Академический Документы
Профессиональный Документы
Культура Документы
Parotidectomy
Updated: Feb 08, 2016
Author: Alexander Langerman, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
OVERVIEW
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.
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]
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.
Periprocedural Care
Preprocedural Planning
Measures that may be considered before parotidectomy include diagnostic imaging, fine-needle
aspiration (FNA), neck dissection, and antibiotic prophylaxis.
Preoperative imaging
Both computed tomography (CT) and magnetic resonance imaging (MRI) can be helpful in operative
planning, but they may not be necessary in patients with small, mobile tumors of the parotid tail. Any
clinical feature suggestive of malignancy (eg, lymphadenopathy, fixation to surrounding structures, or
preoperative facial nerve weakness) warrants radiographic evaluation of the parotid gland and nodal
basins in the neck.
Imaging can provide useful clues to the relation between the tumor and the facial nerve. If the tumor
lies in a plane inferior to the stylomastoid foramen, the nerve will probably lie on the superior surface
of the tumor; likewise, if the tumor is high in the gland, the nerve may pass inferiorly. If the tumor
occupies the most superficial portion of the gland, with a significant area of parotid tissue deep to it,
the nerve is likely to be deep to the tumor (see the image below); similarly, a deep tumor abutting the
mandible should have the nerve on its superficial surface.
Axial contrast-enhanced CT scan demonstrating mass in right parotid. Mass extends to superficial surface of gland, but
uninvolved parotid is seen between mass and mandible. Facial nerve would likely be found deep to mass in this situation (and
was in this patient). Image courtesy of Dr. Alexander Langerman.
It should be kept in mind, however, that these statements represent general tendencies, not ironclad
laws. They should not be used as substitutes for proper intraoperative identification of the facial
nerve.
FNA can be used to diagnose parotid tumors preoperatively with a high degree of sensitivity and
specificity. [3] With small, mobile tumors of the tail of the parotid, preoperative histologic diagnosis
may not be required, but even in this setting, such diagnosis can contribute to patient counseling and
informed consent.
If a malignant tumor is suspected on the basis of radiographic evaluation (see above) or physical
examination, FNA should be done to establish the diagnosis and help guide operative planning. If
preoperative FNA is nondiagnostic, intraoperative frozen-section evaluation can be used to establish
the diagnosis in most cases. [3]
Neck dissection
Removal of all palpable or radiographically suspicious lymph nodes via selective neck dissection is
appropriate in the setting of malignancy. Elective neck dissection is controversial and usually is
performed only for high-grade malignancies in the N0 neck. [4, 5]
Antibiotic prophylaxis
The use of perioperative antibiotics is controversial and may not be necessary in cases where no
infection exists before the operation. The authors typically give only 24 hours of a first-generation
cephalosporin but administer antibiotics more liberally if an implantable biological material such as
acellular dermis is used. In most patients, closed suction drains are removed once drainage
minimizes, but the authors empirically maintain the drains for longer (about 7 days) if acellular dermis
was used.
Equipment
Some surgeons use a facial nerve monitor to facilitate identification of the facial nerve. This device
consists of electromyography (EMG) electrodes that are placed, at a minimum, in the orbicularis oris
and the orbicularis oculi. Stimulation of the cervicofacial and temporofacial divisions of the facial
nerve causes the respective muscles to contract. In addition to the stimulation inherent in
manipulation of the nerve, a probe can be connected to the monitor to permit direct stimulation of
suspected nerve branches.
At present, there is no substantial evidence to suggest that continuous EMG facial nerve monitoring
prevents injury to the facial nerve. [6, 7] Moreover, intraoperative abnormalities on the facial nerve
monitor have not been shown to predict postoperative dysfunction. [8]
The facial nerve can also be monitored through simple observation of facial twitching, although such
monitoring requires a vigilant observer during facial nerve dissection. When identification of the facial
nerve is in question, the nerve can be directly stimulated with a handheld nerve stimulator to elicit
twitching.
Patient Preparation
Anesthesia
Parotidectomy is typically performed with the patient under general anesthesia. To allow adequate
monitoring of the facial nerve, paralytics should not be used beyond the induction of anesthesia. It is
important to confirm that the patient has regained full motor function (as determined by twitch
monitoring) before attempting to dissect out the facial nerve and its branches.
Positioning
The patient is placed in the supine position with the head turned as far as possible away from the side
of the operation. A shoulder roll can help with neck extension and thereby facilitate surgical exposure.
The eye on the side to be operated on is lubricated and closed with either a transparent dressing or a
fine suture that approximates the lids (the so-called tarsorrhaphy stitch). If continuous facial nerve
monitoring is to be performed, monitoring electrodes are placed (at a minimum) in the orbicularis oris
and the orbicularis oculi, and grounding electrodes are placed outside the field. Incisions are marked
(see Technique), and local anesthetic with epinephrine is injected into the skin.
