1. © 2008 BC Decker Inc ACS Surgery: Principles and Practice
2 HEAD AND NECK 6 PAROTIDECTOMY — 1
6 PAROTIDECTOMY
Leonard R. Henry, MD, and John A. Ridge, MD, PhD, FACS
Anatomic Considerations the surgical anatomy are essential in parotid surgery. The
The parotid (“near the ear”) gland, the largest of the salivary use of magnifying loupes and headlights is recommended.
glands, occupies the space immediately anterior to the ear, General anesthesia without muscle relaxation should be
overlying the angle of the mandible. It drains into the oral employed.
cavity via Stensen’s duct, which enters the oral vestibule The patient is placed in the supine position, with the head
opposite the upper molars. The gland is invested by a strong elevated and turned away from the side undergoing operation
fascia and is bounded superiorly by the zygomatic arch, ante- and with the neck slightly extended. The table is positioned
riorly by the masseter muscle, posteriorly by the external to allow the first assistant to stand directly above the patient’s
auditory canal and the mastoid process, and inferiorly by the head, while the surgeon faces the operative field. A small
sternocleidomastoid muscle. The masseter muscle, the styloid cottonoid sponge is placed in the external auditory canal,
muscles, the posterior belly of the digastric muscle, and a where it remains for the duration of the procedure to prevent
portion of the sternocleidomastoid muscle lie deep to the otitis externa from blood clots in the external auditory
parotid. Terminal branches of the external carotid artery, the canal. The skin is painted with an antiseptic agent. A single
facial vein, and the facial nerve are found within the gland. perioperative dose of an antibiotic is administered.
Parasympathetic innervation to the parotid is via the otic The patient is draped in a fashion that permits the operat-
ganglion, which gives fibers to the auriculotemporal branch of ing team to see all of the muscle groups innervated by
the trigeminal nerve. Sympathetic innervation to the gland the facial nerve. To this end, we employ a head drape that
originates in the sympathetic ganglia and reaches the auricu- incorporates the endotracheal tube and hose. This drape
lotemporal nerve by way of the plexus around the middle secures the airway, keeps the tube from interfering with the
meningeal artery.1 surgeon, and permits rotation of the head without tension
The facial nerve trunk exits the stylomastoid foramen and on the endotracheal tube. The skin of the upper chest and
courses toward the parotid. Once inside the gland, it com- neck is widely painted and draped with a split sheet to allow
monly bifurcates into superior (temporal-frontal) and inferior additional exposure in the unlikely event that a neck dissec-
(cervicomarginal) divisions before giving rise to its terminal tion or a tracheostomy becomes necessary. The nose, the lips,
branches. The nerve branching within the parotid can be and the eyes are covered with a sterile transparent drape that
quite complex, but the common patterns are well known and allows observation of movement during the procedure and
their relative frequencies well established.2,3 The portion of permits access to the oral cavity (if desired) [see Figure 1].
the parotid gland lateral to the facial nerve (about 80% of the
gland) is designated as the superficial lobe; the portion medial
to the facial nerve (the remaining 20%) is designated as the Operative Technique
deep lobe. Deep-lobe tumors often present clinically as retro- step 1: incision and skin flaps
mandibular or parapharyngeal masses, with displacement of
the tonsil or the soft palate appreciated in the throat. The incision is planned so as to permit excellent exposure
with good cosmetic results. It begins immediately anterior to
the ear, continues downward past the tragus, curves back
Operative Planning under the ear (staying close to the earlobe), and finally turns
Obtaining informed consent for parotidectomy entails downward to descend along the sternocleidomastoid muscle
discussing both the features and the potential complications [see Figure 1]. Either all or part of this incision may be used,
of the procedure. It is appropriate to address the possibility depending on circumstances. The incision is marked before
of facial nerve injury, but in doing so, the surgeon should not draping. Skin creases typically help conceal the resulting
neglect other, far more common sequelae, such as cosmetic scar.
deformity, earlobe numbness, and Frey syndrome. Even con- Skin flaps are then created to expose the parotid gland. A
ditions that are expected beforehand may prove distressing tacking suture is placed within the dermis of the earlobe so
or debilitating for the patient. The risk of complications that it can be retracted posteriorly. Skin hooks are used to
such as nerve injury is greater in cases involving reoperation apply vertical traction. The anterior flap is created superficial
or resection of malignant or deep-lobe tumors. The over- to the parotid fascia to afford access to the appropriate dis-
whelming majority of parotid tumors, however, are benign section plane. Vertically oriented blunt dissection minimizes
and lateral to the facial nerve. Accordingly, in what follows, the risk of injury to the distal branches of the facial nerve [see
we focus primarily on superficial parotidectomy, referring to Figure 2]. The face is observed for muscle motion. The flap
variants of the procedure where relevant. is raised until the anterior border of the gland is identified.
