5 parotidectomy

© 2004 WebMD, Inc. All rights reserved.2 HEAD AND NECK

ACS Surgery: Principles and Practice5 PAROTIDECTOMY — 1

Leonard R. Henry, M.D., and John A. Ridge, M.D., Ph.D., F.A.C.S.

5 PAROTIDECTOMY

Anatomic Considerations

The parotid (“near the ear”) gland, the largest of the salivaryglands, occupies the space immediately anterior to the ear, over-lying the angle of the mandible. It drains into the oral cavity viaStensen’s duct, which enters the oral vestibule opposite the uppermolars. The gland is invested by a strong fascia and is boundedsuperiorly by the zygomatic arch, anteriorly by the masseter, pos-teriorly by the external auditory canal and the mastoid process,and inferiorly by the sternocleidomastoid muscle. The massetermuscle, the styloid muscles, the posterior belly of the digastricmuscle, and a portion of the sternocleidomastoid muscle lie deepto the parotid. Terminal branches of the external carotid artery,the facial vein, and the facial nerve are found within the gland.Parasympathetic innervation to the parotid is via the otic gan-glion, which gives fibers to the auriculotemporal branch of thetrigeminal nerve. Sympathetic innervation to the gland originatesin the sympathetic ganglia and reaches the auriculotemporal nerveby way of the plexus around the middle meningeal artery.1

The facial nerve trunk exits the stylomastoid foramen andcourses toward the parotid. Once inside the gland, it commonlybifurcates into superior (temporal-frontal) and inferior (cervico-marginal) divisions before giving rise to its terminal branches.Thenerve branching within the parotid can be quite complex, but thecommon patterns are well known and their relative frequencieswell established.2,3 The portion of the parotid gland lateral to thefacial nerve (about 80% of the gland) is designated as the super-ficial lobe; the portion medial to the facial nerve (the remaining20%) is designated as the deep lobe. Deep-lobe tumors often pre-sent clinically as retromandibular or parapharyngeal masses, withdisplacement of the tonsil or soft palate appreciated in the throat.

Operative Planning

Obtaining informed consent for parotidectomy entails dis-cussing both the features and the potential complications of theprocedure. It is appropriate to address the possibility of facialnerve injury, but in doing so, the surgeon should not neglectother, far more common sequelae, such as cosmetic deformity,earlobe numbness, and Frey syndrome. Even conditions that areexpected beforehand may prove distressing or debilitating for thepatient.The risk of complications such as nerve injury is greaterin cases involving reoperation or resection of malignant or deep-lobe tumors.The overwhelming majority of parotid tumors, how-ever, are benign and lateral to the facial nerve. Accordingly, inwhat follows, we focus primarily on superficial parotidectomy,referring to variants of the procedure where relevant.

Excellent lighting, correctly applied traction and countertrac-tion, adequate exposure, and clear definition of the surgical anato-my are essential in parotid surgery.The use of magnifying loupesand headlights is recommended. General anesthesia without mus-cle relaxation should be employed.

The patient is placed in the supine position, with the head ele-vated and turned away from the side undergoing operation andwith the neck slightly extended. The table is positioned to allowthe first assistant to stand directly above the patient’s head, while

the surgeon faces the operative field. A small cottonoid sponge isplaced in the external auditory canal, where it remains for theduration of the procedure to prevent otitis externa from bloodclots in the external auditory canal. The skin is painted with anantiseptic agent. A single perioperative dose of an antibiotic isadministered.

The patient is draped in a fashion that permits the operatingteam to see all of the muscle groups innervated by the facialnerve. To this end, we employ a head drape that incorporatesthe endotracheal tube and hose. This drape secures the airway,keeps the tube from interfering with the surgeon, and permitsrotation of the head without tension on the endotracheal tube.The skin of the upper chest and neck is widely painted anddraped with a split sheet to allow additional exposure in theunlikely event that a neck dissection or a tracheostomy becomesnecessary. The nose, the lips, and the eyes are covered with asterile transparent drape that allows observation of movementduring the procedure and permits access to the oral cavity (ifdesired) [see Figure 1].