The face may be covered in a transparent dressing or may be prepared, with particular care taken
around the eyes and mouth. The remainder of the operative field is prepared, including the temple, the
ear, the preauricular and postauricular areas, and the neck. A cotton ball can be placed in the ear canal
during prepping to prevent cleaning solution from collecting and causing postoperative irritation.
If a mass develops lateral to the sternocleidomastoid in the location of the greater auricular nerve, a
greater auricular neuroma should be considered. Such masses tend to be painful with manipulation.
Diagnosis is accomplished through FNA or removal, especially in the setting of a previous malignancy.
Technique
Approach Considerations
Incisions should be camouflaged in normal facial contours. Postauricular and neck incisions are
designed to produce flaps with a broad base to avoid long, sharp corners, which are prone to
decreased blood flow and skin necrosis. The position of the earlobe should be precisely marked for
repositioning at the conclusion of the case.
Positive identification and preservation of the facial nerve are essential to prevent inadvertent facial
nerve injury. An expert in parotid surgery is an expert in facial nerve anatomy.
Whenever possible, tumors should be resected with a margin of normal parotid tissue to prevent
recurrence.
Any raw gland surface remaining at the conclusion of the procedure should be covered to prevent
salivary leakage and minimize the risk of gustatory sweating (Frey syndrome).
Parotidectomy
Skin incisions are placed with consideration of whether a neck dissection is necessary (see
Periprocedural Care). The anterior skin incision can be placed either in the preauricular crease or
posttragally, in the manner of a facelift [9] (see the image below).
Cosmetically guided parotidectomy incision, designed pretragally. Dotted line identifies hairline. Incision is carried
postauricularly to yellow mark for small mass removal, to orange mark for larger operation, and to red mark if neck dissection
is included. Note that earlobe position has been marked with dots of methylene blue. Image courtesy of Dr. James Netterville.
The earlobe position is marked, and the incision is continued posteriorly under the earlobe with an
adequate cuff of skin to prevent tethering of the lobule and a pixie-ear deformity. The incision
continues for a variable distance posteriorly and may be extended into the hairline for cosmesis or
curved down to a prominent neck crease to allow a neck dissection.
After the patient is prepared as described previously and incisions are made, an anterior
subplatysmal/subsuperficial musculoaponeurotic system (SMAS) flap is made by using the natural
plane on the surface of the parotid gland. This incision is carried beyond the extent of the tumor to
completely expose parotid fascia anterior to the tissue to be removed.
Great caution is exercised in approaching the zygomatic arch, the anterior border of the parotid gland,
and the submandibular fascia, all of which are areas where distal branches of the facial nerve emerge
from the gland.
A posterior flap is then raised at the level of the sternocleidomastoid (SCM) fascia. At the uppermost
end of the SCM, some muscle fibers insert into the skin; these must be transected. The greater
auricular nerve branches and the external jugular vein are identified, and the plane is developed
superficial to these structures.
At this point, if necessary, the anterior branch of the greater auricular nerve is transected sharply and
tagged for reanastomosis. The proximal end is left enveloped in SCM fascia to facilitate
reapproximation at the end of the case (see the image below). It is often necessary to ligate the
external jugular vein.
Greater auricular nerve has been transected near junction of parotid gland and sternocleidomastoid (SCM). Junction is
marked with dotted line. Proximal nerve is left enveloped in fascia of SCM to aid in reapproximation at end of case. Posterior
branch of greater auricular nerve can be seen crossing SCM more superiorly and was left intact. Image courtesy of Dr.
Alexander Langerman and Dr. James Netterville.
The tail of the parotid gland is elevated off the SCM until the posterior belly of the digastric muscle is
seen. During this maneuver, one should watch for the small nerve branch to the posterior belly of the
digastric muscle, which is not always seen but can provide a clue to the location of the facial nerve.
More important in this area is to avoid the cervical and marginal branches, which usually pass over
the facial veins and in the submandibular fascia.
The posterior gland is then separated from the cartilage of the tragus and the external auditory canal,
with care taken to preserve the perichondrium. This elevation is continued deep to the bony-
cartilaginous junction. Once this step is accomplished, attention is turned to identification of the facial
nerve.
The basic principle of facial nerve dissection is to avoid any unnecessary stimulation of the nerve.
Specific tools used in dissection vary from surgeon to surgeon and include cold, bipolar
electrocauterization, and ultrasonic dissection. Most surgeons caution against the use of a
monopolar cautery in close proximity to the facial nerve.
