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Parotidectomy

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    Background: The parotid gland is a salivary gland located immediately in from the ear on each side of the face. This gland is the salivary gland most commonly affected by tumors. The treatment for the vast majority of salivary tumors is surgical excision. Depending on the size and location of the salivary tumor, one of the following procedures may be recommended:
    Superficial parotidectomy: The parotid gland is artificially divided into a superficial and deep lobe by the facial nerve that runs in a set plane in the middle of the gland. A superficial parotidectomy requires removal of the parotid gland superficial to the plane of the facial nerve. This is the most common type of parotid surgery. A less than complete superficial parotidectomy, but one that has still removed the entire tumor with negative margin, may also be referred to as a partial parotidectomy.
    Total parotidectomy: This requires removal of the entire parotid gland, including the superficial and deep lobe. If the facial nerve is not involved, this will require identifying all of the branches and carefully retracting them out of the way as meticulous dissection is performed.
    Radical parotidectomy: This procedure is a total parotidectomy, along with resection of the facial nerve. An extended radical parotidectomy will involve removal of additional structures as well, such as the temporal bone or the skin of face overlying the parotid gland.
    In some cases, additional procedures might be done at the same time as the parotidectomy. For example, a neck dissection might be indicated in certain types of parotid cancer, a facial nerve graft might be done if part or all of the facial nerve has to be sacrificed or a temporal bone resection might be required if the parotid cancer is growing into the side of the head where the ear is located. Dr. Reilly will talk with you about any associated procedures prior to surgery.

    Parotidectomy Pre-operative Considerations

    As with any surgery, there are both potential benefits and risks.  The following information will help you understand the risks of surgery.  As with any operation, there may be some unanticipated complications in addition to those listed here:

    The risks of parotidectomy include, but are not limited to:

    Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.

    Seroma: This is a collection of normal body fluid in the neck after removal of the drain. This can be treated with observation, as the body will eventually resorb it, or repeated needle aspirations. The risk of leaving seroma is that it could become infected.

    Infection: Parotidectomies are done under completely sterile conditions. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.

    Sialocele: This is a collection of saliva under the skin. This can occur because a cut end of the parotid gland might continue to make saliva. It will manifest as a fluid-filled swelling somewhere near the surgical site and get bigger with eating. Treatment can include doing nothing, applying a pressure dressing or repeated aspirations to draw off the saliva.

    Sensory disturbance: A decrease in sensation of skin of the neck, around the face and the lobule occur when the greater auricular nerve or some of its branches are cut. This is required in most parotidectomy procedures. Over time, the area of numbness will shrink, but the lobule of the ear will probably remain numb forever.

    Frey’s syndrome: Another term for this is “gustatory sweating.” This manifests by sweating on your face when you eat or even think about eating. This occurs because after removing the parotid gland, the nerve endings that normally stimulate saliva production and secretion (from the auriculotemporal nerve) end up against the skin (now that the parotid gland is gone). Because the same neurotransmitter that stimulates salivary release also stimulates sweating, whenever that nerve is activated, it causes sweating instead of salivary release. The severity of this problem can vary from not even noticeable to very severe and troublesome. Treatment options include applying antiperspirant to the facial skin, injecting botulinum toxin (Botox) in that region of the skin (which blocks the neurotransmitter that causes sweating), surgery to place a barrier just under skin or extensive middle ear surgery to cut the nerve that causes all of these problems near its origin. One way to prevent this complication is to place a barrier between the free nerve endings and the skin at the time of the parotidectomy itself. This barrier can be in the form of sewing the parotid fascia back together (thereby covering up those free nerve endings), moving muscle into the defect or using a dermal substitute immediately under the skin.
    Facial nerve injury: This is an important risk of parotidectomy. It will manifest as inability to move all or part of your facial muscles on one side. The nerve injury can be partial (if only some of the branches of the facial nerve are injured) or total (if the main trunk of the facial nerve or all branches of the facial nerve are injured). It can be temporary (if the nerve is just stretched) or permanent (if the nerve is cut). This can be prevented by meticulous surgical skill; but in some cases, especially if the nerve goes directly through the cancerous tumor, one or more branches might have to be sacrificed. Treatment is geared toward preventing complications related to facial nerve injury, including making sure the eye is well lubricated at all times if you can no longer blink as well as performing nerve grafts to attempt to maintain tone of the facial muscles and possibly get some sort of movement. Facial reanimation procedures to improve appearance might also be undertaken.

    Details of Parotidectomy Surgery:

    You will be put completely to sleep with general anesthesia. Dr. Reilly may choose to use a special monitor that makes a noise when the facial nerve (including certain branches) is stimulated. A parotidectomy is done via an incision just in front of the ear in a natural skin crease that extends down into a natural skin crease in the neck. This allows the scar to be hidden as much as possible rather than making an incision directly in the middle of your face.

    When the tumor is in the deep lobe of the parotid gland, a different or additional approach might be required. For example, a deep lobe tumor can be approached from an incision in the neck (without an incision in front of your ear). More rarely, the deep lobe could be approached through the mouth.
    At the end of the procedure, your surgeon might place a small drain temporarily coming out of the skin. This will drain any fluid and/or blood that accumulates in the space where the surgery was performed. When the time is right (one day to a few days), the drain will be removed by your surgical team. This takes only a few seconds, and you can think of it as removing a bandage. There will be a little discomfort, but it will be over quickly.

    Parotidectomy Post-operative Recovery

    Depending on whether any additional procedures were done, you will go home the same day or within a few days of the surgery. You should be able to drink and eat very soon after the surgery. There is little pain associated with this procedure, but you will probably be given a little pain medication anyway. You should be up and out of bed by the same or next day. You should be able to drink liquids and eat by the same or next day as well.

    Arrange for someone to stay with you for the first 24 hours.
    Go to bed and rest, lying on your back, with your head elevated with 2-3 pillows. You should be lying at a 45 degree angle.
    You may be up and around and able to go to the bathroom. You will be able to eat a light meal with assistance.
    Take medication only as directed.
    Some swelling and bruising are a normal occurrence.
    Place ice packs to the surgical site for the first 48 hours (on for 20 minutes, then off for 20 minutes).
    Keep the incisions moist with petroleum-based ointment. Cover any draining area with bandages. If they loosen, secure them with more tape. You will have a drain in place, which will be removed once the output is less than 25 milliliters in a 24-hour period.

    You may be up and around as tolerated but expect to tire more quickly than usual.
    Keep activity and meals light, avoiding meals that require significant chewing.
    On the 3rd day, you can remove all bandages and gently shampoo your hair in the shower with baby shampoo. It is advised to let your hair air-dry, but you may use a cool setting if you need to use a hair dryer.

    You will come into the office for a post-operative check-up.
    No alcohol for the first 7 days after surgery, which can increase bruising and swelling.

    Your swelling and bruising will gradually fade over this time period, but it may persist for up to 3 weeks.

    1. Rest and good nutrition are important healing factors, especially during the first 6 weeks.
    2. Numbness, tingling, hardness, tightness, and bumpiness of the surgical area are common occurrences. If any of these things do occur, they will gradually subside over several months.