Intravenous methylene blue is a well-described method to assist in intraoperative localisation of parathyroid glands. The technique does come with challenges as anybody will know who has had to run adjacent to a theatre-bound trolley to ensure that the infusion starts preoperatively. This randomised trial involving 144 patients investigated the benefits of methylene blue during parotid surgery. The technique involves trans-oral cannulation of Stensen’s duct, ‘several minutes’ before surgery. The surgery types were divided into four groups; partial superficial, standard superficial, selective deep lobe and total parotidectomies. There were 70 cases where methylene blue was used and 74 without. Importantly 4/70 patients had total parotidectomy using methylene blue whilst 9/74 underwent total parotidectomy without methylene blue. There was a significant difference reported in rates of tumour recurrence and permanent facial nerve palsy, with higher rates in the non-methylene blue group (1.4% vs 6.7%). However it is not clear in what type of procedure these complications arose (i.e. total vs superficial parotidectomy) and what pathology was identified in these cases. The authors acknowledge that the non-methylene blue group did have a disproportionate number of procedures that inherently placed the facial nerve at greater risk. The lower rate of tumour recurrence may point towards methylene blue making it easier to identify the capsule of the salivary gland in order to facilitate complete excision. The authors suggest that methylene blue staining of the parotid gland does not increase the risk of complications, it may help to identify the nerve and does not compromise the subsequent histological diagnosis. 

Methylene blue staining in the parotid surgery: Randomized trial, 144 patients.
Vaiman M, Jabarin B, Abuita R.
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Rohit Verma

North West Deanery, UK.

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