The styloid process can be exposed bluntly from a superior approach, and the nerve is found
inferolateral to it
The so-called tragal pointer is a triangular extension of cartilage inferiorly off the tragus and
suggests the location of the facial nerve in the direction of its inferoanterior point
The posterior belly of the digastric muscle crosses the SCM approximately 1 cm inferior and 1
cm superficial to the location of the nerve; it is highly useful as a marker of the depth of the
facial nerve
Any peripheral branch, including the branch to the digastric muscle, can be followed back to the
main trunk, which is then dissected in the usual fashion
The mastoid can be drilled to allow identification of the facial nerve in settings of severely
abnormal anatomy, complicated revision surgery, or large tumors abutting the stylomastoid
foramen
Once the nerve is identified, it is traced to the pes anserinus, the structure marking the separation of
the cervicofacial (lower) and temporofacial (upper) divisions (see the image below).
Main trunk of facial nerve (asterisk) has been exposed to pes anserinus, branch point of upper (U) and lower (L) divisions.
Image courtesy of Dr. Alexander Langerman.
Smaller branches are then followed carefully with the aim of mapping their relation to the tumor. The
typical approach is to start at the uppermost branch of the upper division or the lowermost branch of
the lower division, as appropriate, and follows the branch out to a point where it is well clear of the
tumor. The next branch is then followed, and so forth, until all branches in the area of the tumor are
dissected free and the tumor is mobilized for removal.
A common technique for nerve dissection is to use a small, fine hemostat or a nonlocking, smooth-
jawed, right-angle dissector (McCabe facial nerve dissector) to gently elevate the parotid tissue in the
natural plane just superficial to each nerve. The tissue lateral to and between the tines of the
instrument is sealed with a bipolar cautery and divided, and the process is continued. Very cautious
and gentle traction of the nerve can be accomplished with gauze held in a forceps (see the image
below).
Branch of facial nerve is dissected in natural plane just superficial to nerve with McCabe dissector. Gentle back traction is
applied with small gauze sponge, and free gland is pulled away by clamp to provide forward traction. Image courtesy of Dr.
Alexander Langerman.
If the whole gland is to be removed and not just the cuff of gland around the tumor, all of the facial
nerve branches are dissected and mobilized, and the deep parotid tissue is then removed from
between the branches. If a tumor must be removed from the deep lobe via a lateral approach (as with
a tumor invading between nerve branches from the superficial lobe), some authors advocate selective
division of some nerve branches with immediate reanastomosis after tumor removal to avoid
stretching branches and causing permanent dysfunction.
Once tissue removal is complete, the facial nerve can be tested with a handheld stimulator or monitor
probe to confirm that it is unharmed. Repeated unnecessary stimulation of the nerve, however, is to be
avoided out of concern for potential injury.
After the patient is gently awakened and has recovered from anesthesia, the face is examined for
motor nerve function. If the facial nerve was not identified as intact and the patient wakes up with a
dense paralysis that persists beyond the effects of any local anesthetic, reexploration should be
considered. If the nerve is known to be intact, the patient can be reassured that mild postoperative
facial nerve weakness will usually resolve completely.
Many techniques are used for reconstruction. In small resections, the parotid capsule can often be
closed primarily. In larger resections, the defect can be filled with autologous buccal or abdominal fat
(see the first image below) or acellular dermis (see the second image below).
Abdominal fat with attached dermis has been implanted in parotidectomy defect. Fat maintains bulk well over time if handled
atraumatically, and dermis allows closure of capsule. Image courtesy of James Netterville and Alexander Langerman.
Rolled acellular dermis used to fill small defect after removal of parotid tumor. Image courtesy of James Netterville and
Alexander Langerman.
The digastric muscle can be cut at the intermediate tendon and the posterior belly rotated into the
defect, or a superiorly based flap that includes a portion of the SCM can be used in a similar manner.
However, muscle reconstruction tends to lose volume over time. In massive resections involving
removal of mandible or skin, options include skin (eg, cervicofacial), myocutaneous (eg, pectoralis
major), and free flaps.
To reconstruct the greater auricular nerve, the fascia next to the opposing ends of the cut nerve are
sutured together to allow tension-free neurorrhaphy. Interrupted 8-0 or 9-0 nylon sutures are then
placed in the perineurium to reapproximate the nerve. If the nerve cannot be reapproximated, some
authors advocate clipping or burying the proximal end to prevent neuroma formation, although
evidence for the effectiveness of these techniques is lacking.
Once reconstruction is complete, closed suction drains are placed through stab incisions in the
posterior neck or hairline. The skin is then closed in layers in an interrupted fashion. To prevent a
pixie-ear deformity, care is taken not to put excessive tension on the earlobe.
Complications of Pr ocedure
Potential complications of parotidectomy include facial nerve injury, Frey syndrome, salivary leakage,
ear numbness, facial asymmetry, flap necrosis, and tumor recurrence.
