Otolaryngology: Parotidectomy

Parotidectomy

Positioning

  • Supine
  • Head Turned Away

Incision

  • Superior – Preauricular Crease to the Root of the Helix (Superior Extent of Ear Attachment)
  • Inferior – Over the Mastoid, Down Along the SCM & Forward Along a Natural Skin Crease Under Jaw
    • *Alternative – Posterior Along the Hair Line (Facelift Incision – Allows Better Cosmesis)

Expose the Facial Nerve

  • Elevate Skin Flaps
  • Identify & Divide the Greater Auricular Nerve & External Jugular Vein (Over the SCM)
    • Frees Tail of the Parotid Gland
    • *May Consider Preserving the Greater Auricular Nerve – Minimal Impact on Quality of Life
  • Dissect the Fascia Between the Parotid Gland & External Auditory Canal
  • Identify the Facial Nerve
    • Retract Parotid Gland Anteriorly to Expose the Tragal Pointer
    • Identify the Main Trunk of the Facial Nerve Between the Tragal Pointer & the Posterior Belly of the Digastric Attachment to the Mastoid Bone

Dissection

  • Superficial Parotidectomy:
    • Meticulously Dissect the Superficial Lobe from the Facial Nerve Until the Entire Superficial Lobe is Free
  • Total Parotidectomy:
    • First Free the Superficial Lobe
    • Then Meticulously Dissect the Facial Nerve from the Deep Lobe Until the Entire Deep Lobe is Free

Complications

Most Common Nerve Injuries

  • From Parotid Gland: Greater Auricular Nerve
    • Presentation: Lower Ear Numbness
  • From Submandibular Gland: Marginal Mandibular Nerve
    • Presentation: Droop at the Corner of Mouth

Facial Nerve Paresis/Paralysis

  • Cause: Traction Injury During Parotidectomy
  • Usually Resolves in Days-Months
  • Higher Risk After a Total or Subtotal Parotidectomy
  • Facial Nerve Monitoring:
    • Reduces Rates of Transient Facial Nerve Paralysis
    • No Change in Rates of Permanent Facial Nerve Paralysis
  • If Facial Nerve Transected/Sacrificed:
    • Short-Length: Repair by Direct Neurorrhaphy
    • Long-Length: Repair by Cable Graft
  • Immediate Rehabilitation Requires Thorough Eye Care to Prevent Exposure Keratitis
    • Includes Liberal Use of Artificial Tears, Lubricating Ointment & Eyewear

Frey’s Syndrome (Gustatory Sweating)

  • Cause: Aberrant Cross-Reinnervation/Regeneration of Parasympathetic Fibers to the Parotid Gland with Postganglionic Sympathetic Fibers of the Sweat Glands
    • Both Parasympathetic & Sympathetic Fibers Originate from the Auriculotemporal Nerve (Branch of the Trigeminal Nerve)
  • Presentation: Ipsilateral Facial Flushing & Sweating During Mastication
  • Incidence: 35-60%
  • Diagnosis: Minor Starch-Iodine Test
    • Test:
      • Skin Painted with Iodine & Once Dry, Dusted with Starch Powder
      • Patient Chews on a Sialagogue (Lemon Wedge)
      • Positive Test – Appearance of Dark Blue Spots from Reaction of Dissolved Iodine & Starch
  • Treatment: Antiperspirant to Involved Skin
    • If Fails: Surgical Tympanic Neurectomy
      • May Consider Botulinum Toxin Injection

Salivary Fistula

  • Presentation:
    • Clear Sialorrhea from the Wound
    • Salivary Fluid Collection Under Skin Flaps
  • Mostly Self-Limiting
  • Treatment: Repeated Aspiration & Wound Care
    • Anticholinergics (Glycopyrrolate) Can Provide Temporary Saliva Reduction