Operative Technique

STEP 1: INCISION AND SKIN FLAPS

The incision is planned so as to permit excellent exposure withgood cosmetic results. It begins immediately anterior to the ear,continues downward past the tragus, curves back under the ear(staying close to the earlobe), and finally turns downward todescend along the sternocleidomastoid muscle [see Figure 1].Either all or part of this incision may be used, depending on cir-cumstances.The incision is marked before draping. Skin creasestypically help conceal the resulting scar.

Skin flaps are then created to expose the parotid gland. A tack-ing suture is placed within the dermis of the earlobe so that it canbe retracted posteriorly. Skin hooks are used to apply vertical trac-tion.The anterior flap is created superficial to the parotid fascia toafford access to the appropriate dissection plane.Vertically orient-ed blunt dissection minimizes the risk of injury to the distalbranches of the facial nerve [see Figure 2].The face is observed formuscle motion.The flap is raised until the anterior border of thegland is identified. The facial nerve branches are rarely encoun-tered during flap elevation until they emerge from the parenchy-ma of the parotid. If muscle movement occurs, the flap has beenmore than adequately developed. The anterior flap is retractedwith a suture through the dermis.

The posterior-inferior skin flap is then elevated in a similarmanner. Careful dissection is performed to define the relation-ship of the parotid tail to the anterior border of the sternocleido-mastoid. During this portion of the procedure, the great auricu-lar nerve is identified coursing cephalad and superficial to thesternocleidomastoid muscle. Uninvolved branches of this nerveshould be preserved if possible to prevent postoperative numb-ness of the earlobe.4,5 The parotid tail is dissected away from thesternocleidomastoid muscle. Vertical traction is applied to thegland surface with clamps to facilitate exposure.



Troubleshooting

A favorable skin crease, if available, may be used for the inci-sion to improve the postoperative cosmetic result; however, it isimportant to keep the incision a few millimeters from the earlobeitself. A wound at the junction of the earlobe with the facial skinwill distort the earlobe and create a visible contour change. Anincision behind the tragus may lead to similar problems.

STEP 2: IDENTIFICATION OF FACIAL NERVE

Once the flaps have been developed and retracted, the nextstep is to identify the facial nerve. Usually, the nerve may be iden-tified either at its main trunk (the antegrade approach) or at oneof the distal branches, with subsequent dissection back towardthe main trunk (the retrograde approach). For a lateral parotidec-tomy, our preference is to identify the main trunk first (unless itis thoroughly obscured by tumor or scar).

Antegrade Approach

The dissection plane is immediately anterior to the cartilage ofthe external auditory canal. The gland is mobilized anteriorly bymeans of blunt dissection.To reduce the risk of a traction injury,tissue is spread in a direction that is perpendicular to the incisionand thus parallel to the direction of the main trunk of the nerve[see Figure 3].The nerve trunk can usually be located underlying apoint about halfway between the tip of the mastoid process andthe ear canal. In addition, there are several anatomic landmarksthat facilitate identification of the nerve, including the tragal point-er, the posterior belly of the digastric muscle, and the tympa-nomastoid suture. Of these, the tympanomastoid suture is closestto the main trunk of the facial nerve.6 The clinical utility of thislandmark is limited, however, because the tympanomastoid sutureis not easily appreciated in every case. In addition, deep-lobe

tumors may displace the nerve from its normal location. Forappropriate and safe exposure of the nerve trunk, it is necessary tomobilize several centimeters of the parotid, thereby creating atrough rather than a deep hole. Small arteries run superficial andparallel to the facial nerve; these must be divided. Use of the elec-trocautery this close to the nerve is potentially hazardous. Bleedingis typically minor but nonetheless must be controlled.

Retrograde Approach

As noted, when the main trunk cannot be exposed, the mostcommon alternative method of identifying the facial nerve is tofind a peripheral branch and then dissect proximally toward themain trunk.Which branch is sought may depend on factors suchas the surgeon’s level of comfort with the relevant anatomy andknown consistency or inconsistency of the nerve branch’s loca-tion. Often, in this setting, tumor bulk is the deciding factor.

