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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.

This is a malignant tumour of salivary gland origin. It may occur in any of the paired salivary glands (submandibular, sublingual or parotid) but also may occur in the minor salivary glands in the upper aerodigestive tract. It is a high grade tumour that if cure  is the aim, the primary treatment is that of surgical resection. This means a parotidectomy if the site of origin is in the parotid gland a extended submandibular gland excision if the tumour is in the submandibular gland and a wide local excision if the tumour is anywhere else. The overall management of these tumours is best undertaken in a Head and Neck Cancer Center.

Radiotherapy can be used as an adjunct to surgery for microscopic disease control but is of little benefit if it is the only upfront treatment of this salivary gland tumour.

Unfortunately patients with adenoid cystic carcinoma can develop distant metastasis many years after surgery typically in the lungs but can also have local nerve spread referred to as perineural invasion.

Freys syndrome is not an uncommon phenomenon after surgery to the parotid gland (parotidectomy). The patient complains of sweating on the cheek, face or neck. Its name comes from a female french neurologist who described the phenomenon.

If warned preoperatively few patients have a problem from the phenomenon. However in some the problem is significant and extremeley problematic. Peole have advocated redivision of the nerves and interposition of soft tissue, the use of Botox or simply the use of antiperspirants in the area.

Freys syndrome occurs because of division of branches of the auricultemporal nerve which carry sympathetic nerve supply to sweat glands and parasympathetic fibres to the parotid. Rerouting causes the abnormal sweating on eating.

In the vast majority of patients the correct treatment is do nothing at all.

Parotidectomy - Anatomy and Physiology

The parotid glands are paired glands that are situated in front of the ears typically but portions of them extend below the ear and occasionally behind the lower ear. They are a salivary gland and are one of three major paired salivary glands the other two being the submandibular and sublingual glands. In addition there are multiple other minor salivary glands dotted around the oral cavity that help with saliva production.

Occasionally swellings occur in the parotid gland. It is important to determine if these swellings are benign or malignant. This can be done with a careful history and examination together with investigations such as fine needle aspirate cytology and further radiological imaging.

Thankfully over 90 % of swellings in the parotid are benign in their nature, however, even if benign they have a tendency to grow and it may be prudent to have them removed.

Parotidectomy

This operation requires some skill and experience as there are some definite hazards involved with doing the procedure.

Most importantly the facial nerve runs through the parotid gland and there is always a small risk of damaging it. This nerve has a number of branches that make you blink wink and smile on that side of your face. More often than not this damage is related to bruising and therefore temporary effect. The effect of this depends on the portion of the nerve that is affected. It is critical that the surgeon knows his landmarks and can identify follow and preserve the nerve and it’s branches to decrease the chances of damage.

A carefully placed incision often leaves a very difficult to spot scar, however, some people have a tendency to overscarring (hypertrophic or keloid scarring).

Incision for parotidectomy

It is not uncommon to have a numb feeling of the ear on the side that is operated on. This is related to the nerve supply to this portion of the ear that often is sacrificed in the approach. Most patients cope well with this as long as they are told in advance.

An unusual effect of the operation is that a large percentage of patients will experience sweating in and around the neck on chewing and eating. This side effect of the operation is called Frey’s syndrome or gustatory sweating as usually is not too troublesome a symptom.

The operation itself is performed under a general anaesthetic and the nerve will be stimulated or monitored through the operation.The operation may take between one to three hours on average depending on the degree of difficulty involved.

Normally patients would have a drain placed that would stay in place for a day or two and on removal usually can go home with an out-patient follow up with the results of the specimen sent for histology.

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.