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Parotidectomy
DR CARUNYA MANNAN
Indications
Benign
 Chronic parotitis
 Salivary calculi
 Parotid abscess
 Pleomorphic adenoma
 Warthin’s tumor
Malignant
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Adenocarcinoma
Squamous cell carcinoma
Parotid Gland
 Largest of the salivary glands
 Wedge-shaped when viewed externally, with the
base above & the apex behind the angle of the
mandible
Parotid Gland
 Situated anteriorly and inferiorly to the
ear
 Overlie the vertical mandibular rami
and masseter muscles, behind which
they extend into the retromandibular
sulci
 Superiorly - zygomatic arches
 Inferiorly - below the angles of the
mandible , overlie the posterior bellies
of the digastric & the sterno-
cleidomastoid muscles
Wedge-shaped in horizontal section with the base in the lateral position and apex against the
pharyngeal wall
It exhibits 3 surfaces:
 Lateral
 Anteromedial
 Posteromedial
Superficial Muscular Aponeurotic System and Parotid
Fascia
 Fibrous network that invests the facial muscles & connects them with the dermis
 Continuous with the platysma inferiorly; superiorly it attaches to the zygomatic arch
 Facial nerve courses deep to the SMAS and the platysma
 Parotid glands are contained within two layers of parotid fascia, which extend from the zygoma
above and continue as cervical fascia below
Lobes
The facial nerve courses
horizontally through the gland and
divides it into:
 Superficial lobe
 Deep lobe
Superficial lobe
Deep lobe
Facial nerve
Processes
 Glenoid process, that extends upward
behind the temporo-mandibular joint,
in front of external auditory meatus
 Facial process, that extends anteriorly
onto the masseter muscle
 Accessory process (part), small part of
facial process lying along the parotid
duct
 Pterygoid process, that extends
forward from the deeper part, lies
between the medial pterygoid muscle
& the ramus of mandible
 Carotid process, that lies posterior to
the external carotid artery
Capsules
The parotid gland is enclosed in two capsules:
 An inner connective tissue capsule
 An outer dense fibrous capsule derived from the investing
layer of the deep cervical fascia
The deep cervical fascia extends upward, reaches the inferior
border of parotid gland, splits into the superficial & the deep
layer, to enclose the gland
Above the gland, the:
 Superficial layer gets attached to the zygomatic arch
 Deep layer gets attached to the tympanic plate of
temporal bone
 A portion of fascia extending from the styloid process to
the angle of mandible is called stylomandibular ligament.
It separates the parotid gland from the submandibular
gland
Relations
Superficial (lateral):
• Skin & superficial fascia
• Great auricular nerve
• Parotid lymph nodes
Superior:
• External auditory meatus
• Temporomandibular joint
• Its glenoid process is related to the
auriculo-temporal nerve
Anteromedial:
• Stylomandibular ligament
• Medial pterygoid
• Posterior border of the ramus of
mandible
• Massater
• Terminal branches of the facial
nerve
• Temporo-mandibular joint
Posteromedial:
• Carotid sheath with its contents
• Styloid process & attached muscles
• Facial nerve
• Posterior belly of digastric muscle
• Mastoid process
• Sternocleidomastoid
The Parotid Bed
The structures intimately related to the deep surface of the
parotid gland (anteromedial & posteromedial relations)
Structures Coursing Within the Parotid Gland
 Auriculotemporal nerve
 External carotid artery
 Retromandibular vein
 Facial nerve
A few lymph nodes are scattered in the
substance of the gland
Deep
Superficial
Parotid (Stensen’s) Duct
About 2 inches long
Emerges from the facial process of the
gland
Passes forward over the lateral surface
of the masseter muscle
 about a fingerbreadth below the
zygomatic arch
 accompanied by the:
 transverse facial vessels & upper
zygomatic branches of facial nerve
above
 lower zygomatic branches of facial
nerve below
Turns around the anterior border
of masseter muscle
Pierces the:
• Buccal pad of fat
• Buccopharyngeal fascia
• Buccinator muscle &
• Buccal mucosa
Opens into the vestibule of mouth
on a small papilla, opposite the
second upper molar tooth
Parotid duct
Buccinator
Masseter
Parotid (Stensen’s) Duct - course
The oblique passage of the duct in the buccinator muscle acts
as a valve-like mechanism & prevents inflation of the duct
during blowing
Parotid Duct
• The duct can be rolled over the
clenched masseter muscle
• The duct is represented by the
middle 1/3 of a line extending
from the tragus of the auricle to a
point midway between the ala of
nose & upper lip
Venous drainage
 Maxillary and superficial temporal veins
merge into the retro-mandibular vein within
the parotid gland, but are not responsible for
draining the gland
 Tributaries of external and internal jugular
veins
Retromandibular v.