The anatomic relationships between the nerve branches andvarious landmarks can be exploited for more efficient identifica-tion. For example, the marginal mandibular branch of the facialnerve characteristically lies below the horizontal ramus of themandible.7 Often, the facial vein can be traced toward the parotidor the submandibular gland; the nerve branch can then be foundcoursing perpendicular and superficial to the vein. The buccalbranch of the facial nerve has a typical location in the so-calledbuccal pocket—the area inferior to the zygoma and deep to thesuperficial musculoaponeurotic layer, which contains the buccalfat pad and Stensen’s duct in addition to the buccal branch.7Thezygomatic branch of the facial nerve lies roughly 3 cm anterior to the tragus, and the temporal-frontal branch lies at the mid-point between the outer canthus of the eye and the junction of the ear’s helix with the preauricular skin.7 Nerve branches tothe eye should be dissected with particular care: even transient

a

b

Figure 1 Parotidectomy. (a) Shown are the recommended headposition and incision. A transparent drape is placed over the eyes,the lip, and the oral cavity. (b) The head drape incorporates the hosefrom the endotracheal tube.



weakness of these branches may have a significant impact onmorbidity.

Troubleshooting

Special efforts should be made to ensure that the cartilage of theear canal is not injured during exposure of the facial nerve trunk.Any injury to this cartilage must be repaired, or else an intensewhistling will be heard from the closed suction drain after operation.

The anxiety associated with isolation of the nerve trunk may bealleviated somewhat by keeping in mind that the nerve typicallylies deeper than one might expect. In a study of 46 cadaver dis-sections, the facial nerve was found to lie at a median depth of22.4 mm from the skin at the stylomastoid foramen (range, 16 to27 mm). The diameter of the nerve trunk was found to rangefrom 1.1 to 3.4 mm.8 In our experience, the facial nerve trunk isslightly larger than the nearby deep vessels.

Some surgeons advocate the use of a nerve stimulator to aidin identifying the facial nerve trunk or its branches; however, wehave substantial reservations about whether this measureshould be employed on a regular basis [see Complications,Facial Nerve Injury, below]. Knowledge of the anatomy andsound surgical technique are the keys to a safe parotidectomy;it may be hazardous to rely too much on practices that maydiminish them.

STEP 3: PARENCHYMAL DISSECTION

Once identified, the plane of the facial nerve remains uniformthroughout the gland (unless the nerve is displaced by a tumor)and serves to guide the parenchymal dissection. We divide thesubstance of the parotid gland sharply, using ligatures as appro-

a

b

Figure 2 Parotidectomy. (a) Shown is the creation ofthe anterior skin flap superficial to the parotid gland.(b) Vertically oriented blunt dissection minimizes the riskof injury to facial nerve branches as they exit the gland.

Figure 3 Parotidectomy. Depicted is identification of the facialnerve at its trunk. A wide trough is created anterior to the externalauditory canal and deepened by spreading a blunt curved instru-ment in a direction perpendicular to the incision and parallel to thenerve trunk. Anatomic landmarks assist in identification of thenerve.

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice5 PAROTIDECTOMY — 42 HEAD AND NECK

priate when bleeding is encountered. Usually, there is no signif-icant hemorrhage: loss of more than 30 ml of blood is rare.

The parenchymal dissection proceeds directly over the facialnerve. We favor using fine curved clamps for this portion of theprocedure.To prevent trauma to the nerve, care must be taken toresist the tendency to rest the blades of the clamp on the nerveduring dissection. Each division of the gland should reveal moreof the facial nerve [see Figure 4].When this is the case, the surgeoncan continue the parenchymal dissection with confidence that thenerve will not be injured.As a rule, if a parenchymal division doesnot immediately show more of the facial nerve, it is in an improp-er plane.