Excellent lighting, correctly applied traction and The facial nerve branches are rarely encountered during flap
countertraction, adequate exposure, and clear definition of elevation until they emerge from the parenchyma of the
DOI 10.2310/7800.S02C06
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a
b
Figure 1 Parotidectomy. (a) Shown are the recommended head position and incision. A transparent drape is placed over the
eyes, the lip and oral cavity. (b) The head drape incorporates the hose from the endotracheal tube.
parotid. If muscle movement occurs, the flap has been more branches of this nerve should be preserved if possible to pre-
than adequately developed. The anterior flap is retracted with vent postoperative numbness of the earlobe.4,5 The parotid
a suture through the dermis. tail is dissected away from the sternocleidomastoid muscle.
The posterior-inferior skin flap is then elevated in a similar Vertical traction is applied to the gland surface with clamps
manner. Careful dissection is performed to define the rela- to facilitate exposure.
tionship of the parotid tail to the anterior border of the ster-
nocleidomastoid. During this portion of the procedure, the Troubleshooting
great auricular nerve is identified coursing cephalad and A favorable skin crease, if available, may be used for
superficial to the sternocleidomastoid muscle. Uninvolved the incision to improve the postoperative cosmetic result;
a b
Figure 2 Parotidectomy. (a) Shown is the creation of the anterior skin flap superficial to the parotid gland. (b) Vertically
oriented blunt dissection minimizes the risk of injury to facial nerve branches as they exit the gland.
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however, it is important to keep the incision a few millimeters deep-lobe tumors may displace the nerve from its normal
from the earlobe itself. A wound at the junction of the earlobe location. For appropriate and safe exposure of the nerve
with the facial skin will distort the earlobe and create a visible trunk, it is necessary to mobilize several centimeters of the
contour change. An incision behind the tragus may lead to parotid, thereby creating a trough rather than a deep hole.
similar problems. Small arteries run superficial and parallel to the facial nerve;
these must be divided. Use of the electrocautery this close to
step 2: identification of facial nerve
the nerve is potentially hazardous. Bleeding is typically minor
Once the skin flaps have been developed and retracted, the but nonetheless must be controlled.
next step is to identify the facial nerve. Usually, the nerve may
be identified either at its main trunk (the antegrade approach) Retrograde Approach
or at one of the distal branches, with subsequent dissection As noted, when the main trunk cannot be exposed, the
back toward the main trunk (the retrograde approach). For a most common alternative method of identifying the facial
lateral parotidectomy, our preference is to identify the main nerve is to find a peripheral branch and then dissect proxi-
trunk first (unless it is thoroughly obscured by tumor or mally toward the main trunk. Which branch is sought may
scar). depend on factors such as the surgeon’s comfort with the
anatomy and the known consistency of the nerve branch’s
Antegrade Approach
location. In this setting, tumor bulk is often the deciding
The dissection plane is immediately anterior to the factor.
cartilage of the external auditory canal. The gland is mobi- The anatomic relationships between the nerve branches
lized anteriorly by means of blunt dissection. To reduce the and various landmarks can be exploited for more efficient
risk of a traction injury, tissue is spread in a direction that is identification. For example, the marginal mandibular branch
perpendicular to the incision and thus parallel to the direction of the facial nerve characteristically lies below the horizontal
of the main trunk of the nerve [see Figure 3]. The nerve trunk ramus of the mandible.7 Often, the facial vein can be traced
can usually be located underlying a point about halfway toward the parotid on the submandibular gland; the nerve
between the tip of the mastoid process and the ear canal. In branch can then be found coursing perpendicular and super-
addition, there are several anatomic landmarks that facilitate
ficial to the vein. The buccal branch of the facial nerve has a
identification of the nerve, including the tragal pointer, the
typical location in the so-called buccal pocket—the area infe-
posterior belly of the digastric muscle, and the tympanomas-
rior to the zygoma and deep to the superficial musculoapo-
toid suture. Of these, the tympanomastoid suture is closest to
neurotic layer, which contains the buccal fat pad and Stensen’s
the main trunk of the facial nerve.6 The clinical utility of this
duct in addition to the buccal branch.7 The zygomatic branch
landmark is limited, however, because the tympanomastoid
of the facial nerve lies roughly 3 cm anterior to the tragus,
suture is not easily appreciated in every case. In addition,
and the temporal-frontal branch lies at the midpoint between
the outer canthus of the eye and the junction of the ear’s helix
with the preauricular skin.7 Nerve branches to the eye should
be dissected with particular care: even transient weakness of
these branches may have a significant impact on morbidity.