External carotid
a.
Maxillary a.
Superficial temporal a.
Blood supply
Terminal branches of External carotid
artery
 maxillary
 superficial temporal artery
 Into the parotid & then into the
deep cervical lymph nodes
Parotid n.
Deep cervical n.
Lymphatic drainage
Nerve Supply
Sensory :
 Auriculotemporal n.
Autonomic:
Sympathetic through plexus around the
arteries ( plexus around ECA)
 Parasympthetic through otic ganglion
(CN9 → tympanic n. → tympanic plexus →
lesser petrosal n. → otic ganglion →
auriculotemporal n.)
Facial nerve
 Exits the stylomastoid foramen  enters the
parotid gland
 Trunk  divides at the pes anserinus 
upper and lower division  branch into
temporal (frontal), zygomatic, buccal, marginal
mandibular and cervical branches
 Innervate the muscles of facial expression
 Small branches to the posterior belly of
digastric, stylohyoid, and auricular muscles
Facial nerve – branches
A bout 2/3 of the gland substance being -
superficial to the nerve
 Midfacial nerve branches - multiple cross-
innervations  injury  no loss of facial
function
Temporal & marginal mandibular branches do
not have cross-innervations  injury to these
branches is followed by paralysis of the
forehead and depressors of the lower lip
Types of Parotidectomy
Partial parotidectomy:
Resection of parotid pathology with a margin of normal parotid tissue
 Standard operation for benign pathology / favourable malignancies
Superficial parotidectomy:
Resection of the entire superficial lobe of parotid
Metastases to parotid lymph nodes / high grade malignant parotid tumours
Total parotidectomy:
 Resection of the entire parotid gland, usually with preservation of the facial
Preoperative consent
 Scar
 Anaesthesia: greater auricular distribution: Skin of inferior part of auricle, and overlying the
angle of the mandible
 Facial nerve weakness: Temporary weakness common (<50%); permanent weakness rare
Facial contour: loss of parotid tissue leads to a more defined angle of mandible/deepening of
retromandibular sulcus
Prominence of auricle: Due to loss of innervation of the postauricular muscles and preauricular
scarring
Frey’s syndrome (gustatory sweating)
Anaesthesia
 General anaesthesia
 Short-acting muscle relaxation for intubation only, so that facial nerve may be stimulated
and/or monitored
 No perioperative antibiotics unless specifically indicated
 Hyperextension of the neck, and turned to opposite side
 Infiltrate with vasoconstrictor along planned skin incision, so as to reduce thermal injury to skin
from electro-cautery to skin vessels
 Corners of the eye and mouth -- exposed  to be able to see facial movement when facial
nerve mechanically or electrically stimulated
Incision
 Lazy-S incision: This is placed in pre-auricular and cervical skin creases
Parotidectomy
  Superficial cervicofacial flap raised - anterior
border of parotid mass or of the parotid gland
in the plane between the SMAS and the
parotid fascia with a scalpel/diathermy
 Assistant - monitor the face for muscle
contraction to avoid facial nerve injury
 Traction suture placed in the subcutaneous
tissue of the ear lobule / anterior skin flap
secured to the drapes
Parotidectomy
Anterior border of sternocleidomastoid
skeltonized
 External jugular vein – divided
 Division of greater auricular nerve as it
crosses sternocleidomastoid muscle/posterior
to the external jugular vein
Digastric
SCM
EJV
Gr A
An attempt can be made to preserve the
posterior branch of the nerve to retain
sensation of the skin of the auricle
Posterior branch of greater auricular nerve
 Identification and skeletonisation of posterior
belly of the digastric muscle
 Cephalad dissection – avoided  prevent
injury to the facial nerve
Where is the facial nerve?