We do not regularly resect the entire lateral lobe of the parotidunless the tumor is large and such resection is required on onco-logic grounds.The goal in resecting the substance of the parotidgland is to obtain sound margins while preserving the remainderof the gland. This so-called partial superficial parotidectomy hasbeen shown to reduce the incidence of Frey syndrome withoutincreasing the rate of recurrence of pleomorphic adenoma.9 Theplane of dissection is developed along facial nerve branches untilthe lateral margins have been secured. This is the portion of theprocedure during which the risk of nerve injury is highest. Oncethe lateral margins have been secured, the parenchymal dissectioncan proceed from deep to superficial for the excision of thetumor. The vertical portion of the dissection seldom poses athreat to the integrity of the facial nerve, but care must be takento maintain appropriate margins. If division of Stensen’s duct isrequired, the distal remnant may be either left open10 or ligated.

Caution is appropriate in the resection of deep-lobe tumors.Tumors medial to the facial nerve may displace this structure lat-erally. Thus, after establishing the plane of the facial nerve, thesurgeon must remain careful when dissecting near the tumor tokeep from injuring the nerve. Once the substance of the glandobscuring the tumor has been removed, the nerve branches in the

area of the tumor are retracted to allow exposure of the deep por-tion of the gland and facilitate resection. Traction injury to thenerve may still result in transient facial weakness.

Troubleshooting

Complete superficial parotidectomy with full dissection of allfacial nerve branches is seldom necessary, though in some cases,it is mandated by tumor size or histologic findings. Removal ofthe entire superficial lobe with the intention of gaining a largerlateral margin is rarely useful, because the closest margin is usu-ally where the tumor is nearest the facial nerve. Even temporaryparesis of the temporal-frontal branch of the facial nerve mayhave devastating consequences, and dissection near this branch isusually unnecessary in treating a benign tumor in the parotid tail.Any close margins remaining after nerve-preserving cancer treat-ment can be addressed by means of postoperative radiation ther-apy, usually with excellent results.11

The question of whether to sacrifice the facial nerve almostinvariably arises in the setting of malignancy. In our view, thismeasure is seldom necessary. Benign tumors tend to displace thenerve, not invade it. Sacrifice of the nerve probably does notenhance survival.12,13 Although the issue remains the subject ofdebate, it is our practice, like that of others,14 to sacrifice onlythose branches intimately involved with tumor. Repair, if feasi-ble, should be performed [see Complications, Facial NerveInjury, below].

STEP 4: DRAINAGE AND CLOSURE

Before closure, absolute hemostasis is confirmed; the Valsalvamaneuver is approximated by transiently increasing airway pres-sure to 30 cm H2O.We may then assess the integrity of the facialnerve with a nerve stimulator. A 5 mm closed suction drain isplaced through a stab incision posterior to the inferior aspect ofthe ear in a hair-bearing area.The tip of the drain is loosely tackedto the sternocleidomastoid muscle, with care taken to avoid directcontact with the facial nerve.The wound is closed with the drainplaced on continuous suction.The skin is closed with interrupted5-0 nylon sutures. Bacitracin is applied to the wound. No addi-tional dressing is necessary or desirable [see Figure 5].

Troubleshooting

The use of interrupted skin sutures instead of a continuoussuture allows the surgeon to perform directed suture removal todrain the rare postoperative hematoma or fluid collection insteadof reopening the entire wound.

Postoperative Care

The patient is evaluated for facial nerve function in the recov-ery room, with particular attention paid to whether the patient isable to close the eyelid.The patient resumes eating when nausea(if any) abates. Pain is generally well controlled by means of oralagents. At discharge, the patient should be warned to protect thenumb earlobe against cold injury.The closed suction drain is keptin place for 5 to 7 days (until the first postoperative visit) to min-imize the risk of salivary fistula.