Unintentional injury to the facial nerve is the most devastating complication of parotid surgery. In a
study of surgery for benign disease, temporary postoperative weakness was reported in 18-65% and
permanent weakness in 0-19%. [10] This risk must be explicitly discussed with every patient
undergoing parotid surgery. Even with ostensibly perfect technique, facial nerve injury can occur for
unknown reasons. If injury occurs, timely diagnosis and a sensitive bedside manner are essential to
prevent further complications and minimize potential litigation. [11]
If the motor supply to the orbicularis oculi is weak or absent, aggressive eye care must be instituted to
prevent corneal drying and injury. Such care includes the use of lubricants, taping the eye shut at night,
and moisture chambers during the day. Consultation with an ophthalmologist may be warranted.
If long-term paralysis occurs, static facial rehabilitation techniques may be used, including brow lift,
gold weight insertion and canthoplasty, and facial slings. Dynamic techniques or nerve repair may
also be appropriate.
The incidence of Frey syndrome may be correlated with the amount of gland removed. It has been
suggested that the greater the quantity of parotid tissue removed, the greater the amount of raw
surface available to provide aberrant innervation to the skin. To minimize this risk, the authors make
an effort to interpose gland capsule, autologous tissue, or implantable biologic material between the
gland and the skin.
If Frey syndrome develops, various interventions may be employed, including topical application of
antiperspirant, injection of botulinum toxin, and surgical interposition of tissue (eg, temporoparietal
fascia or SCM) or implantable material (eg, acellular dermis). [13] Surgical approaches carry the risks
associated with reoperative surgery but are usually effective in minimizing or eliminating Frey
syndrome.
Salivary leakage
Raw gland surface can result in a collection of saliva below the skin (sialocele) or leakage of saliva
from the wound (salivary fistula) in 1-14% of patients. [10]
Conservative measures include drainage of sialoceles with pressure dressings. Salivary fistula can be
treated with local wound revision if low-flow leakage is present. Botulinum toxin, by blocking the
release of acetylcholine from postganglionic parasympathetic fibers, results in decreased salivary
flow and has been reported to be remarkably effective in several small series. [14, 15, 16] Recalcitrant
salivary leakage may necessitate surgical reexploration.
Ear numbness
Hypoesthesia in the distribution of the greater auricular nerve occurs in almost all patients undergoing
parotid surgery. The numbness lessens over time in some patients. Its incidence may be reduced by
making efforts to preserve the greater auricular nerve. [10] When the greater auricular nerve must be
sacrificed, the authors perform neurorrhaphy at the conclusion of the case whenever possible.
Facial asymmetr y
The significance of the defect and the resulting facial asymmetry after parotidectomy is related to the
amount of gland removed and the thinness of the patient. Patients with more subcutaneous fat may
be better able to hide small defects than thin patients are and therefore may not require
reconstruction. The authors tend to reconstruct most defects if potential asymmetry is a question.
Acellular dermis, rolled and implanted in the defect, can both reconstruct normal facial contours and
serve to close the parotid capsule and cover raw gland surface.
Local rotation of the posterior belly of the digastric muscle can fill moderate defects and does not
result in significant morbidity. An abdominal fat graft can be used to fill large defects and maintains
volume over the long term if carefully and atraumatically harvested. The authors harvest fat attached
to deepithelialized dermis to facilitate implantation and closure of the capsule.
Flap necrosis
Appropriate design of skin incisions can minimize distal flap necrosis. If flap necrosis does occur,
appropriate topical care and reassurance are usually all that is necessary.
Tumor recurrence
Parotid tumors can recur as a result of positive margins, microsatellite disease, or unrecognized nerve
invasion. A full discussion of the different parotid tumors, the extent of parotid surgery, and the need
for postoperative radiation is beyond the scope of this article. A few basic principles should be
followed to ensure adequate extirpation and minimize recurrence.
If the facial nerve or branch is grossly invaded, sacrifice of the nerve should be considered to
ensure complete removal
Every effort should be made to keep tumor capsules intact in both benign and malignant
disease; if tumor spillage occurs, copious irrigation of the surgical field is wise
Capsular dissection of malignant tumors can lead to incomplete excision as a result of failure to
recognize microscopic extensions of tumor; therefore, a cuff of healthy gland should be
removed with these tumors
Capsular dissection of pleomorphic adenoma and malignant tumors can lead to incomplete
excision as a result of failure to recognize microscopic extensions of tumor; therefore, a cuff of
normal gland should be removed with these tumors
Large-bore needle or incisional biopsies should not be performed; if they have been performed,
the biopsy tract should be removed in continuity with the surgical specimen whenever possible