POINTS TO INDENTIFY
Facial nerve
 Facial nerve trunk  exits the skull at the
stylomastoid foramen
 Situated at the deep end of the tympano-
mastoid suture line  the junction between
the mastoid process and the tympanic ring of
the external ear canal
Temporal branch
 Crosses the zygomatic arch
 Runs within the SMAS and lies superficial to
the deep temporalis fascia
 Courses along a line drawn between the
attachment of the lobule of the ear to a point
1.5 cm above the lateral aspect of the eyebrow
To avoid injury to the temporal branch 
dissection done either in a subcutaneous
plane / deep to the SMAS
Intraoperative location of facial nerve
 Prograde dissection
 Nerve trunk  dissection continued
anteriorly along the trunk, the pes anse-rinus
and the divisions and nerve branches

Intraoperative location of facial nerve
Retrograde dissection
 Temporal branch where it crosses the zygoma
 Buccal branches which lie parallel to the
parotid duct
Intraoperative location of facial nerve
Retrograde dissection
 Marginal mandibular branch  crosses the
facial artery and vein just below or at the
inferior margin of the mandible –> deep to
platysma
Facial nerve - surgical landmarks
Facial nerve - surgical landmarks
Posterior belly of digastric muscle - same
depth, bisects the angle between the muscle
and the styloid process
Cartilage pointer: medial-most, pointed end
of the cartilage of the external auditory
meatus
 Exits the foramen - 1cm deep and 1cm
inferior to this point
Facial nerve - surgical landmarks
 Tympanomastoid suture line - most precise
landmark for the facial nerve  leads medially,
directly to the stylomastoid foramen
 Styloid process- Crosses the styloid process 
palpating the styloid process  useful to
determine the depth and position of the facial
nerve
 Branch of occipital artery - branch of the
occipital artery is encountered lateral to the
facial nerve close to the stylomastoid foramen
Brisk arterial bleeding  alert the surgeon to
the proximity of the facial nerve
Landmarks for the facial nerve
Tympanic ring
Facial nerve
Cartilage pointer
Digastric
Tympanomastoid
suture
Sternomastoid
Mastoid process
Dissection of facial nerve
 Facial nerve trunk located by blunt dissection
with a fine haemostat
 Fine curved blunt tipped scissors for the
remainder of the nerve dissection
 It is important to dissect directly on the nerve
so as not to lose sight of it
 Parotid tissue – should never be divided
beyond exposed facial nerve
Dissection of facial nerve
Dissection - along the trunk to the pes
anserinus
Facial nerve trunk dividing into superior and inferior divisions at
the pes anserinus
Dissection of facial nerve
Dissection - back towards the stylomastoid
foramen to exclude early branching from the
trunk
 Division of the parotid fascia and parotid
tissue superiorly and inferiorly  releases the
parotid posteriorly & permits anterior
mobilisation of the gland/tumour
 Dissection along the nerve
 Superficial lobe stripped off the branches of
facial nerve
Retromadibular vein
Identification of the retromandibular vein
 Crosses medial to the facial nerve
Completed superficial parotidectomy;
 Removal of the superior part of the gland, 
identification/ligation the superficial temporal
artery superiorly anterior to auricle
 Dissection at the anterior border of the gland
 identification and transection the parotid
duct
 Tumour removed with a cuff of the superficial
parotid lobe
Parotid dissection for deep lobe tumours
 Identification, dissection of the facial nerve
off the underlying deep lobe or tumour to
provide access to the deep lobe
 Superficial parotidectomy / reflecting the
superficial lobe anteriorly, with parotid duct
intact, and replaced at the conclusion of
surgery
Deep lobe
 Tumour delivered either between, or inferior