Complications

FACIAL NERVE INJURY

Studies have found that transient paralysis of all or part of thefacial nerve occurs in 17% to 100% of patients undergoing parot-

Figure 4 Parotidectomy. Dissection of the gland parenchyma iscarried out over the branches of the facial nerve to minimize therisk of nerve injury. Each division of the substance of the glandshould reveal more of the facial nerve.



idectomy,15-18 depending on the extent of the resection and thelocation of the tumor. Fortunately, permanent paralysis is uncom-mon, occurring in fewer than 5% of cases.17,19

Nerve monitoring has been advocated to reduce the incidenceof facial nerve injury. To date, however, no randomized trial hasdemonstrated that intraoperative facial nerve monitoring ornerve stimulators yield any significant reduction in the incidenceof facial nerve paralysis. Indeed, indiscriminate use of nervemonitoring and nerve stimulators may imbue the surgeon with afalse sense of security and cause him or her to pay insufficientattention to the appearance of nerve tissue.Transient nerve dys-function may follow inappropriate (or even appropriate andunavoidable) trauma to or traction and pressure on nerve trunks.Nerve monitoring does not prevent such problems; moreover, itadds to the cost of the procedure and increases operating time.20

Some, in fact, have suggested that nerve stimulators may actual-ly increase transient dysfunction. Accordingly, our use of nervestimulators is selective.

The management of facial nerve injury depends on when theinjury is discovered and on how sure the surgeon is of theanatomic integrity of the nerve. If the injury is discovered intra-operatively, it should be repaired if possible. Primary repair—performed with interrupted fine permanent monofilamentsutures under magnification21—is preferred if sufficient nerve isavailable for a tension-free anastomosis. If both transected nerveends are identified but tension-free repair is not feasible, inter-position nerve grafts may be used. Sensory nerves harvested fromthe neck (e.g., the great auricular nerve) are often employed forthis purpose. If the nerve is injured (or deliberately sacrificed) inconjunction with treatment of malignancy, use of nerve graftsfrom distant sites may be indicated.21

If unexpected facial nerve dysfunction is identified in thepostanesthesia care unit and if the surgeon is unsure of theanatomic integrity of the nerve (ideally, a rare occurrence), thepatient should be returned to the operating room for wound

exploration so that either the continuity of the nerve can be con-firmed or the injury to the nerve can be identified and repaired ifpossible.When the surgeon is certain that the nerve is intact, facialnerve dysfunction can be managed without reoperation, in antic-ipation of recovery21; however, this may take many months.

Management of enduring facial nerve paralysis (from anycause) is beyond the scope of our discussion and constitutes a sur-gical subspecialty in itself.21

GUSTATORY SWEATING (FREY SYNDROME)

Gustatory sweating, or Frey syndrome, occurs in most patientsafter parotidectomy; it has been seen after submandibular glandresection as well. The symptom complex includes sweating, skinwarmth, and flushing after chewing food and is caused by cross-innervation of the parasympathetic and sympathetic fibers sup-plying the parotid gland and the overlying skin.The reported inci-dence of Frey syndrome varies greatly, apparently depending onthe sensitivity of the test used to elicit it. When Minor’s starchiodine test is employed, the incidence of Frey syndrome mayreach 95% at 1 year after operation.22 Fortunately, the majority ofpatients exhibit only subclinical findings, and only a small fractioncomplain of debilitating symptoms.22 Most symptomatic patientsare adequately treated with topical antiperspirants; eventually,however, they tend to become noncompliant with such measures,preferring simply to dab the face with a napkin while eating.22

Despite the relatively low incidence of clinically significant Freysyndrome, there is an extensive literature addressing preventionand treatment of this condition.9,19,23-30

SIALOCELE (SALIVARY FISTULA)

Sialocele, or salivary fistula, has been reported to occur after 1%to 15% of parotidectomies.9,31 Although this condition is general-ly minor and self-limited, it may nonetheless be embarrassing forthe patient. We believe that the incidence of sialocele can bereduced by maintaining closed suction drainage for 5 to 7 days (to

a b

Figure 5 Parotidectomy. Shown is drainage and closure after parotidectomy. (a) A closed suction drain isplaced in the operative bed and loosely tacked to the sternocleidomastoid muscle. (b) Interrupted monofila-ment sutures are used for the skin. Bacitracin is applied. No additional dressings are used.



