18.2%) patients reported facial

nerve impairment during the early postoperative period, and four of these cases recovered. Two patients

reported fistula during the early postoperative period, and but the symptoms were resolved after

intervention. Frey’s syndrome was reported by three (9.1%) patients.

Conclusion: Parotidectomy has a limited negative impact on pediatric patients’ quality of life.

� 2013 Elsevier Ireland Ltd. All rights reserved.

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International Journal of Pediatric Otorhinolaryngology

jo ur n al ho m ep ag e: ww w.els evier . c om / lo cat e/ i jp o r l

Introduction

Parotid tumors are rare in pediatric patients [1–5]. Previousreports have described the high reliability of surgical resection[1–5], with a focus on reporting postoperative complicationssuch as Frey’s syndrome, facial nerve paralysis and other similarproblems, but no study has evaluated the quality of life (QoL) ofpediatric patients who have undergone parotidectomies.

As health care systems become more patient-centered andpatients are given greater involvement in their own healthmanagement, the patient’s own assessment of their surgicalresults is becoming increasingly important [6]. Therefore, QoL isconsidered to be a key measure in the evaluation of a successfulmedical therapy. In this study, we investigated the long term QoLin pediatric patients who suffered from parotid tumors.

Methods

The China Medical University Review Board approved ourretrospective chart review and all participants signed an informedconsent agreement.

* Corresponding author. Tel.: +86 24 22894773; fax: +86 24 86602310.

E-mail addresses: changfusun@hotmail.com, qigenfang527@163.com,

qigenfang@hotmail.com (C.-F. Sun).

0165-5876/$ – see front matter � 2013 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijporl.2013.11.011

A QoL questionnaire was created according to the Hebrewversion of the University of Washington Quality of Life instrument[7]. The domain was scored based on the instructions [8]. Thequestionnaire was mailed to patients who had previouslyundergone a parotidectomy at the China Medical University OralMaxillofacial and Head Neck Tumor Center during 2000 to 2008.Patients met the following eligibility criteria: They were less than19 years of age at diagnosis; they suffered from no systemicdiseases; they had no communication impairment; the duration offollow up was longer than 5 years; they had not undergone anypostoperative radiotherapy and they had not undergone neckdissection.

Results

The questionnaire was sent to 43 patients and 33 (76.7%)responded: 18 males and 15 females. The mean age of the patientsat the time of surgery was 15.5 (range: 10–18) years. All patientshad lesions: 28 cases were benign, four cases were malignant, andthe pathology of one case was unknown (Table 1). Preoperativeultrasound or computed tomography examinations revealedthe size of these tumors varied from 1.0 cm � 1.0 cm to3.0 cm � 3.5 cm. All patients had received a superficial parotidresection and facial nerve dissection operation. The mean follow-up time was 8.5 (range: 5–13) years. In one case, pleomorphicadenoma recurred, so revision surgery was performed.

Table 1Distribution of parotid lesions.

Histopathological diagnoses Number (n = 33)

Pleomorphic adenoma 24

Myoepithelioma 1

Neurilemoma 2

Calcified epithelioma 1

Acinic cell carcinoma 2

Mucoepidermoid carcinoma 1

Cystadenocarcinoma 1

Unknown 1

Q.-G. Fang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 235–237236

The mean general health score was 3.45, which indicated goodto very good, and the highest overall score was 99.24, indicatingthat almost no patients complained of pain. Initially, 10 patientsreported that sensation was affected, but six of these cases now

Table 2Results of quality of life.

Domain Range

Your general health is 1—Poor

2—Not bad

3—Good

4—Very good

5—Excellent

Compared to 1 year prior to diagnosis, your health is now 1—Much wors

2—Worse

3—The same

4—Better

5—Much bette

Pain 100—No pain

75—Some pain

50—Some pain

25—Much pain

0—Severe, unc

Appearance 100—No chang

75—Some chan

50—Bothering

25—Servere ch

0—Can not be

The Scar 100—Is hardly

75—Noticeable

50—Noticable

25—Noticeable

0—Unbearable

Facial contour change or asymmetry 100—Is hardly

75—Noticeable

50—Noticable

25—Noticeable

0—Unbearable

Sensation in the operated site 100—Not affec

75—Was affec

50—Sensation

25—Sensation

0—Sensation d

Local effects 100—No local

75—Erythema

50—Erythema

25—Erythema

0—Erythema a

Salivary secretion through the wound scar (fistula) 100—No secre

66—Nonbothe

33—Bothersom

0—Secretion p

Facial nerve 100—No dama

66—Facial mov

33—Partial fac

0—Compete fa

Is your mouth dry? Yes/No

Do you associate dryness of mouth with the surgery Yes/No

report normal sensation. Three (9.1%) patients reported a change intheir appearance. Two patients (6.1%) reported surgical sitedepression and a further two (6.1%) reported scarring depression.Six (18.2%) patients reported facial nerve impairment during theearly postoperative period, and four of these cases recovered. Twopatients reported fistula during the early postoperative period, andbut the symptoms were resolved after intervention. Frey’ssyndrome was reported by three (9.1%) patients (Table 2).

