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ACS Surgery: Principles and Practice

2 HEAD AND NECK

5 PAROTIDECTOMY 1

PAROTIDECTOMY

Leonard R. Henry, M.D., and John A. Ridge, M.D., Ph.D., F.A.C.S.

Anatomic Considerations

The parotid (near the ear) gland, the largest of the salivary
glands, occupies the space immediately anterior to the ear, overlying the angle of the mandible. It drains into the oral cavity via
Stensens duct, which enters the oral vestibule opposite the upper
molars. The gland is invested by a strong fascia and is bounded
superiorly by the zygomatic arch, anteriorly by the masseter, posteriorly by the external auditory canal and the mastoid process,
and inferiorly by the sternocleidomastoid muscle. The masseter
muscle, the styloid muscles, the posterior belly of the digastric
muscle, and a portion of the sternocleidomastoid muscle lie deep
to the parotid. Terminal branches of the external carotid artery,
the facial vein, and the facial nerve are found within the gland.
Parasympathetic innervation to the parotid is via the otic ganglion, which gives fibers to the auriculotemporal branch of the
trigeminal nerve. Sympathetic innervation to the gland originates
in the sympathetic ganglia and reaches the auriculotemporal nerve
by way of the plexus around the middle meningeal artery.1
The facial nerve trunk exits the stylomastoid foramen and
courses toward the parotid. Once inside the gland, it commonly
bifurcates into superior (temporal-frontal) and inferior (cervicomarginal) divisions before giving rise to its terminal branches.The
nerve branching within the parotid can be quite complex, but the
common patterns are well known and their relative frequencies
well established.2,3 The portion of 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 deep lobe. Deep-lobe tumors often present clinically as retromandibular or parapharyngeal masses, with
displacement of the tonsil or soft palate appreciated in the throat.
Operative Planning

Obtaining informed consent for parotidectomy entails discussing both the features and the potential complications of the
procedure. It is appropriate to address the possibility of facial
nerve injury, but in doing so, the surgeon should not neglect
other, far more common sequelae, such as cosmetic deformity,
earlobe numbness, and Frey syndrome. Even conditions that are
expected beforehand may prove distressing or debilitating for the
patient. The risk of complications such as nerve injury is greater
in cases involving reoperation or resection of malignant or deeplobe tumors.The overwhelming majority of parotid tumors, however, are benign and lateral to the facial nerve. Accordingly, in
what follows, we focus primarily on superficial parotidectomy,
referring to variants of the procedure where relevant.
Excellent lighting, correctly applied traction and countertraction, adequate exposure, and clear definition of the surgical anatomy are essential in parotid surgery. The use of magnifying loupes
and headlights is recommended. General anesthesia without muscle relaxation should be employed.
The patient is placed in the supine position, with the head elevated and turned away from the side undergoing operation and
with the neck slightly extended. The table is positioned to allow
the first assistant to stand directly above the patients head, while

the surgeon faces the operative field. A small cottonoid sponge is

placed in the external auditory canal, where it remains for the
duration of the procedure to prevent otitis externa from blood
clots in the external auditory canal. The skin is painted with an
antiseptic agent. A single perioperative dose of an antibiotic is
administered.
The patient is draped in a fashion that permits the operating
team to see all of the muscle groups innervated by the facial
nerve. To this end, we employ a head drape that incorporates
the endotracheal tube and hose. This drape secures the airway,
keeps the tube from interfering with the surgeon, and permits
rotation of the head without tension on the endotracheal tube.
The skin of the upper chest and neck is widely painted and
draped with a split sheet to allow additional exposure in the
unlikely event that a neck dissection or a tracheostomy becomes
necessary. The nose, the lips, and the eyes are covered with a
sterile transparent drape that allows observation of movement
during the procedure and permits access to the oral cavity (if
desired) [see Figure 1].
Operative Technique
STEP 1: INCISION AND SKIN FLAPS

