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Parotidectomy

Updated: Feb 08, 2016


Author: Alexander Langerman, MD; Chief Editor: Arlen D Meyers, MD, MBA

Overview

Background

The parotid gland is a primarily serous salivary gland that is located high in the neck in
the preauricular area extending towards the cheek. The extratemporal facial nerve and
its branches pass through the parotid gland and supply motor innervation to the muscles
of facial expression, as well as to the postauricular muscles, the posterior belly of the
digastric muscle, and the stylohyoid muscles.
The motor branches to the face are divided into cervicofacial and temporofacial
branches, with the former supplying the muscles of the mouth and neck and the latter
supplying the muscles of the forehead and eye (there is some overlap in the nasal
region). There is no anatomic feature that formally separates the parotid gland into
superficial and deep lobes, but the plane of the facial nerve (see the image below)
generally serves for demarcation of the superficial and deep portions of the gland.
Surgical landmarks to the facial nerve include the tympanomastoid suture line, the
tragal pointer, and the posterior belly of the digastric muscle. The tympanomastoid
suture line lies between the mastoid and tympanic segments of the temporal bone and is
approximately 6-8 mm lateral to the stylomastoid foramen. The main trunk of the nerve
can also be found midway between (10 mm posteroinferior to) the cartilaginous tragal
pointer of the external auditory canal and the posterior belly of the digastric muscle.
The nerve is usually located inferior and medial to the pointer. For more information
about the relevant anatomy, see Facial Nerve Anatomy.
A superficial (or lateral) parotidectomy involves removing all of the gland superficial
to the facial nerve, whereas a partial superficial parotidectomy involves removing only
the portion of the gland surrounding a tumor or mass. In a partial superficial
parotidectomy, only some branches of the facial nerve are usually dissected, whereas in
a formal superficial parotidectomy, the entire cervicofacial and temporofacial divisions
are dissected.
For a total parotidectomy, the superficial gland is dissected free of all of the facial nerve
branches to the extent feasible, and the branches are then completely mobilized and the
deep portion of the gland removed. Many deep lobe or parapharyngeal parotid tumors
can be approached transcervically rather than by means of parotidectomy; however,
this transcervical technique is not discussed in this article.

Indications

Neoplasms are the most common indication for parotidectomy. The vast majority of
primary parotid tumors are benign, but approximately 20% are found to be malignant.
In addition, regional and distant disease can metastasize to the parotid and necessitate
removal for diagnosis or cure.
Inflammatory processes (eg, chronic parotitis, deep salivary calculi, or parotid abscess)
are occasionally treated with total parotidectomy, with the recognition that surgery in
an inflamed gland probably carries a higher risk of postoperative facial nerve
dysfunction. [1]
Sialorrhea is rarely treated with parotidectomy; more often, it is medically managed
with antisialagogues or botulinum toxin or treated with duct ligation.

Contraindications
Patients with benign tumors who are at high anesthetic risk may be observed on a
case-by-case basis.
Patients with multiple parotid cysts should be tested for HIV before undergoing
surgical excision. Benign lymphoepithelial cysts are relatively common in the
HIV-positive population but otherwise uncommon. Because these cysts are usually
multiple and tend to recur, they are typically managed by means of repeated aspiration
or sclerotherapy rather than parotidectomy; they may also respond to antiretroviral
therapy. [2]

Technical Considerations

Positive identification and preservation of the facial nerve are essential for preventing
inadvertent facial nerve injury. A thorough understanding of the anatomy of the
stylomastoid foramen, the facial nerve, and the parotid gland and its surrounding
structures underlies identification and preservation of the nerve.
Whenever possible, a normal cuff of parotid tissue should be resected around a tumor to
prevent recurrence. In the setting of a benign tumor, if a facial nerve branch is found
directly on the tumor capsule, the nerve should be gently dissected off the tumor. In the
setting of a malignancy, consideration should be given to sacrificing as opposed to
preserving the nerve (see Technique).
Raw gland surface contributes to postoperative salivary leakage (sialocele or salivary
fistula) In addition, raw gland apposed to skin provides a ready pathway for
postganglionic parasympathetic fibers to migrate from the salivary tissue and
cross-innervate facial sweat glands, resulting in gustatory sweating (Frey syndrome).
Efforts should be made to close the parotid capsule after removal of a parotid tumor or
a portion of the gland. If closure of the capsule is not feasible, consideration should be
given to interposing tissue or implantable biologic material (eg, acellular dermis)
between the raw gland and the skin.
Injury to the posterior branch of the greater auricular nerve, which supplies sensation to
the ear, is often avoidable. If the nerve must be cut, it can be marked with a stitch to
facilitate reapproximation at the conclusion of the case. Patients should be warned to
expect at least temporary earlobe numbness and should take precautions to prevent heat
or cold injury to the insensate area (eg, frostbite or curling iron burns).
Closed suction drainage is used in most cases to prevent postoperative hematoma or
seroma.