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Parotidectomy: H.Shameer Ahamed
Parotidectomy: H.Shameer Ahamed
H.SHAMEER AHAMED
INTRODUCTION
• A parotidectomy is the surgical excision (removal) of
the parotid gland, the major and largest of the salivary
glands.
• The procedure is most typically performed due to benign or
malignant tumors.
• The majority of parotid gland tumors are benign, however
20% of parotid tumors are found to be malignant.
Parotid gland is divided
by the facial nerve into
i. a superficial lobe
ii. a deep lobe
Relevant surgical relations
• Posterior: Cartilage of external auditory meatus;
tympanic bone, mastoid process, sternocleidomastoid
muscle
• Deep: Styloid process, stylomandibular tunnel,
parapharyngeal space, posterior belly of digastric,
sternocleidomastoid muscle
• Superior: Zygomatic arch, temporomandibular joint
TYPES
• Partial parotidectomy: Resection of parotid pathology
with a margin of normal parotid tissue. This is the
standard operation for benign pathology and low grade
malignancies
• Superficial parotidectomy: Resection of the entire
superficial lobe of parotid and is generally used for
metastases to parotid lymph nodes e.g. from skin
cancers, and for high grade malignant parotid tumors.
• Total parotidectomy: This involves resection of the entire
parotid gland, usually with preservation of the facial nerve
• Extended Total Parotidectomy: Removal of the superficial
and deep parotid gland also may be extended to involve
adjacent structures such as the overlying skin, the
underlying mandible, the temporal bone and external
auditory canal, or the deep musculature of the
parapharyngeal space.
CONSENT
• Scar
• Anaesthesia –greater auricular region
• Facial nerve weakness
• Facial contour
• Frey's syndrome
• Prominence of auricle
• Salivary fistula
PREPARATION
Intraoperative facial nerve monitoring.
• for patients with large and/or malignant
tumours,
• undergoing revision surgery,
• retrograde dissection of the facial nerve,
• less experienced surgeons.
The facial nerve monitor should be applied and
testing prior to prepping and draping the patient.
ANAESTHESIA
• General anaesthesia
• Short acting muscle relaxant for intubation
only if nerve monitoring planned
POSITION AND INFILTRATION
• Supine
• Hyper extend the head and turn to opposite side
• Infiltrate along planned skin incision
• Keep corner of eye and mouth exposed so as to be
able to see facial movement
Superficial Parotidectomy
• The most common indications are:
1. Benign or low grade tumor of the superficial lobe of the parotid
gland
2. metastases to parotid lymph nodes from adjacent sites of skin
cancer or melanoma, or from cancer of the external auditory
meatus.
3. Access to the deep lobe of the gland or other structures deep to
the facial nerve.
4. Chronic inflammation of parotid gland, resistant to conservative
treatment.
INCISION
Modified Blair incision
• An incision should be carefully
marked out extending from
• Intermediate
– hematoma
– Facial palsy
• Late
– Salivary fistula
– Gustatory sweating
– cosmesis
FACIAL NERVE INJURY
• Facial nerve injury is usually the biggest concern in parotid
surgery.
• Postoperative weakness may be temporary, if the injury is a
neuropraxia.
• more common - between 10 and 50 per cent
• The precise cause of neuropraxia is not known, but probably
results from a combination of trauma while dissecting right
on the nerve, traction injury to the nerve, heat injury
secondary to the use of cautery, and prolonged operating
time.
• The lower division branches, in particular, the marginal
mandibular branch
• Permanent, due to transection of,
or cautery injury to, the main trunk
of the facial nerve, or, more
commonly, one of the terminal
branches.
• More commonly in difficult cases,
i.e. large tumours, tumours located
in the deep lobe, malignant cases
and revision surgery.
• The incidence of permanent facial
nerve injury is generally reported
as 0-5 percent
HAEMATOMA
• up to 5 percent.
• Small haematomas should be evacuated
promptly, as their presence leads to
compromise of the skin flap with possible
necrosis.
SEROMA/SAIIVOMA/SALIVARY FISTULA
• After superficial parotidectomy, leakage of serous
fluid and saliva from the transected parotid tissue is
expected
• This usually lasts for a few days.
• Thus, a drainshould always be placed after parotid
surgery and left in place for at least 2-3 days.
• At this stage, the skin flap should have begun to
adhere to the parotid bed, so obliterating the dead
space in which fluid can accumulate.
• If, after removing the drain, patients develop swelling
underneath the wound, this should be aspirated.
• Seromas usually resolve within a few days of serial
aspiration.
• Drainage of saliva out of the drain site or through the
wound when the patient is eating is not uncommon.
• A pressure dressing, similar to the type used after
otoplasty, may also be useful to speed resolution.
FREY'S SYNDROME/ gustatory
sweating
• Is a phenomenon seen after parotid surgery
where the patient develops sweating on the side
of the face while eating.
• Due to transection of
cholinergic secretomotor
fibres to the secretory
units of the parotid gland,
which subsequently sprout
new axons and come to
innervate sweat glands in
the skin flap, which are
also responsive to
acetylcholine.
• Around 10 per cent of
patients who undergo
parotidectomy will
complain of gustatory
sweating.
• Objective demonstration is possible using Minor's starch-
iodine test.
• This is performed by covering the affected skin with iodine
solution. Once this has dried, it is dusted with starch powder,
and the patient given a lemon sweet. As a result of absorption
of the wet iodine by starch, the affected area will turn deep
blue purple.
• These include raising a thick skin flap, rotation of a superficial
temporal artery-based temporoparietal vascular flap, rotation of
the superficial musculoaponeurotic system (SMAS), and rotation
of sternomastoid muscle flaps.
• Topical anticholinergics may be useful, but have variable efficacy
and may lead to anticholinergic side effects.
• For persistent cases, the most effective treatment would appear
to be injection of botulinum tvpe A toxin. This inhibits
neurotransmitter release and gives long lasting relief, and may be
repeated if recurrent symptoms develop.
• Antiperspirants : Glycopyrrolate 1% lotion
• Tympanic neurectomy
OTHER
• Ear numbness is an expected outcome from parotid
surgery. It results from transection of the greater
auricular nerve. Patients are usually very aware of
sensory change immediately after the surgery. Over
the course of several months, the area of numbness
diminishes, but patients are usually left with an area of
persistent numbness around the ear lobe. Patients who
wear earrings will not be able to insert them without
looking in a mirror.
• Duskiness of the postauricular skin flap may occur if
the flap is too large or the blade of the knife was
bevelled while making the skin incision. This usually
settles spontaneously.
• Necrosis of the skin tip can occur; this will usually
heal by secondary intention.
• In patients with bulky parotids, a sizeable 'hollow'
may be left on the side of the head after surgery,
particularly after more extensive resections.
REFERENCES
• STELL AND MARAN
• SCOTT BROWN 7TH EDITION
• Salivary Gland Disorders: Eugene N. Myers,
Robert L. Ferris; Springer.
• Otolaryngology clinics of north america;
Management of neck in salivary gland cancers:
38(2005) 99-105
• Cumming’s text book of Otolaryngology & head
and neck surgery
• Internet