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 under the ear
(staying close to the earlobe), and finally turns downward to
descend along the sternocleidomastoid muscle [see Figure 1].
Either all or part of this incision may be used, depending on circumstances. The incision is marked before draping. Skin creases
typically help conceal the resulting scar.
Skin flaps are then created to expose the parotid gland. A tacking suture is placed within the dermis of the earlobe so that it can
be retracted posteriorly. Skin hooks are used to apply vertical traction.The anterior flap is created superficial to the parotid fascia to
afford access to the appropriate dissection plane.Vertically oriented blunt dissection minimizes the risk of injury to the distal
branches of the facial nerve [see Figure 2].The face is observed for
muscle motion. The flap is raised until the anterior border of the
gland is identified. The facial nerve branches are rarely encountered during flap elevation until they emerge from the parenchyma of the parotid. If muscle movement occurs, the flap has been
more than adequately developed. The anterior flap is retracted
with a suture through the dermis.
The posterior-inferior skin flap is then elevated in a similar
manner. Careful dissection is performed to define the relationship of the parotid tail to the anterior border of the sternocleidomastoid. During this portion of the procedure, the great auricular nerve is identified coursing cephalad and superficial to the
sternocleidomastoid muscle. Uninvolved branches of this nerve
should be preserved if possible to prevent postoperative numbness of the earlobe.4,5 The parotid tail is dissected away from the
sternocleidomastoid muscle. Vertical traction is applied to the
gland surface with clamps to facilitate exposure.

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ACS Surgery: Principles and Practice

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5 PAROTIDECTOMY 2

Figure 1 Parotidectomy. (a) Shown are the recommended head

position and incision. A transparent drape is placed over the eyes,
the lip, and the oral cavity. (b) The head drape incorporates the hose
from the endotracheal tube.

Troubleshooting
A favorable skin crease, if available, may be used for the incision to improve the postoperative cosmetic result; however, it is
important to keep the incision a few millimeters from the earlobe
itself. A wound at the junction of the earlobe with the facial skin
will distort the earlobe and create a visible contour change. An
incision behind the tragus may lead to similar problems.
STEP 2: IDENTIFICATION OF FACIAL NERVE

Once the flaps have been developed and retracted, the next
step is to identify the facial nerve. Usually, the nerve may be identified either at its main trunk (the antegrade approach) or at one
of the distal branches, with subsequent dissection back toward
the main trunk (the retrograde approach). For a lateral parotidectomy, our preference is to identify the main trunk first (unless it
is thoroughly obscured by tumor or scar).
Antegrade Approach
The dissection plane is immediately anterior to the cartilage of
the external auditory canal. The gland is mobilized anteriorly by
means of blunt dissection. To reduce the risk of a traction injury,
tissue is spread in a direction that is perpendicular to the incision
and thus parallel to the direction of the main trunk of the nerve
[see Figure 3].The nerve trunk can usually be located underlying a
point about halfway between the tip of the mastoid process and
the ear canal. In addition, there are several anatomic landmarks
that facilitate identification of the nerve, including the tragal pointer, the posterior belly of the digastric muscle, and the tympanomastoid suture. Of these, the tympanomastoid suture is closest
to the main trunk of the facial nerve.6 The clinical utility of this
landmark is limited, however, because the tympanomastoid suture
is not easily appreciated in every case. In addition, deep-lobe