Troubleshooting
Special efforts should be made to ensure that the cartilage
of the ear canal is not injured during exposure of the facial
nerve trunk. Any injury to this cartilage must be repaired, or
else an intense whistling will be heard from the closed suction
drain after operation.
The anxiety associated within isolation of the nerve trunk
may be alleviated somewhat by keeping in mind that the
nerve typically lies deeper than one might expect. In a study
of 46 cadaver dissections, the facial nerve was found to lie at
a median depth of 22.4 mm from the skin at the stylomastoid
foramen (range, 16 to 27 mm). The diameter of the nerve
trunk was found to range from 1.1 to 3.4 mm.8 In our expe-
rience, the facial nerve trunk is slightly larger than the nearby
deep vessels.
Some surgeons advocate the use of a nerve stimulator to
aid in identifying the facial nerve trunk or its branches; how-
ever, we have substantial reservations about whether this
Figure 3 Parotidectomy. Depicted is identification of the
facial nerve at its trunk. A wide trough is created anterior to
measure should be employed on a regular basis [see Compli-
the external auditory canal and deepened by spreading a blunt cations, Facial Nerve Palsy, below]. Knowledge of the ana-
curved instrument in a direction perpendicular to the incision tomy and sound surgical technique are the keys to a safe
and parallel to the nerve trunk. Anatomic landmarks assist in parotidectomy; it may be hazardous to rely too much on
identification of the nerve. practices that may diminish them.
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step 3: parenchymal dissection The vertical portion of the dissection seldom poses a threat
Once identified, the plane of the facial nerve remains uni- to the integrity of the facial nerve, but care must be taken to
form throughout the gland (unless the nerve is displaced by maintain appropriate margins. If division of Stensen’s duct is
a tumor) and serves to guide the parenchymal dissection. required, the distal remnant may be either left open12 or
Although some surgeons advocate the use of hemostatic ligated.
devices for parenchymal division,9,10 our practice is to divide Caution is appropriate in the resection of deep-lobe tumors.
the substance of the parotid gland sharply and use ligatures Tumors medial to the facial nerve may displace this structure
as appropriate when bleeding is encountered. Usually, there laterally. Thus, after establishing the plane of the facial nerve,
is no significant hemorrhage: loss of more than 30 mL of the surgeon must remain careful when dissecting near the
blood is rare. tumor to keep from injuring the nerve. Once the substance of
The parenchymal dissection proceeds directly over the the gland obscuring the tumor has been removed, the nerve
facial nerve. We favor using fine curved clamps for this branches in the area of the tumor are retracted to allow expo-
portion of the procedure. To prevent trauma to the nerve, sure of the deep portion of the gland and facilitate resection.
care must be taken to resist the tendency to rest the blades of Traction injury to the nerve may still result in transient facial
the clamp on the nerve during dissection. Each division of the weakness.
gland should reveal more of the facial nerve [see Figure 4].
