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Salivary Gland Surgery

What is the Parotid Gland?

The parotid gland is the largest of the salivary glands, all of which produce saliva to help lubricate the oral cavity during meals. It is located just anterior to the ear, with extensions behind the ear and inferiorly into the upper neck. The most common indication for parotidectomy is tumors in the gland; the operation is rarely performed for severe, recurrent infections within the gland. Fortunately, most parotid tumors (85-90%) are benign. The malignancies vary widely in their aggressiveness and prognosis; many low grade parotid cancers are highly curable with surgery. The most common parotid tumor is a pleomorphic adenoma, also called a benign mixed tumor. Pleomorphic adenomas have been known to degenerate into cancers if they are neglected for many years, hence the standard treatment for most parotid tumors is surgery. Fine needle aspiration biopsy (FNA) can be done preoperatively but rarely changes the decision as to whether to operate or not, hence FNA is not always required.

Parotidectomy

Parotidectomy is performed under general anesthesia. The operation usually takes about 1-2 hours to perform, and the recovery is usually rapid. Most patients are ambulatory the day of surgery, and most are discharged from the hospital the following morning. Most are able to return to work without restriction within 2 weeks. A drain is routinely inserted at the conclusion of surgery to evacuate any fluid that might accumulate. This drain is removed in the office about 72 hours after surgery.

Surgery Risks

Unfortunately, every operation entails some risk, and parotidectomy is no exception. Every operation carries a risk of anesthesia, infection, bleeding, and poor cosmetic result. The risk of general anesthesia is small in otherwise healthy patients; those with significant medical problems are urged to speak with their primary care physicians preoperatively. Infections are rare after parotid surgery, as is the risk of significant bleeding. However, all patients are counseled to avoid blood-thinning agents before surgery. These include aspirin, Advil, Motrin, Naprosyn, ibuprofen, and other non-steroidal anti-inflammatory drugs. Vitamin E and Gingko biloba are also blood-thinners to be avoided. The parotidectomy incision is very similar to that used for a facelift. Although this scar will be noticeable immediately after the surgery, it will usually become much less visible with time. Permanent unsightly scars are quite unusual.
Patient learning about surgery risks

The cheek area will be numb after the surgery, as will the lower half of the earlobe. This numbness improves with time but never resolves completely. In addition, when the cheek skin is lifted up to gain access to the parotid gland, tiny nerves that supply the salivary gland and the sweat glands in the skin are unavoidably divided. When these nerves grow back, sometimes a nerve that supplied the salivary gland grows into a sweat gland by mistake. Therefore when the patient smells or tastes food, the nerve fires but stimulates the wrong gland. This facial sweating during meals (Frey’s syndrome) occurs in most patients after parotidectomy to a variable degree. It is rarely a significant problem.

The major risk of parotid surgery is the risk of facial paralysis. The facial nerve is a motor nerve; each nerve supplies all the muscles on that side of the face. This nerve exits the skull underneath the earlobe, the nerve then directly enters the substance of the parotid gland where it divides into small branches that supply all the muscles of the face. If the facial nerve is cut or severely damaged, the results are devastating. The patient will lose the ability to move all the muscles on that side of the face, leading to a twisted facial appearance. In addition, facial paralysis has significant functional consequences, since the patient cannot close the eye or blink. Eye drops and ointment are then required to prevent infections of the cornea of the eye.

Fortunately, facial paralysis is an extremely rare occurrence after parotid surgery. Facial nerve injury is prevented by identifying and dissecting out the facial nerve before attempting to remove the tumor. Although the risk of permanent facial nerve weakness is extremely small, many patients do experience some temporary weakness in one or more branches of the nerve as a result of the facial nerve dissection. This weakness, which in rare instances may be a complete facial paralysis, usually resolves completely within several weeks to months of the operation.

Despite the afore-mentioned risks, the vast majority of patients undergoing parotidectomy do not experience any significant complications from the operation. Although this is obviously not an operation to be undertaken without clear indications, in experienced hands it is a very safe procedure.