to the facial nerve or its branches, after
identification of the branches of the facial
nerve around the tumour
 Tumor removed between the splayed facial
nerve branches
Deep lobe
Deep lobe -delivered from the parapharyngeal
space by blunt dissection
 Division of the external carotid, deep
transverse facial and superficial temporal
arteries and the retromandibular and
superficial temporal veins
 Additional access – division of the styloid
process and/or via a transcervical approach
Completed total parotidectomy in patient
shown
Silk ties are on branches of the external
carotid artery
Tumour spillage
Great care should be taken to avoid rupture
and spillage of pleomorphic adenoma tissue
into the operative site
 Multifocal tumour recurrence, often more
than 20yrs following surgery
 Extensive ruptures - postoperative radiation
therapy
Multifocal recurrence of pleo-morphic adenoma
Wound closure
 Confirm nerve continuity: Careful inspection/nerve stimulator
 Obtain meticulous haemostasis: Using ties and bipolar diathermy/ Valsalva manoeuvre to
identify venous bleeding
 Sealed suction drain: Until drainage <50ml/24 hrs
 Skin closure: Subcutaneous and subcuticular absorbable sutures
Facial nerve repair
 Transection of the temporal (frontal) and marginal mandibular nerves- repaired with 8/0
nylon/prolene epineural sutures
 Undue tension / nerve resection- grafted with greater auricular nerve, or sural nerve
Greater auricular nerve
 Approxi-mately the same diameter as the
facial nerve trunk
 Few branches that can be used to graft more
than one facial nerve branch
Sural nerve
 Greater length
 more branches
 better suited to bridging longer defects and for grafting to more peripheral branches
Hypoglossal-facial nerve interposition
 Proximal end of the facial nerve is not
available, e.g. with extensive proximal
perineural tumour extension
 Nerve graft  sutured end-to-end to the
distal facial nerve and end-to-side to the
hypoglossal nerve
 25% cutting made into the side of the
hypoglossal nerve to expose the nerve axons
Thank you!

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Parotidectomy

  • 2. Indications Benign  Chronic parotitis  Salivary calculi  Parotid abscess  Pleomorphic adenoma  Warthin’s tumor Malignant Mucoepidermoid carcinoma Adenoid cystic carcinoma Adenocarcinoma Squamous cell carcinoma
  • 3. Parotid Gland  Largest of the salivary glands  Wedge-shaped when viewed externally, with the base above & the apex behind the angle of the mandible
  • 4. Parotid Gland  Situated anteriorly and inferiorly to the ear  Overlie the vertical mandibular rami and masseter muscles, behind which they extend into the retromandibular sulci  Superiorly - zygomatic arches  Inferiorly - below the angles of the mandible , overlie the posterior bellies of the digastric & the sterno- cleidomastoid muscles
  • 5. Wedge-shaped in horizontal section with the base in the lateral position and apex against the pharyngeal wall It exhibits 3 surfaces:  Lateral  Anteromedial  Posteromedial
  • 6. Superficial Muscular Aponeurotic System and Parotid Fascia  Fibrous network that invests the facial muscles & connects them with the dermis  Continuous with the platysma inferiorly; superiorly it attaches to the zygomatic arch  Facial nerve courses deep to the SMAS and the platysma  Parotid glands are contained within two layers of parotid fascia, which extend from the zygoma above and continue as cervical fascia below
  • 7. Lobes The facial nerve courses horizontally through the gland and divides it into:  Superficial lobe  Deep lobe Superficial lobe Deep lobe Facial nerve