Troubleshooting
When this is the case, the surgeon can continue the paren-
chymal dissection with confidence that the nerve will not Complete superficial parotidectomy with full dissection of
be injured. As a rule, if a parenchymal division does not all facial nerve branches is seldom necessary, though in some
immediately show more of the facial nerve, it is in an improper cases it is mandated by tumor size or histologic findings.
plane. Removal of the entire superficial lobe with the intention of
We do not regularly resect the entire lateral lobe of the obtaining a larger lateral margin is rarely useful, because the
parotid unless the tumor is large and such resection is required closest margin is usually where the tumor is nearest the facial
on oncologic grounds. The goal in resecting the substance of nerve. Even temporary paresis of the temporal-frontal branch
the parotid is to obtain sound margins while preserving the of the facial nerve may have devastating consequences, and
remainder of the gland. This so-called partial superficial dissection near this branch is usually unnecessary in treating
parotidectomy has been shown to reduce the incidence of a benign tumor in the parotid tail. Any close margins remain-
Frey syndrome without increasing the rate of recurrence of ing after nerve-preserving cancer treatment can be addressed
pleomorphic adenoma.11 The plane of dissection is developed by means of postoperative radiation therapy, usually with
along facial nerve branches until the lateral margins have excellent results.13
been secured. This is the portion of the procedure during The question of whether to sacrifice the facial nerve almost
which the risk of nerve injury is highest. Once the lateral invariably arises in the setting of malignancy. In our view, this
margins have been secured, the parenchymal dissection can measure is seldom necessary. Benign tumors tend to displace
proceed from deep to superficial for the excision of the tumor. the nerve, not invade it. Sacrifice of the nerve probably does
not enhance survival.14,15 Although this issue remains a sub-
ject of debate, our practice, like that of others,16 is to sacrifice
only those branches intimately involved with tumor. Repair,
if feasible, should be performed [see Complications, Facial
Nerve Injury, below].
step 4: drainage and closure
Before closure, absolute hemostasis is confirmed (including
hemostasis during the Valsalva maneuver, which is approxi-
mated by transiently increasing airway pressure to 30 cm
H2O1). We may then assess the integrity of the facial nerve
with a nerve stimulator. A 5 mm closed suction drain is
placed through a stab incision posterior to the inferior aspect
of the ear in a hair-bearing area. The tip of the drain is loosely
tacked to the sternocleidomastoid muscle, with care taken to
avoid direct contact with the facial nerve). The wound is
closed with the drain placed on continuous suction. The skin
is closed with interrupted 5-0 nylon sutures. Bacitracin is
applied to the wound. No additional dressing is necessary or
desirable [see Figure 5].
Troubleshooting
Figure 4 Parotidectomy. Dissection of the gland
The use of interrupted skin sutures instead of a continuous
parenchyma is carried out over the branches of the facial
nerve to minimize the risk of nerve injury. Each division of suture allows the surgeon to perform directed suture removal
the substance of the gland should reveal more of the facial to drain the rare postoperative hematoma or fluid collection
nerve. instead of reopening the entire wound.
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a
b
Figure 5 Parotidectomy. Shown is drainage and closure after parotidectomy. (a) A closed suction drain is placed in the
operative bed and loosely tacked to the sternocleidomastoid muscle. (b) Interrupted monofilament sutures are used for the skin.
Bacitracin is applied. No additional dressings are used.
Postoperative Care Complications
Facial nerve function is evaluated in the recovery room, facial nerve injury
with particular attention paid to whether the patient is able
to close the eyelid. The patient resumes eating when nausea Studies have found that transient paralysis of all or part of
(if any) abates. Pain is generally well controlled by means of the facial nerve occurs in 17 to 100% of patients undergoing
oral agents. At discharge, the patient should be warned to parotidectomy,17–20 depending on the extent of the resection
protect the numb earlobe against cold injury. The closed and the location of the tumor. Fortunately, permanent paral-
suction drain is kept in place for 5 to 7 days (until the ysis is uncommon, occurring in fewer than 5% of cases.19,21
first postoperative visit) to minimize the risk of salivary Nerve monitoring has been advocated to reduce the
fistula. incidence or severity of facial nerve injury, particularly in the
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setting of surgery for a recurrent parotid tumor.22 To date, iodine test is employed, the incidence of Frey syndrome
however, no randomized trial has demonstrated that intra- may reach 95% at 1 year after operation.25 Fortunately, the
operative facial nerve monitoring or nerve stimulators yield majority of patients have only subclinical findings, and only a
any significant reduction in the incidence of facial nerve small fraction complain of debilitating symptoms.25 Most