1. Berkovitz BKG, Moxham BJ: A Textbook of Headand Neck Anatomy.Year Book Medical Publishers,Inc, Chicago, 1988

2. Davis BA, Anson BJ, Budinger JM, et al: Surgicalanatomy of the facial nerve and the parotid glandbased upon a study of 350 cervico-facial halves.Surg Gynecol Obstet 102:385, 1956

3. Bernstein L, Nelson RH: Surgical anatomy of theextraparotid distribution of the facial nerve. ArchOtolaryngol 110:177, 1984

4. Hui Y, Wong DSY, Wong LY, et al: A prospectivecontrolled double-blind trial of great auricularnerve preservation at parotidectomy. Am J Surg185:574, 2003

5. Christensen NR, Jacobsen SD: Parotidectomy:preserving the posterior branch of the great auric-ular nerve. J Laryngol Otol 111:556, 1997

6. De Ru JA, van Benthem PPG, Bleys RLAW, et al:Landmarks for parotid gland surgery. J LaryngolOtol 115:122, 2001

7. Peterson RA, Johnston DL: Facile identification ofthe facial nerve branches. Clin Plast Surg 14:785,1987

8. Salame K, Ouaknine GER, Arensburg B, et al: Mi-crosurgical anatomy of the facial nerve trunk. ClinAnat 15:93, 2002

9. Leverstein H, van der Wal JE, Tiwari RM, et al:Surgical management of 246 previously untreatedpleomorphic adenomas of the parotid gland. Br JSurg 84:399, 1997

10. Woods JE: Parotidectomy: points of technique forbrief and safe operation. Am J Surg 145:678, 1983

11. Garden AS, El-Naggar AK, Morrison WH, et al:Postoperative radiotherapy for malignant tumorsof the parotid gland. Int J Radiat Oncol Biol Phys37:79, 1997

12. Renehan AG, Gleave EN, Slevin NJ, et al: Clinico-pathological and treatment-related factors influ-encing survival in parotid cancer. Br J Cancer80:1296, 1999

13. Magnano M, Gervasio CF, Cravero L, et al:Treat-ment of malignant neoplasms of the parotid gland.Otolaryngol Head Neck Surg 121:627, 1999

14. Spiro JD, Spiro RH: Cancer of the parotid gland:role of 7th nerve preservation. World J Surg, 27:863, 2003

15. Witt RL: Facial nerve monitoring in parotid sur-gery: the standard of care? Otolaryngol Head NeckSurg 119:468, 1998

16. Reilly J, Myssiorek D: Facial nerve stimulation andpostparotidectomy facial paresis. OtolaryngolHead Neck Surg 128:530, 2003

17. Dulguerov P, Marchal F, Lehmann W: Post-parotidectomy facial nerve paralysis: possible etio-logic factors and results with routine facial nervemonitoring. Laryngoscope 109:754, 1999

18. Bron LP, O’Brien CJ: Facial nerve function afterparotidectomy. Arch Otolaryngol Head Neck Surg123:1091, 1997

19. Debets JMH, Munting JDK: Parotidectomy forparotid tumours: 19-year experience from theNetherlands. Br J Surg 79:1159, 1992

20. Terrell JE, Kileny PR, Yian C, et al: Clinical out-come of continuous facial nerve monitoring duringprimary parotidectomy. Arch Otolaryngol HeadNeck Surg 123:1081, 1997

21. Shindo M: Management of facial nerve paralysis.Otolaryngol Clin North Am 32:946, 1999

22. Linder TE, Huber A, Schmid S: Frey’s syndromeafter parotidectomy: a retrospective and prospec-tive analysis. Laryngoscope 107:1496, 1997

23. Bonanno PC, Palaia D, Rosenberg M, et al: Pro-phylaxis against Frey’s syndrome in parotidsurgery. Ann Plast Surg 44:498, 2000

24. Ahmed OA, Kolhe PS: Prevention of Frey’s syn-drome and volume deficit after parotidectomyusing the superficial temporal artery fascial flap. BrJ Plast Surg 52:256, 1999

25. Bugis SP, Young JEM, Archibald SD: Stern-ocleidomastoid flap following parotidectomy.Head Neck 12:430, 1990

26. Jeng SF, Chien CS: Adipofascial turnover flap forfacial contour deformity during parotidectomy.Ann Plast Surg 33:439, 1994