  • 8. Processes  Glenoid process, that extends upward behind the temporo-mandibular joint, in front of external auditory meatus  Facial process, that extends anteriorly onto the masseter muscle  Accessory process (part), small part of facial process lying along the parotid duct  Pterygoid process, that extends forward from the deeper part, lies between the medial pterygoid muscle & the ramus of mandible  Carotid process, that lies posterior to the external carotid artery
  • 9. Capsules The parotid gland is enclosed in two capsules:  An inner connective tissue capsule  An outer dense fibrous capsule derived from the investing layer of the deep cervical fascia The deep cervical fascia extends upward, reaches the inferior border of parotid gland, splits into the superficial & the deep layer, to enclose the gland Above the gland, the:  Superficial layer gets attached to the zygomatic arch  Deep layer gets attached to the tympanic plate of temporal bone  A portion of fascia extending from the styloid process to the angle of mandible is called stylomandibular ligament. It separates the parotid gland from the submandibular gland
  • 10. Relations Superficial (lateral): • Skin & superficial fascia • Great auricular nerve • Parotid lymph nodes Superior: • External auditory meatus • Temporomandibular joint • Its glenoid process is related to the auriculo-temporal nerve
  • 11. Anteromedial: • Stylomandibular ligament • Medial pterygoid • Posterior border of the ramus of mandible • Massater • Terminal branches of the facial nerve • Temporo-mandibular joint
  • 12. Posteromedial: • Carotid sheath with its contents • Styloid process & attached muscles • Facial nerve • Posterior belly of digastric muscle • Mastoid process • Sternocleidomastoid
  • 13. The Parotid Bed The structures intimately related to the deep surface of the parotid gland (anteromedial & posteromedial relations)
  • 14. Structures Coursing Within the Parotid Gland  Auriculotemporal nerve  External carotid artery  Retromandibular vein  Facial nerve A few lymph nodes are scattered in the substance of the gland Deep Superficial
  • 15. Parotid (Stensen’s) Duct About 2 inches long Emerges from the facial process of the gland Passes forward over the lateral surface of the masseter muscle  about a fingerbreadth below the zygomatic arch  accompanied by the:  transverse facial vessels & upper zygomatic branches of facial nerve above  lower zygomatic branches of facial nerve below
  • 16. Turns around the anterior border of masseter muscle Pierces the: • Buccal pad of fat • Buccopharyngeal fascia • Buccinator muscle & • Buccal mucosa Opens into the vestibule of mouth on a small papilla, opposite the second upper molar tooth Parotid duct Buccinator Masseter Parotid (Stensen’s) Duct - course
  • 17. The oblique passage of the duct in the buccinator muscle acts as a valve-like mechanism & prevents inflation of the duct during blowing Parotid Duct • The duct can be rolled over the clenched masseter muscle • The duct is represented by the middle 1/3 of a line extending from the tragus of the auricle to a point midway between the ala of nose & upper lip
  • 18. Venous drainage  Maxillary and superficial temporal veins merge into the retro-mandibular vein within the parotid gland, but are not responsible for draining the gland  Tributaries of external and internal jugular veins Retromandibular v.
  • 19. External carotid a. Maxillary a. Superficial temporal a. Blood supply Terminal branches of External carotid artery  maxillary  superficial temporal artery
  • 20.  Into the parotid & then into the deep cervical lymph nodes Parotid n. Deep cervical n. Lymphatic drainage
  • 21. Nerve Supply Sensory :  Auriculotemporal n. Autonomic: Sympathetic through plexus around the arteries ( plexus around ECA)  Parasympthetic through otic ganglion (CN9 → tympanic n. → tympanic plexus → lesser petrosal n. → otic ganglion → auriculotemporal n.)
