THE PAROTID GLAND Anatomy

The parotid gland lies in a recess bounded by the ramus of the mandible, the base of the
skull and the mastoid process. It lies on the carotid sheath and CNs XI and XII and extends
forward over the masseter muscle. The gland is enclosed in a sheath of dense deep cervical
fascia. Its upper pole extends just below the zygoma and its lower pole (tail) into the neck.
Several important structures run through the parotid gland. These include:

● the facial nerve trunk that divides into its major five branches;

● the terminal branch of the external carotid artery that divides into the maxillary artery and
the superficial temporal artery;

● the retromandibular vein;

● intraparotid lymph nodes.

Developmental disorders
Developmental disorders such as agenesis, duct atresia and congenital fistula are extremely
rare.

Inflammatory disorders
Viral infections

Mumps is the most common cause of acute painful parotid swelling and predominantly
affects children. It is spread via airborne droplets of infected saliva.

Bacterial infections

Acute ascending bacterial sialadenitis is historically described in dehydrated elderly patients

following major surgery. Reduced salivary flow secondary to dehydration results in
ascending infection via the parotid duct into the parotid parenchyma. The more common
picture today is an acute bacterial parotitis associated with a salivary calculus. The patient
presents with a tender, painful parotid swelling that arises over several hours .There is
generalised malaise, pyrexia and occasional cervical lymphadenopathy. The pain is
exacerbated by eating or drinking. The parotid swelling may be diffuse, but often localises to
the lower pole of the gland. Intraoral examination may reveal pus exuding from the parotid
gland papilla. The infecting organism is usually Staphylococcus aureus or Streptococcus
viridans, and treatment is with appropriate intravenous antibiotics.
Recurrent parotitis of childhood

Recurrent parotitis of childhood is a distinct clinical entity of unknown aetiology and variable
prognosis. It is characterised by rapid swelling of one or both parotid glands, in which the
symptoms are made worse by chewing and eating. Systemic upset with fever and malaise is
variable.

Human immunodeficiency virus-associated sialadenitis

Chronic parotitis in children may signify human immunodeficiency virus (HIV) infection. The
presentation of HIVassociated sialadenitis is very similar to classical Sjögren’s syndrome in
adulthood

Obstructive parotitis

There are several causes of obstructive parotitis, which produces intermittent painful
swelling of the parotid gland, particularly at mealtimes.

Stone formation and strictures

Papillary obstruction

Tumours of the parotid gland

The parotid gland is the most common site for salivary tumours. Most tumours arise in the
superficial lobe and present as slow-growing, painless swellings below the ear, in front of the
ear or in the upper aspect of the neck. Less commonly, tumours may arise from the
accessory lobe and present as persistent swellings within the cheek. Rarely, tumours may
arise from the deep lobe of the gland and present as a parapharyngeal mass. Symptoms
include difficulty in swallowing and snoring. Clinical examination reveals a diffuse firm
swelling in the soft palate and tonsil. Some 80–90% of tumours of the parotid gland are
benign, the most common being pleomorphic adenoma. Malignant salivary gland tumours
are divided into two distinct sub-groups:

1 Low-grade malignant tumours (e.g. acinic cell carcinoma) are indistinguishable on clinical
examination from benign neoplasms

2 High-grade malignant tumours usually present as rapidly growing, often painless swellings
in and around the parotid gland. The tumour presents as either a discrete mass with
infiltration into the overlying skin or a diffuse but hard swelling of the gland with no discrete
mass. Presentation with advanced disease is common, and cervical lymph node metastases
may be present.
Parotidectomy
The aim of superficial parotidectomy is to remove the tumour
With a cuff of normal surrounding tissue. The most important
structure traversing the parotid gland in the facial nerve.
Parotid tumour excision techniques are classified based on
the approach onto the facial nerve. Essentially the traditional
parotidectomy is in reality a dissection of the facial nerve. A
parotidectomy is conservative when the nerve is spared and
radical when the nerve is excised en bloc with the tumour.
A superficial parotidectomy is when the part of the gland
superficial to the facial nerve is removed. A deep lobe parotidectomy
is when the part of the gland beneath the nerve is
removed and total parotidectomy is when both are dissected
and removed. Superficial parotidectomy can be partial in relatively
small tumours that are removed with a cuff of clinically
normal parenchyma without removal of the entire superficial
portion of the gland.
An alternative surgical approach is to focus on the tumour
itself as the principal procedure and not facial nerve dissection.
Extracapsular dissection is now an established alternative
to parotidectomy. It does not require formal facial nerve
dissection and is a less invasive technique with reduced morbidity.
Temporary facial nerve injury rates are 7% compared
with 25% for superficial parotidectomy.

Superficial parotidectomy
Superficial parotidectomy is the most common procedure for
parotid gland pathology. Surgery is performed under endotracheal
general anaesthesia, which may or may not be accompanied
by hypotensive anaesthesia to facilitate dissection,
improve the visual surgical field and reduce blood loss. The
operation has several distinct phases.
COMPLICATIONS OF PAROTID
GLAND SURGERY
Complications of parotid gland surgery include:
●● haematoma formation;
●● infection;
●● deformity: unsightly scar and retromandibular hollowing;
●● temporary facial nerve weakness;
●● transection of the facial nerve and permanent facial weakness;
●● sialocele;
●● facial numbness;
●● permanent numbness of the ear lobe associated with great
auricular nerve transection;
●● Frey’s syndrome
.