Parotidectomy - Indications, Types, and Associated Complications

Introduction:

A parotid gland is one of the most prominent major salivary glands, bounded by masseter muscles, zygomatic arch, and sternocleidomastoid muscle. The parotid gland consists of two lobes divided by Patey's facial-venous plane (facial nerve): the superficial and deep lobes. The duct coming from the parotid gland is called Stenson's duct, which pierces the cheek muscles and opens into the oral cavity near the second molar tooth of the upper jaw. Surgery for the removal of the parotid gland should be done cautiously to prevent facial nerve damage. The facial nerve is the main nerve supply of the facial muscles and controls all facial expressions like smiling, raising eyebrows, and closing eyes.

What Are the Indications of Parotidectomy?

Surgical removal of the parotid glands is usually indicated in cases of:

• Cancerous or Non-cancerous Tumors: Involving parotid glands like pleomorphic adenoma and Warthin's tumor.

• Chronic Parotitis: Swelling of the parotid gland (when conservative management fails).

• Recurrent Sialadenitis: Inflammation of the salivary gland due to the blockage of its duct (Stenson’s duct) by infections or salivary stones. Surgical removal of the gland is preferred if sialendoscopy fails.

• Lymphoepithelial Cyst of the Parotid Gland: Cystic (fluid-filled) swelling of the parotid gland involving the lymph nodes.

• Tuberculous Parotitis: Swelling/abscess of the parotid gland seen in extrapulmonary tuberculosis (tuberculosis infections affecting organs other than the lungs).

What Are the Signs and Symptoms of a Parotid Gland Tumor?

• Presence of swelling or lumps in cheek, jaw, or neck.

• Numbness in part of the face.

• Difficulty swallowing.

• Reduced mouth opening.

• Asymmetry of the face from the affected side to the normal side.

• Pain/tenderness in face, mouth, or jaw.

What Are the Types of Parotidectomy?

Different types of parotidectomy surgery include:

• Superficial Parotidectomy: It is the removal of the superficial (outer part) or upper lobe of the parotid gland. It is a preferred surgical procedure when the infection/tumor is confined to the outer part of the parotid gland only. In this procedure, a surgeon gives an incision (cut) in front of the ear and extends it deep to the neck, under, and along the jawline, depending on the exposure needed for tumor visibility. It has fewer chances of facial nerve damage as the involvement of the tumor is in a small outer area of the gland, and the surgeon performs facial nerve identification and preservation before surgical removal of the gland.

Superficial parotidectomy (lateral) is done to remove the gland superficial to the facial nerve. Partial superficial parotidectomy means removing only the portion of the gland surrounding the tumor.

• Total Parotidectomy: This is a surgical procedure followed to remove both the superficial (outer part) and the deep lobe (inner part) of the parotid gland. This procedure is preferred by the surgeon when the tumor or infection involves both the outer and inner parts of the parotid gland along with the lymph nodes of the neck. In some cases, the lymph nodes of the neck (involved in advanced cancer) also need to be removed to prevent a recurrence. The cut given for this procedure is similar to that of superficial parotidectomy. In some patients with an advanced grade of cancer, radiotherapy, and chemotherapy are recommended by the doctor to prevent the recurrence of cancer again in the future.

Parotidectomy on both sides is done for bilateral parotid gland tumors. Bilateral parotid gland tumors are estimated to occur in three percent of all cases. Warthin tumors are more common on both sides. Basal cell adenoma also occurs bilaterally but is rare in occurrence.

• Radical Parotidectomy: In this surgical procedure, the entire salivary gland, along with the facial nerve, lymph nodes, and other tissues, are removed completely. It is done in patients with obvious facial nerve paralysis because of the involvement of the facial nerve by cancer. In these patients, facial nerve grafting and reanimation are performed simultaneously during surgery.

What Are the Investigations That Need to Be Done Before Parotidectomy?

Investigations that can be done before the surgery are:

• Oral Cavity Examination: This is done to rule out the involvement of the parapharyngeal (space around the pharynx) space.

• Fine Needle Aspiration Cytology (FNAC): It is done using a small needle into the lesion to aspirate the contents, and the fluid is sent to the lab for diagnosis. It helps to differentiate between cancerous and non-cancerous tumors.

• Magnetic Resonance Imaging (MRI): A magnetic resonance imaging scan is done to evaluate the size and the extent of the tumor.

• Positron Emission Tomography (PET) Scan: These scans use radioactive material to identify the cancerous tissue.

What Are the Precautions and Instructions to Be Followed After Parotidectomy Surgery?

Some instructions that need to be followed after post-operation parotidectomy surgery are:

• Take all the prescribed medications on time and in the correct doses.

• Maintain the diet as the doctor advises (avoid salty/spicy food and alcohol).

• Avoid excess exercise.

• Keep the surgical area clean and dry (apply betadine ointment as advised by the doctor in the wound/cut surgical area to prevent infection/sepsis).

• Avoid traveling until two weeks after surgery.

• Avoid smoking (smoking causes a delay in wound healing).

• Regular follow-up with the doctor and getting regular wound dressing done.

• Radiotherapy or chemotherapy sessions for cancer should be taken as advised by the doctor.

What Are the Complications Associated With Parotidectomy?

Risk factors associated with surgical removal of the parotid gland during or after the procedures are:

• Recurrence of the tumor.

• Bleeding (bleeding within tissues after surgery leads to hematoma).

• Ear numbness (loss of sensation in the ear)

• Facial nerve paralysis (causes an inability to use facial muscles for expressions like smiling, raising an eyebrow, whistling, or closing eyes).

• Frey’s syndrome or gustatory sweating (excessive sweating and flushing on the face while eating or taking due to facial nerve damage)

• Dry eyes.

• Infection on the surgical site.

• First Byte Syndrome (FBS): Painful spasm in muscles of mastication while chewing near the parotid region.

• Trismus (decreased mouth opening).

• Change in physical appearance due to depression of the surgical site.

Conclusion:

Parotid surgery is a complicated and sensitive technical procedure. The surgery is a challenging experience for both the patient and their family. Although the surgical procedure is done as perfectly as possible by the surgeon, some complications and risks of the surgery may arise in terms of aesthetics, recovery of functions, and other potential complications like facial nerve paralysis causing loss of facial expressions in cases of cancer (cancer which has spread). Early diagnosis of parotid gland tumor and its management is critical to avoid the complexity of the surgical procedure and to minimize the risk/complications associated with the surgical procedure.