tumors may displace the nerve from its normal location. For
appropriate and safe exposure of the nerve trunk, it is necessary to
mobilize several centimeters of the parotid, thereby creating a
trough rather than a deep hole. Small arteries run superficial and
parallel to the facial nerve; these must be divided. Use of the electrocautery this close to the nerve is potentially hazardous. Bleeding
is typically minor but nonetheless must be controlled.
Retrograde Approach
As noted, when the main trunk cannot be exposed, the most
common alternative method of identifying the facial nerve is to
find a peripheral branch and then dissect proximally toward the
main trunk.Which branch is sought may depend on factors such
as the surgeons level of comfort with the relevant anatomy and
known consistency or inconsistency of the nerve branchs location. Often, in this setting, tumor bulk is the deciding factor.
The anatomic relationships between the nerve branches and
various landmarks can be exploited for more efficient identification. For example, the marginal mandibular branch of the facial
nerve characteristically lies below the horizontal ramus of the
mandible.7 Often, the facial vein can be traced toward the parotid
or the submandibular gland; the nerve branch can then be found
coursing perpendicular and superficial to the vein. The buccal
branch of the facial nerve has a typical location in the so-called
buccal pocketthe area inferior to the zygoma and deep to the
superficial musculoaponeurotic layer, which contains the buccal
fat pad and Stensens duct in addition to the buccal branch.7 The
zygomatic branch of the facial nerve lies roughly 3 cm anterior
to the tragus, and the temporal-frontal branch lies at the midpoint between the outer canthus of the eye and the junction
of the ears helix with the preauricular skin.7 Nerve branches to
the eye should be dissected with particular care: even transient

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ACS Surgery: Principles and Practice

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5 PAROTIDECTOMY 3

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.

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 with 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 experience, 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; however, we
have substantial reservations about whether this measure
should be employed on a regular basis [see Complications,
Facial Nerve Injury, below]. Knowledge of the anatomy and
sound surgical technique are the keys to a safe parotidectomy;
it may be hazardous to rely too much on practices that may
diminish them.
Figure 3 Parotidectomy. Depicted is identification of the facial
nerve at its trunk. A wide trough is created anterior to the external
auditory canal and deepened by spreading a blunt curved instrument in a direction perpendicular to the incision and parallel to the
nerve trunk. Anatomic landmarks assist in identification of the
nerve.

STEP 3: PARENCHYMAL DISSECTION

Once identified, the plane of the facial nerve remains uniform

throughout the gland (unless the nerve is displaced by a tumor)
and serves to guide the parenchymal dissection. We divide the
substance of the parotid gland sharply, using ligatures as appro-

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2 HEAD AND NECK

ACS Surgery: Principles and Practice

5 PAROTIDECTOMY 4
area of the tumor are retracted to allow exposure of the deep portion of the gland and facilitate resection. Traction injury to the
nerve may still result in transient facial weakness.
Troubleshooting

Figure 4 Parotidectomy. Dissection of the gland parenchyma is

carried out over the branches of the facial nerve to minimize the
risk of nerve injury. Each division of the substance of the gland
should reveal more of the facial nerve.

priate when bleeding is encountered. Usually, there is no significant hemorrhage: loss of more than 30 ml of blood is rare.
The parenchymal dissection proceeds directly over the facial
nerve. We favor using fine curved clamps for this portion of the
procedure.To prevent trauma to the nerve, care must be taken to
resist the tendency to rest the blades of the clamp on the nerve
during dissection. Each division of the gland should reveal more
of the facial nerve [see Figure 4].When this is the case, the surgeon
can continue the parenchymal dissection with confidence that the
nerve will not be injured. As a rule, if a parenchymal division does
not immediately show more of the facial nerve, it is in an improper plane.
We do not regularly resect the entire lateral lobe of the parotid
unless the tumor is large and such resection is required on oncologic grounds. The goal in resecting the substance of the parotid
gland is to obtain sound margins while preserving the remainder
of the gland. This so-called partial superficial parotidectomy has
been shown to reduce the incidence of Frey syndrome without
increasing the rate of recurrence of pleomorphic adenoma.9 The
plane of dissection is developed along facial nerve branches until
the lateral margins have been secured. This is the portion of the
procedure during which the risk of nerve injury is highest. Once
the lateral margins have been secured, the parenchymal dissection
can proceed from deep to superficial for the excision of the
tumor. The vertical portion of the dissection seldom poses a
threat to the integrity of the facial nerve, but care must be taken
to maintain appropriate margins. If division of Stensens duct is
required, the distal remnant may be either left open10 or ligated.
Caution is appropriate in the resection of deep-lobe tumors.
Tumors medial to the facial nerve may displace this structure laterally. Thus, after establishing the plane of the facial nerve, the
surgeon must remain careful when dissecting near the tumor to
keep from injuring the nerve. Once the substance of the gland
obscuring the tumor has been removed, the nerve branches in the