  • 22. Facial nerve  Exits the stylomastoid foramen  enters the parotid gland  Trunk  divides at the pes anserinus  upper and lower division  branch into temporal (frontal), zygomatic, buccal, marginal mandibular and cervical branches  Innervate the muscles of facial expression  Small branches to the posterior belly of digastric, stylohyoid, and auricular muscles
  • 23. Facial nerve – branches A bout 2/3 of the gland substance being - superficial to the nerve  Midfacial nerve branches - multiple cross- innervations  injury  no loss of facial function Temporal & marginal mandibular branches do not have cross-innervations  injury to these branches is followed by paralysis of the forehead and depressors of the lower lip
  • 24. Types of Parotidectomy Partial parotidectomy: Resection of parotid pathology with a margin of normal parotid tissue  Standard operation for benign pathology / favourable malignancies Superficial parotidectomy: Resection of the entire superficial lobe of parotid Metastases to parotid lymph nodes / high grade malignant parotid tumours Total parotidectomy:  Resection of the entire parotid gland, usually with preservation of the facial
  • 25. Preoperative consent  Scar  Anaesthesia: greater auricular distribution: Skin of inferior part of auricle, and overlying the angle of the mandible  Facial nerve weakness: Temporary weakness common (<50%); permanent weakness rare Facial contour: loss of parotid tissue leads to a more defined angle of mandible/deepening of retromandibular sulcus Prominence of auricle: Due to loss of innervation of the postauricular muscles and preauricular scarring Frey’s syndrome (gustatory sweating)
  • 26. Anaesthesia  General anaesthesia  Short-acting muscle relaxation for intubation only, so that facial nerve may be stimulated and/or monitored  No perioperative antibiotics unless specifically indicated  Hyperextension of the neck, and turned to opposite side  Infiltrate with vasoconstrictor along planned skin incision, so as to reduce thermal injury to skin from electro-cautery to skin vessels  Corners of the eye and mouth -- exposed  to be able to see facial movement when facial nerve mechanically or electrically stimulated
  • 27. Incision  Lazy-S incision: This is placed in pre-auricular and cervical skin creases
  • 28. Parotidectomy   Superficial cervicofacial flap raised - anterior border of parotid mass or of the parotid gland in the plane between the SMAS and the parotid fascia with a scalpel/diathermy  Assistant - monitor the face for muscle contraction to avoid facial nerve injury  Traction suture placed in the subcutaneous tissue of the ear lobule / anterior skin flap secured to the drapes
  • 29. Parotidectomy Anterior border of sternocleidomastoid skeltonized  External jugular vein – divided  Division of greater auricular nerve as it crosses sternocleidomastoid muscle/posterior to the external jugular vein Digastric SCM EJV Gr A
  • 30. An attempt can be made to preserve the posterior branch of the nerve to retain sensation of the skin of the auricle Posterior branch of greater auricular nerve
  • 31.  Identification and skeletonisation of posterior belly of the digastric muscle  Cephalad dissection – avoided  prevent injury to the facial nerve
  • 32. Where is the facial nerve? POINTS TO INDENTIFY
  • 33. Facial nerve  Facial nerve trunk  exits the skull at the stylomastoid foramen  Situated at the deep end of the tympano- mastoid suture line  the junction between the mastoid process and the tympanic ring of the external ear canal
  • 34. Temporal branch  Crosses the zygomatic arch  Runs within the SMAS and lies superficial to the deep temporalis fascia  Courses along a line drawn between the attachment of the lobule of the ear to a point 1.5 cm above the lateral aspect of the eyebrow To avoid injury to the temporal branch  dissection done either in a subcutaneous plane / deep to the SMAS
  • 35. Intraoperative location of facial nerve  Prograde dissection  Nerve trunk  dissection continued anteriorly along the trunk, the pes anse-rinus and the divisions and nerve branches 
  • 36. Intraoperative location of facial nerve Retrograde dissection  Temporal branch where it crosses the zygoma  Buccal branches which lie parallel to the parotid duct
  • 37. Intraoperative location of facial nerve Retrograde dissection  Marginal mandibular branch  crosses the facial artery and vein just below or at the inferior margin of the mandible –> deep to platysma
  • 38. Facial nerve - surgical landmarks
