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Parotidectomy

Parotidectomy is the removal of part or all of the parotid gland on one side of the face. Understanding the anatomy of the facial nerve as it relates to the parotid gland is key to understanding the surgery.

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Some technical terms related to the extent of the surgery:

  • 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. Your doctor should tell you about these associated procedures prior to surgery.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

You will be put completely to sleep with general anesthesia.

In some cases, your surgeon might 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 your surgeon to hide the scar as much as possible rather than making an incision directly in the middle of your face.

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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 go by quickly.

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 not notice effects of dry mouth after removal of just one parotid gland. You have many salivary glands to maintain salivary flow.

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.

Recovery and aftercare

The recovery course will depend on the extent of any additional surgery and reconstruction. With a parotidectomy alone, you should be ready to go home the same day, the next day or, at most, two to three days later. A lot of that time will be spent waiting for the drainage in the drain to decrease.

As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

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 anti-perspirant 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.

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