Complete superficial parotidectomy with full dissection of all

facial nerve branches is seldom necessary, though in some cases,
it is mandated by tumor size or histologic findings. Removal of
the entire superficial lobe with the intention of gaining a larger
lateral margin is rarely useful, because the closest margin is usually where the tumor is nearest the facial nerve. Even temporary
paresis of the temporal-frontal branch of the facial nerve may
have devastating consequences, and dissection near this branch is
usually unnecessary in treating a benign tumor in the parotid tail.
Any close margins remaining after nerve-preserving cancer treatment can be addressed by means of postoperative radiation therapy, usually with excellent results.11
The question of whether to sacrifice the facial nerve almost
invariably arises in the setting of malignancy. In our view, this
measure is seldom necessary. Benign tumors tend to displace the
nerve, not invade it. Sacrifice of the nerve probably does not
enhance survival.12,13 Although the issue remains the subject of
debate, it is our practice, like that of others,14 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; the Valsalva

maneuver is approximated by transiently increasing airway pressure to 30 cm H2O. 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
The use of interrupted skin sutures instead of a continuous
suture allows the surgeon to perform directed suture removal to
drain the rare postoperative hematoma or fluid collection instead
of reopening the entire wound.
Postoperative Care

The patient is evaluated for facial nerve function in the recovery room, with particular attention paid to whether the patient is
able to close the eyelid. The patient resumes eating when nausea
(if any) abates. Pain is generally well controlled by means of oral
agents. At discharge, the patient should be warned to protect the
numb earlobe against cold injury.The closed suction drain is kept
in place for 5 to 7 days (until the first postoperative visit) to minimize the risk of salivary fistula.
Complications
FACIAL NERVE INJURY

Studies have found that transient paralysis of all or part of the

facial nerve occurs in 17% to 100% of patients undergoing parot-

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ACS Surgery: Principles and Practice

2 HEAD AND NECK

idectomy,15-18 depending on the extent of the resection and the
location of the tumor. Fortunately, permanent paralysis is uncommon, occurring in fewer than 5% of cases.17,19
Nerve monitoring has been advocated to reduce the incidence
of facial nerve injury. To date, however, no randomized trial has
demonstrated that intraoperative facial nerve monitoring or
nerve stimulators yield any significant reduction in the incidence
of facial nerve paralysis. Indeed, indiscriminate use of nerve
monitoring and nerve stimulators may imbue the surgeon with a
false sense of security and cause him or her to pay insufficient
attention to the appearance of nerve tissue. Transient nerve dysfunction may follow inappropriate (or even appropriate and
unavoidable) trauma to or traction and pressure on nerve trunks.
Nerve monitoring does not prevent such problems; moreover, it
adds to the cost of the procedure and increases operating time.20
Some, in fact, have suggested that nerve stimulators may actually increase transient dysfunction. Accordingly, our use of nerve
stimulators is selective.
The management of facial nerve injury depends on when the
injury is discovered and on how sure the surgeon is of the
anatomic integrity of the nerve. If the injury is discovered intraoperatively, it should be repaired if possible. Primary repair
performed with interrupted fine permanent monofilament
sutures under magnification21is preferred if sufficient nerve is
available for a tension-free anastomosis. If both transected nerve
ends are identified but tension-free repair is not feasible, interposition nerve grafts may be used. Sensory nerves harvested from
the neck (e.g., the great auricular nerve) are often employed for
this purpose. If the nerve is injured (or deliberately sacrificed) in
conjunction with treatment of malignancy, use of nerve grafts
from distant sites may be indicated.21
If unexpected facial nerve dysfunction is identified in the
postanesthesia care unit and if the surgeon is unsure of the
anatomic integrity of the nerve (ideally, a rare occurrence), the
patient should be returned to the operating room for wound