Discussion

The University of Washington Quality of Life questionnaire hasseveral advantages: It is multi-factorial, allowing for sufficientdetail to identify subtle changes; it is brief and self-administered; itreflects the QoL as indicated by the patient as there is no input fromthe health provider; it provides questions specific to parotid

Results

Mean (SD) Range

3.45 3–5

e 3.48 3–5

r

99.24 75–100

, treatment not needed

treatment needed

, narcotically treated

ontrollable pain

e 97.73 75–100

ge

change

ange

with people

noticeable 98.48 75–100

but not bothersome

and bothersome

and very bothersome

noticeable 98.48 75–100

but not bothersome

and bothersome

and very bothersome

ted 89.39 50–100

ted but is now normal

deficit exists but is not bothersome

deficit exists and is bothersome

eficit exists and is unbearable

effects 96.97 50–100

or sweating during eating

and sweating but not bothersome

and sweating and are bothersome

nd sweating are intolerable

tion through the wound at any time 97.94 66-100

rsome secretion that resolved

e secretion that resolved

ersists

ge to the facial movement 91.82 33–100

ement impaired but resolved completely

ial movement impairment

cial movement impairment

Yes: 4

No: 29

Yes: 3

No: 1

Q.-G. Fang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 235–237 237

surgery. The scale is proven to be both valid and reliable [7,9]. Thisstudy was the first to evaluate the QoL of pediatric patients whohad survived parotid tumors.

The mean general health score was 3.45, indicating that parotidsurgery had no significant impact on the overall health of thepatients. As this was the first study to investigate this specificpostoperative patient group for QoL, no other studies wereavailable for comparison, so it was not possible check our resultsagainst any other reports. However, we believe that our favorableresult could be due to the fact that all the patients were very young,energetic and active.

With regard to pain, the mean score for the group was 99.24 andonly one patient reported a positive result. Similarly, a study byWormald et al. [10] which used a visual analogue scale, reportedthe mean pain score to be 2.4. They concluded that pain seemed tohave a limited impact on the patient postoperatively and that thiswas not unexpected, as most incisions heal without causingsignificant discomfort. Unlike our study, the Wormald study onlyincluded patients older than 18 years. Another study published byKoch et al. [11] reported a mean pain score of three, with only 3% ofthe patients reporting that they were seriously disturbed by theirpain. Considering the results from both of these studies in additionto our own study, we believe that pain is uncommon in pediatricpatients who survive parotid diseases.

Previous reports have investigated patients’ cosmetic concernsfollowing parotid operations [7,12,13]. A study by Nitzan et al. [7]stated that 70% of patients reported a change in their appearanceafter superficial or total parotid resection. Another study byMarshall et al. [12] reported that 26.9% of patients recognized analtered appearance shortly after the operation, but only 3.1%complained of long term morbidity. In our study, we weresurprised to find that the mean appearance score was 97.73 andonly three (9.1%) patients reported a change in their appearance.This was not due to any change in methodology: A standardmodified Blair incision was designed for every patient and we didnot apply further techniques to improve the aesthetic outcome.This finding was similar to that reported by Ciuman et al. [13].

Post surgical site depression and scarring can affect facialcontours [9]. A study by Wormald et al. [10] reported a mean scarscore of 4.3 after a modified Blair incision: The authors stated thatthis was to be expected for an operation resulting in scar that wasin a visually prominent position that was difficult to conceal. Incontrast, the mean scar score in our study was 98.48 and only twopatients complained that the scar was noticeable. This difference inscar scores may be due to different patient demographics and/ordifferent measurement methods. In addition to the favorable scarscore, the mean facial contour score in our study was anencouraging 98.48, with only two patients reporting facial contourchange. The favorable results obtained in our study could beexplained by the fact that all of our patients received only asuperficial parotid resection, which did not affect the tissueassociated with facial contour.

The great auricular nerve was sacrificed in 10 patients andsubsequently affected sensation, but six of these patients reportedthat they had fully recovered and the remaining four patientsreported that a sensation deficit existed but was not bothersome.These results are in contrast to that reported by Erkan et al. [9],where 43 (78.2%) patients complained of a sensory deficit and thescore was only 59.54. The reason for the differences between theaforementioned study and our own may be that: Young patients

tended to be more adaptable; the Erkan study did not preserve thegreat auricular nerve in all patients; we focused on the long-termresults; with the passage of time, there is a significant decrease inabnormal symptoms [14].

Frey’s syndrome is a well-known complication associated withparotid surgery. Liu et al. [3] reported that five (20.8%) pediatricpatients complained of Frey’s syndrome in the long term. In ourstudy, only three (9.1%) patients reported local erythema and/orsweating during eating, and none of these patients defined thesesymptoms as bothersome. This may be because the type of parotidresection that is used can vary across studies and Frey’s syndromehas shown a significant positive correlation with extent surgery[11].

Permanent facial nerve weakness was the most seriousmorbidity following parotidectomy, but the relative risk waslow [10]. Liu et al. [3] reported that 14.3% of patients developedimmediate facial paralysis and all of these patients recovered.Similarly, in our study, six patients had immediate facial weaknessafter the operation, and four (66.7%) patients recovered.

In summary, this is the first study to assess the long term QoLoutcomes for pediatric patients who survive parotid tumors.Our results indicate that a parotidectomy has a limited effect onthe QoL, and that the main complication is sensation deficit at theoperation site.

Acknowledgements

None declared.

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