Parotidectomy
Dr. Nirajan Khadka
First year Resident
ENT-HNS, PoAHS
Moderator: Asst. Prof Dr. Ambalika
Shakya
History
• In 1363, Guy de Chauliac, a French surgeon- surgical treatment of
ranula to avoid death by asphyxia
• In 1543, the name “Salivary Gland” by Andreas Vesalius
• In 1765, German surgeon Lorenz Heister described first
parotidectomy
• In 1805, George McClellan, professor at Thomas Jefferson University,
performed the first parotidectomy due to cancer in the USA
History contd…
• In 1823, an American surgeon described first total parotidectomy in a
patient with “bell” parotid tumor, without anesthesia
• In 1847, Charles Emmanuel Sedillot and Auguste Berard, both French
surgeons did total parotidectomy without ligature of carotid artery
with paralysis of facial nerve and without general anesthesia
History contd…
• In 1892, Codreanu performed the first
total parotidectomy with preservation
of facial nerve, under general
anesthesia
• In 1907, Thomas Carwardine England-
first to suggest previous identification of
Pleomorphic adenoma; Lam Qua
facial nerve before resection of parotid Collection in the Gordon Museum at
Guy’s Hospital
tumor
Surgery for benign parotid tumors
• Superficial/partial parotidectomy
• Extracapsular dissection (ECD)
• Total conservative parotidectomy
• Cervico-parotid approach to parapharyngeal space adenomas
• Transmandibulotomy /transpharyngeal approach
• Types of parotidectomy
a) With reference to facial nerve
- Conservative
- Semi-conservative
- Radical
b) With reference to extent of tissue removed
- Superficial
- Deep
- Total
• Partial parotidectomy: Resection of parotid pathology with a margin
of normal parotid tissue.
• Superficial parotidectomy: Resection of the entire superficial lobe of
parotid and is generally used for metastases to parotid lymph nodes.
• Total parotidectomy: Resection of the entire parotid gland, usually
with preservation of the facial nerve.
• Extended total parotidectomy: Removal of the superficial and deep
parotid lobes; extended to involve adjacent structures such as
overlying skin, underlying mandible, the temporal bone and external
auditor canal or the deep musculature of the parapharyngeal space.
Superficial parotidectomy
Indications
• Benign parotid tumors
• Low grade malignant tumors of small size
• Refractory sialolithiasis
• Sialoadenitis
• Chronic sialorrhea
• As a part of lymph node dissection for other head and neck primary
tumors; cutaneous malignancy
Surgical technique
• Preparation
• Pre-operative workup and counselling
• Informed consent
• Facial nerve monitoring
Surgical technique
• Patient positioning
• Anesthesia
• Painting and drapping
Surgical technique
Incision
• Given by Blair (1912),
modified by Bailey (1941)
Surgical technique –incision
Surgical technique –raising skin flaps
Surgical technique-raising the flaps
Surgical technique-locating the facial
nerve
Anatomical landmarks
• Tragal pointer
• Tympanomastoid suture
• Anterior border of
posterior belly of digastric
muscle
• Styloid process
Surgical technique –locating the facial
nerve
Surgical technique- stripping the
superficial
lobe off the facial nerve branches
Surgical technique –locating facial nerve
branches
Surgical technique – branches of facial
nerve
Surgical technique –closure
Extracapsular dissection (ECD)
Indications
• Mobile lesions in parotid tails
• Smaller tumors in superficial lobe
ECD-Surgical steps
• Incision
• Raising of flaps
• Facial nerve monitoring
• Fascial incision
• Development of plane between capsule of tumor and normal parotid
tissue
• Dissection
• If nerve at damage-identification of nerve and conversion to partial
parotidectomy
Total conservative parotidectomy
Indications
• Tumor has developed within deep lobe or extends into it
• Spillage of tumor during superficial parotidectomy
Total conservative surgery – techniques
Deep lobe tumor
• Superficial parotidectomy
• Mobilisation of facial nerve
• Plane deep to main trunk
followed by peripheral
mobilisation
• Tumor removed with
remaining parotid tissue
Total conservative parotidectomy
techniques
Spillage of tumor
• Segments of parotid
tissue deep to and in
between the branches
of facial nerve
removed in piecemeal
fashion
Figure: Completed parotidectomy
Cervicoparotid approach to
parapharyngeal space adenomas
• Removal of lobe portion inferior to
main facial trunk and lowest main
branches
• Mobilisation of facial nerve superiorly
• Removal of deep lobe
• Access to paraphayngeal space
• Division of posterior belly of digastric,
muscles and ligament attached to
styloid process
• Access and removal of tumor
Transmandibulotomy approach
• Transpharyngeal approach
• Incision-skin crease with lip
split
• Dissection deep and under
submandibular gland onto
digastric/hyoglossus muscle
• Identification of hypoglossal
nerve
Transmandibulotomy approach
• Para median mandibulotomy and lateral retraction of mandible
• Extension of incision between papillae of submandibular ducts, along
floor of mouth and up to anterior faucial pillar to superior pole of
tonsil
• Identification of lingual and hypoglossal nerve, displaced medially
• Exposure complete and tumor mobilized and removed by blunt
dissection.
Total parotidectomy
• Indications:
- Metastasis to a superficial parotid node from a primary parotid tumor
or an extraparotid malignancy.
- Parotid malignancy that indicates metastasis by involvement of
cervical lymph nodes.
- High- grade parotid malignancy with a high risk of metastasis.
-Primary parotid malignancies originating in the deep lobe and for
primary malignancies that extend outside the parotid gland.
- Multifocal tumors, such a oncocytomas, to ensure complete removal.
Total conservative parotidectomy
Complications of parotid surgery
Facial weakness
•Temporary or permanent
•Neuropraxia: 4-6weeks
• Severe injury : 6-12 months
•Reassurance
•Eye protection
•Tarsorraphy
•Botox injection for artificial ptosis
Complications of parotid surgery
Sensory loss
•In the distribution of greater auricular nerve
•Decreases in the first 12 months post-operatively
Cosmetic defects
•Less
• Loss of bulk behind the ramus of mandible
Complications of parotid surgery
Frey’s syndrome
•Gustatory sweating or
flushing
•Abberant regeneration of
sectioned parasympathetic
secretomotor fibres
• Minor’s ( iodine test)
Complications of parotid surgery
Prevention Management
• Conservative surgery Anticholinergic
•Restoration of superficial Antiperspirants
muscular aponeurotic
system(SMAS) layer
•Use of interpositional flaps
Complications of parotid surgery
Salivary fistula/ sialocoele
•Resected edge of gland leaks
saliva-drains or collects
• Within few days of surgery
•Resolves in 1-2weeks
• Hyoscine patches
•Inj Botulinum toxin(2-
3months)
Complications of parotid surgery
Stump neuroma of greater auricular nerve
•Painful
•Localized tender nodule just anterior to superior part of SCM muscle
• Local excision
•Burying the fresh nerve end in muscle
Complications of parotid surgery
• Hemorrhage or hematoma
• Infection and wound seroma
• Trismus
• Skin flap necrosis
References
1. Scott-Brown’s Otorhinolaryngology Head and Neck Surgery 8th Edition
2. Scott-Brown’s Otorhinolaryngology Head and Neck Surgery 7th Edition
3. Stell and Maran’s Textbook of Head and Neck Surgery and Oncology 5th
Edition
4. Cummings Otolarnyngology Head and Neck Surgery 6th Edition
Thank You