5 PAROTIDECTOMY 5
exploration so that either the continuity of the nerve can be confirmed or the injury to the nerve can be identified and repaired if
possible.When the surgeon is certain that the nerve is intact, facial
nerve dysfunction can be managed without reoperation, in anticipation of recovery21; however, this may take many months.
Management of enduring facial nerve paralysis (from any
cause) is beyond the scope of our discussion and constitutes a surgical subspecialty in itself.21
GUSTATORY SWEATING (FREY SYNDROME)

Gustatory sweating, or Frey syndrome, occurs in most patients

after parotidectomy; it has been seen after submandibular gland
resection as well. The symptom complex includes sweating, skin
warmth, and flushing after chewing food and is caused by crossinnervation of the parasympathetic and sympathetic fibers supplying the parotid gland and the overlying skin.The reported incidence of Frey syndrome varies greatly, apparently depending on
the sensitivity of the test used to elicit it. When Minors starch
iodine test is employed, the incidence of Frey syndrome may
reach 95% at 1 year after operation.22 Fortunately, the majority of
patients exhibit only subclinical findings, and only a small fraction
complain of debilitating symptoms.22 Most symptomatic patients
are adequately treated with topical antiperspirants; eventually,
however, they tend to become noncompliant with such measures,
preferring simply to dab the face with a napkin while eating.22
Despite the relatively low incidence of clinically significant Frey
syndrome, there is an extensive literature addressing prevention
and treatment of this condition.9,19,23-30
SIALOCELE (SALIVARY FISTULA)

Sialocele, or salivary fistula, has been reported to occur after 1%

to 15% of parotidectomies.9,31 Although this condition is generally minor and self-limited, it may nonetheless be embarrassing for
the patient. We believe that the incidence of sialocele can be
reduced by maintaining closed suction drainage for 5 to 7 days (to

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.

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ACS Surgery: Principles and Practice

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5 PAROTIDECTOMY 6

facilitate adhesion of the skin flaps to the underlying parotid

parenchyma). Postparotidectomy salivary fistula is usually attributable to gland disruption rather than to duct transection and
therefore tends to resolve without difficulty.32 Compression dressings are generally effective.31 Anticholinergic agents have been
used in this setting as well.33-36 Low-dose radiation,37 completion
parotidectomy, and tympanic neurectomy38 have all been employed in refractory cases.
COSMETIC CHANGES

Parotidectomy creates a hollow anterior and inferior to the ear,

which may extend behind the mandible and may reach a significant size in patients with large or recurrent tumors. This cosmetic
change is a necessary feature of the procedure, not a complication;
nonetheless, it should be discussed with the patient before operation. Many augmentation methods, using a wide variety of techniques, have been devised for improving postoperative appearance

(as well as alleviating Frey syndrome).24-28,39,40 All of these methods have limitations or drawbacks that have kept them from being
widely applied and accepted.
Outcome Evaluation

With proper surgical technique, superficial or partial superficial

parotidectomy can be performed safely and within a reasonable
operating time. Blood transfusions should be required only in very
rare cases. Given adequate exposure, good knowledge of the relevant anatomy, limited trauma to the nerve, and appropriate use of
closed suction drains (see above), complications should be
uncommon. Although patients may tolerate parotidectomy on an
outpatient basis, we prefer to keep them in the hospital overnight.
Patients should be able to leave the hospital with minimal pain,
comfortable with their drain care, by the morning of postoperative day 1.

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Acknowledgment
The authors wish to thank Veronica Levin for her assistance in the preparation of this chapter.
Figures 1a, 2b, 3, 4 Tom Moore.