paralysis after either primary parotidectomy or recurrence symptomatic patients are adequately treated with topical
surgery. Indeed, indiscriminate use of nerve monitoring and antiperspirants; eventually, however, they tend to become
nerve stimulators may imbue the surgeon with a false sense noncompliant with such measures, preferring simply to dab
of security and cause him or her to pay insufficient attention the face with a napkin while eating.25 Despite the relatively
to the appearance of nerve tissue. Transient nerve dysfunc- low incidence of clinically significant Frey syndrome, there is
tion may follow inappropriate (or even appropriate and an extensive literature addressing prevention and additional
unavoidable) trauma to or traction and pressure on nerve treatment of this condition.11,21,26–34
trunks. Nerve monitoring does not prevent such problems;
sialocele (salivary fistula)
moreover, it adds to the cost of the procedure and lengthens
the operating time.23 Some, in fact, have suggested that Sialocele, or salivary fistula, has been reported to occur
nerve stimulators may actually increase transient dysfunction. after 1 to 15% of parotidectomies.11,35 Although this condi-
Accordingly, our use of nerve stimulators is selective. tion is generally minor and self-limited, it may nonetheless be
The management of facial nerve injury depends on when embarrassing for the patient. We believe that the incidence of
the injury is discovered and on how sure the surgeon is of the sialocele can be reduced by maintaining closed suction drain-
anatomic integrity of the nerve. If the injury is discovered age for 5 to 7 days (to facilitate adhesion of the skin flaps to
intraoperatively, it should be repaired if posssible. Primary the underlying parotid parenchyma). Postparotidectomy sali-
repair—performed with interrupted fine permanent monofila- vary fistula is usually attributable to gland disruption rather
ment sutures under magnification24—is preferred if sufficient than to duct transection and therefore tends to resolve with-
nerve is available for a tension-free anastomosis. If both tran- out difficulty.36 Compression dressings are generally effec-
sected nerve ends are identified but tension-free repair is not tive.35 Anticholinergic agents have been used in this setting as
feasible, interposition nerve grafts may be used. A sensory well.37–40 Low-dose radiation,41 completion parotidectomy,
nerve harvested from the neck (e.g., the great auricular nerve) and tympanic neurectomy42 have all been employed in
is often employed for this purpose. If the nerve is injured refractory cases.
(or deliberately sacrificed) in conjunction with treatment
cosmetic changes
of malignancy, use of nerve grafts from distant sites may be
indicated.24 Parotidectomy creates a hollow anterior and inferior to the
If unexpected facial nerve dysfunction is identified in the ear, which may extend behind the mandible and may reach a
postanesthesia care unit and if the surgeon is unsure of the significant size in patients with large or recurrent tumors.
anatomic integrity of the nerve (ideally, a rare occurrence), This cosmetic change is a necessary feature of the procedure,
the patient should be returned to the operating room for not a complication; nonetheless, it should be discussed with
wound exploration so that either the continuity of the nerve the patient before operation. Many augmentation methods,
can be confirmed or the injury to the nerve can be identified using a wide variety of techniques, have been devised for
and, if possible, repaired. When the surgeon is certain that improving postoperative appearance (as well as alleviating
the nerve is intact, facial nerve dysfunction can be managed Frey syndrome).27–31,43,44 All of these methods have limitations
without reoperation, in anticipation of recovery24; however, or drawbacks that have kept them from being widely applied
this may take many months. and accepted.
Management of enduring facial nerve paralysis (from any
cause) is beyond the scope of our discussion and constitutes Outcome Evaluation
a surgical subspecialty in itself.24 With proper surgical technique, superficial or partial super-
ficial parotidectomy can be performed safely and within a
gustatory sweating (frey syndrome)
reasonable operating time. The requirement for blood trans-
Gustatory sweating, or Frey syndrome, occurs in most fusions should be vanishingly rare. Given adequate exposure,
patients after parotidectomy; it has been seen after good knowledge of the relevant anatomy, limited trauma to
submandibular gland resection as well. The symptom com- the nerve, and appropriate use of closed suction drains (see
plex includes sweating, skin warmth, and flushing after above), complications should be uncommon. Although
chewing food and is caused by cross-innervation of the para- patients may tolerate parotidectomy on an outpatient basis,
sympathetic and sympathetic fibers supplying the parotid we prefer to keep them in the hospital overnight. Patients
gland and the overlying skin. The reported incidence of should be able to leave the hospital with minimal pain, com-
Frey syndrome varies greatly, apparently depending on the fortable with their drain care, by the morning of postoperative
sensitivity of the test used to elicit it. When Minor’s starch day 1.
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