27. Govindaraj S, Cohen M, Genden EM, et al: Theuse of acellular dermis in the prevention of Frey’ssyndrome. Laryngoscope 111:1993, 2001

28. Nosan DK, Ochi JW, Davidson TM: Preservationof facial contour during parotidectomy. Oto-laryngol Head Neck Surg 104:293, 1991

29. Sinha UK, Saadat D, Doherty CM, et al: Use ofAlloDerm implant to prevent Frey syndrome after

parotidectomy. Arch Facial Plast Surg 5:109, 2003

30. Beerens AJ, Snow GB: Botulinum toxin A in thetreatment of patients with Frey syndrome. Br JSurg 89:116, 2002

31. Wax M, Tarshis L: Post-parotidectomy fistula. JOtolaryngol 20:10, 1991

32. Ananthakrishnan N, Parkash S: Parotid fistulas: areview. Br J Surg 69:641, 1982

33. Cavanaugh K, Park A: Postparotidectomy fistulas:a different treatment for an old problem. Int JPediatr Otorhinolaryngol 47:265, 1999

34. Vargas H, Galati LT, Parnes SM: A pilot studyevaluating the treatment of postparotidectomysialoceles with botulinum toxin type A. ArchOtolaryngol Head Neck Surg 126:421, 2000

35. Guntinas-Lichius O, Sittel C: Treatment of post-parotidectomy salivary fistula with botulinumtoxin. Ann Otol Rhinol Laryngol 110:1162, 2001

36. Chow TL, Kwok SP: Use of botulinum toxin typeA in a case of persistent parotid sialocele. HongKong Med J 9:293, 2003

37. Shimms DS, Berk FK,Tilsner TJ, et al: Low-doseradiation therapy for benign salivary disorders. AmJ Clin Oncol 15:76, 1992

38. Davis WE, Holt GR, Templer JW: Parotid fistulaand tympanic neurectomy. Am J Surg 133:587,1977

39. Kerawala CJ, McAloney N, Stassen LF:Prospective randomized trial of the benefits of asternocleidomastoid flap after superficial parot-idectomy. Br J Oral Maxillofac Surg 40:468, 2002

40. Chao C, Friedman DC, Alford EL, et al: Acellulardermal allograft prevents post-parotidectomy softtissue defects: a preliminary experience. Int OnlineJ Otorhinolaryngol Head Neck Surg 2(5):1, 1999

Acknowledgment

The authors wish to thank Veronica Levin for her assis-tance in the preparation of this chapter.

Figures 1a, 2b, 3, 4 Tom Moore.

facilitate adhesion of the skin flaps to the underlying parotidparenchyma). Postparotidectomy salivary fistula is usually attrib-utable to gland disruption rather than to duct transection andtherefore tends to resolve without difficulty.32 Compression dress-ings are generally effective.31 Anticholinergic agents have beenused in this setting as well.33-36 Low-dose radiation,37 completionparotidectomy, and tympanic neurectomy38 have all been em-ployed in refractory cases.

COSMETIC CHANGES

Parotidectomy creates a hollow anterior and inferior to the ear,which may extend behind the mandible and may reach a signifi-cant size in patients with large or recurrent tumors.This cosmeticchange is a necessary feature of the procedure, not a complication;nonetheless, it should be discussed with the patient before opera-tion. Many augmentation methods, using a wide variety of tech-niques, have been devised for improving postoperative appearance

(as well as alleviating Frey syndrome).24-28,39,40 All of these meth-ods have limitations or drawbacks that have kept them from beingwidely applied and accepted.

Outcome Evaluation

With proper surgical technique, superficial or partial superficialparotidectomy can be performed safely and within a reasonableoperating time. Blood transfusions should be required only in veryrare cases. Given adequate exposure, good knowledge of the rele-vant anatomy, limited trauma to the nerve, and appropriate use ofclosed suction drains (see above), complications should beuncommon. Although patients may tolerate parotidectomy on anoutpatient basis, we prefer to keep them in the hospital overnight.Patients should be able to leave the hospital with minimal pain,comfortable with their drain care, by the morning of postopera-tive day 1.

References

5 parotidectomy

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