  • 39. Facial nerve - surgical landmarks Posterior belly of digastric muscle - same depth, bisects the angle between the muscle and the styloid process Cartilage pointer: medial-most, pointed end of the cartilage of the external auditory meatus  Exits the foramen - 1cm deep and 1cm inferior to this point
  • 40. Facial nerve - surgical landmarks  Tympanomastoid suture line - most precise landmark for the facial nerve  leads medially, directly to the stylomastoid foramen  Styloid process- Crosses the styloid process  palpating the styloid process  useful to determine the depth and position of the facial nerve  Branch of occipital artery - branch of the occipital artery is encountered lateral to the facial nerve close to the stylomastoid foramen Brisk arterial bleeding  alert the surgeon to the proximity of the facial nerve
  • 41. Landmarks for the facial nerve Tympanic ring Facial nerve Cartilage pointer Digastric Tympanomastoid suture Sternomastoid Mastoid process
  • 42. Dissection of facial nerve  Facial nerve trunk located by blunt dissection with a fine haemostat  Fine curved blunt tipped scissors for the remainder of the nerve dissection  It is important to dissect directly on the nerve so as not to lose sight of it  Parotid tissue – should never be divided beyond exposed facial nerve
  • 43. Dissection of facial nerve Dissection - along the trunk to the pes anserinus Facial nerve trunk dividing into superior and inferior divisions at the pes anserinus
  • 44. Dissection of facial nerve Dissection - back towards the stylomastoid foramen to exclude early branching from the trunk  Division of the parotid fascia and parotid tissue superiorly and inferiorly  releases the parotid posteriorly & permits anterior mobilisation of the gland/tumour  Dissection along the nerve  Superficial lobe stripped off the branches of facial nerve
  • 45. Retromadibular vein Identification of the retromandibular vein  Crosses medial to the facial nerve Completed superficial parotidectomy;
  • 46.  Removal of the superior part of the gland,  identification/ligation the superficial temporal artery superiorly anterior to auricle  Dissection at the anterior border of the gland  identification and transection the parotid duct  Tumour removed with a cuff of the superficial parotid lobe
  • 47. Parotid dissection for deep lobe tumours  Identification, dissection of the facial nerve off the underlying deep lobe or tumour to provide access to the deep lobe  Superficial parotidectomy / reflecting the superficial lobe anteriorly, with parotid duct intact, and replaced at the conclusion of surgery
  • 48. Deep lobe  Tumour delivered either between, or inferior to the facial nerve or its branches, after identification of the branches of the facial nerve around the tumour  Tumor removed between the splayed facial nerve branches
  • 49. Deep lobe Deep lobe -delivered from the parapharyngeal space by blunt dissection  Division of the external carotid, deep transverse facial and superficial temporal arteries and the retromandibular and superficial temporal veins  Additional access – division of the styloid process and/or via a transcervical approach
  • 50. Completed total parotidectomy in patient shown Silk ties are on branches of the external carotid artery
  • 51. Tumour spillage Great care should be taken to avoid rupture and spillage of pleomorphic adenoma tissue into the operative site  Multifocal tumour recurrence, often more than 20yrs following surgery  Extensive ruptures - postoperative radiation therapy Multifocal recurrence of pleo-morphic adenoma
  • 52. Wound closure  Confirm nerve continuity: Careful inspection/nerve stimulator  Obtain meticulous haemostasis: Using ties and bipolar diathermy/ Valsalva manoeuvre to identify venous bleeding  Sealed suction drain: Until drainage <50ml/24 hrs  Skin closure: Subcutaneous and subcuticular absorbable sutures
  • 53. Facial nerve repair  Transection of the temporal (frontal) and marginal mandibular nerves- repaired with 8/0 nylon/prolene epineural sutures  Undue tension / nerve resection- grafted with greater auricular nerve, or sural nerve
  • 54. Greater auricular nerve  Approxi-mately the same diameter as the facial nerve trunk  Few branches that can be used to graft more than one facial nerve branch
  • 55. Sural nerve  Greater length  more branches  better suited to bridging longer defects and for grafting to more peripheral branches
  • 56. Hypoglossal-facial nerve interposition  Proximal end of the facial nerve is not available, e.g. with extensive proximal perineural tumour extension  Nerve graft  sutured end-to-end to the distal facial nerve and end-to-side to the hypoglossal nerve  25% cutting made into the side of the hypoglossal nerve to expose the nerve axons