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Parotidectomy is the operation to remove a lump in the parotid gland. This may be a malignant or benign lump but the approach is very often similar albeit that the operation may vary in its extent for these. It is extremely rare to place the incision just over thelump itself even for the limited extracapsular dissection sometimes undertaken. Most incisions avail of relaxed skin tension lines.

My choice of incision is a lazy S cervico facial incision. This is an incision that starts in the skin crease just in front of the ear, goes under the lobe and then heads down in a neck skin crease 2 finger breadths below the jaw line. This approach gives excellent access to find the facial nerve and to remove the tumour. Aesthetically this works very well too. Some people favour the face lift approach, where after the incision in front of the ear the incision is taken behind the ear and down the hair line. This does work and hides more of the incision but does limit access in some situations, especially when undertaking malignant workload.

An alternative to a parotidectomy, a less invasive operation does exist referred to as a extracapsular parotidectomy. This is not an operation practiced by all surgeons!

The concept behind it in comparison with the traditional parotidectomy is that the facial nerve is not sought for prior to the removal of the tumour. The tumour is removed from the parotid gland alone, not with any parotid tissue.

The benefits include not so large an operation with potentially decreased complications

The problems associated with it include the incidental malignant tumour being found, poor margins/spillage on tumour removal (therefore risk of recurrence), the potential risk to a branch of the facial nerve deeper than the tumour.

I do not perform a extracapsular dissection. It is my feeling that this operation is suitable for very small localised superficial tumours. I also feel happier identifying the nerve at the start of the operation which anatomically is in a set position and I fell I perform a thourough operation for the patient with minimal risk of tumour spillage.

The facial nerve is very important as damage to it can cause assymetry in the ability to blink, wink, smile and chew food. The facial nerve unfortunateley lies in the middle of the parotid gland and in a formal parotidectomy is found and preserved.

Thankfully the majority of parotid surgery is performed for benign lesions and so the facial nerve is not significantly at risk. Malignant parotid disease is quite different as often the facial nerve function may have already been affected by the disease process and there may be a need to sacrifice part or all of the nerve.

When looking for the nerve typically the surgeon should have experience with parotid surgery as this will allow him to find it with certainty using normal anatomical landmarks he or she is used to. Once the main trunk is found the nerve should not be handled if at all possible as the less it is touched the less of a chance of weakness postoperativeley will develop.

Inevitably some weakness can ensue even with benign disease and even when the facial nerve is deemed completeley intact at the end of the operation. This sometimes relates to minor trauma to the nerve during the operation and often returns in the few months postoperativeley. One does notice clinically the older a patient is the more sensitive the facial nerve is to this transient weakness postoperativeley and this may be related to a deterioration in the blood supply to the nerve with age. If a nerve is sacrificed the surgeon should be planning or know what to do in this eventuality and it may involve grafting the lost portion of nerve or hitching part of other cranial nerves to the damaged facial nerve for some residual stimulation.

Most importantly for a good result both clinically and for the facial nerve, if a patient is to be operated on for a parotidectomy the surgeon should be well practiced in this surgical technique ie a surgeon with an interest in Head and Neck Surgery.