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Parotidectomy

Parotidectomy is a surgical procedure that involves the partial or complete removal of the parotid gland, the largest salivary gland located in front of the ear and below the jaw, typically performed to excise tumors, alleviate chronic infections, or address other gland pathologies while aiming to preserve the nearby facial nerve.^[1]^[2] The parotid gland produces saliva to aid digestion and oral health, and its superficial and deep lobes envelop branches of the facial nerve, which controls facial expressions, making surgical precision essential to minimize complications.^[3]^[1] Indications for parotidectomy most commonly include benign neoplasms, most commonly pleomorphic adenomas (accounting for 50-70% of parotid tumors) and Warthin's tumors, as well as malignant tumors, chronic sialadenitis, recurrent parotitis, or salivary stones causing obstruction.^[1]^[4] Less frequent reasons encompass inflammatory conditions like tuberculosis or congenital malformations, though surgery is avoided for non-neoplastic issues such as HIV-related cysts unless necessary.^[1] The modern parotidectomy technique was developed in the early 20th century; in 1907, C. A. Cardewine performed the first recorded procedure with facial nerve preservation, and in 1912, Vilray Blair introduced the standard Blair incision for exposing the gland while protecting the nerve.^[5]^[6] Types of parotidectomy vary based on tumor location and extent, including superficial (removing the lobe above the facial nerve), total (both lobes), partial or extracapsular dissection (for small benign lesions), and radical (sacrificing the nerve for advanced malignancies). The procedure is performed under general anesthesia by otolaryngologists or head and neck surgeons to achieve oncologic control while preserving function. Detailed surgical techniques, evaluation, risks, and recovery are discussed in subsequent sections.

Introduction

Definition and Indications

Parotidectomy is the surgical excision of part or all of the parotid gland, the largest of the major salivary glands, which is located in the preauricular region anterior to the ear and external auditory canal.^[1] This procedure involves careful dissection to address pathology within the gland while minimizing damage to surrounding structures.^[7] The primary indications for parotidectomy are neoplasms, which constitute the majority of cases, including benign tumors such as pleomorphic adenoma and Warthin's tumor, as well as malignant tumors like mucoepidermoid carcinoma and adenoid cystic carcinoma.^[1] Parotid tumors account for approximately 80% of all salivary gland neoplasms, with about 80% of parotid neoplasms being benign.^[8] In oncology cases, the surgery is typically performed with curative intent for localized disease to achieve complete resection, whereas in advanced or metastatic scenarios, it may serve a palliative role to control symptoms and improve quality of life.^[9] Additional indications include chronic inflammatory conditions, such as recurrent sialadenitis or chronic parotitis unresponsive to medical management, and sialolithiasis that fails conservative measures or less invasive interventions like sialendoscopy.^[7] Preservation of the facial nerve, which traverses the gland, is a critical aspect of the procedure to avoid postoperative complications.^[1]

Historical Development

The first documented description of parotidectomy appeared in 1765, when German surgeon Lorenz Heister detailed the procedure in his surgical text, highlighting the challenges posed by the gland's rich vascular supply from branches of the external carotid artery, which complicated hemostasis and increased operative risks. Early parotidectomies, often performed without anesthesia or modern sterile techniques, were fraught with high mortality rates, primarily due to severe postoperative infections and inevitable facial nerve damage resulting in permanent paralysis and functional impairment. These initial efforts laid the groundwork for salivary gland surgery but underscored the procedure's dangers in an era before antisepsis and anatomical precision. The 19th century brought pivotal advancements that transformed surgical outcomes. In 1825, Johann Ferdinand Heyfelder of Germany pioneered techniques for facial nerve preservation during parotid resection, marking a shift toward less destructive approaches for tumor removal. The introduction of antiseptic principles by Joseph Lister in 1867, through the use of carbolic acid to combat wound infections, dramatically reduced postoperative sepsis rates across surgical fields, including parotidectomy, thereby lowering overall mortality and enabling safer gland excisions. By 1892, Romanian surgeon M. Codreanu achieved the first total parotidectomy with successful facial nerve preservation under general anesthesia, further establishing the feasibility of nerve-sparing operations. In the early 20th century, refinements in facial nerve identification and surgical access revolutionized parotidectomy. English surgeon Thomas Carwardine advocated in 1907 for systematically locating the facial nerve trunk prior to tumor dissection, reducing inadvertent injury risks. Vilray P. Blair introduced the classic cervicomastoidfacial (Blair) incision in 1912, which provided superior exposure of the parotid region while minimizing cosmetic deformity, and it became the standard approach popularized throughout the 1920s. Mid-century contributions from key figures such as William E. Sistrunk, who in 1921 described en bloc superficial parotidectomy to lower recurrence rates for benign tumors, and Hayes Martin, who in 1952 outlined detailed antegrade nerve dissection techniques, solidified modern superficial parotidectomy as the preferred method for preserving facial function. The late 20th century ushered in technological innovations that enhanced precision and safety. Since the 1970s, computed tomography imaging, first applied to the parotid gland with contrast sialography in 1979, has allowed for detailed preoperative mapping of tumors relative to the facial nerve and adjacent structures, improving surgical planning. Intraoperative facial nerve monitoring emerged in the 1980s, with pioneers like Jack Kartush modifying electromyography devices in 1980 to provide real-time auditory and visual feedback on nerve integrity, significantly decreasing permanent paralysis rates. In parallel, minimally invasive techniques, including extracapsular dissection for benign lesions, gained traction from the late 1980s onward, offering reduced morbidity while maintaining oncologic efficacy.

Anatomy of the Parotid Region

Parotid Gland Structure

The parotid gland is the largest of the major salivary glands, weighing approximately 25 grams in adults and situated in the retromandibular fossa. It is positioned anterior to the external auditory canal and extends from the anterior border of the masseter muscle to the posterior border of the sternocleidomastoid muscle, with superior extension to the zygomatic arch and inferior extension below the angle of the mandible. This location places it superficial to the mandible's ramus and deep to the skin and platysma muscle, making it palpable over the lateral aspect of the cheek below the ear.^[10] The gland is divided into a superficial lobe and a deep lobe by the extratemporal facial nerve and the posterior facial vein, with the superficial lobe comprising approximately 80% of the total parotid tissue volume. The superficial lobe lies lateral to the facial nerve and overlies the masseter muscle and mandibular ramus, while the deep lobe is medial to the nerve and positioned between the mastoid process and the ascending ramus of the mandible. Enclosing the entire gland is a thin fibrous capsule, known as the parotid sheath, derived from the deep cervical fascia, which provides structural support and defines surgical boundaries. The lobes are connected by isthmus tissue containing fatty elements, and the gland's lobular architecture is formed by septa that convey neurovascular structures.^[10]^[11] Histologically, the parotid gland is a purely serous acinar gland composed primarily of serous acini that secrete watery saliva rich in amylase for initial starch digestion. These acini are clusters of pyramidal serous cells surrounded by myoepithelial cells that contract to aid saliva expulsion, embedded within a supportive stroma of extracellular matrix, fibroblasts, immune cells, and nerves. The ductal system begins with intercalated ducts draining the acini, progressing to striated ducts for ion reabsorption, and culminating in excretory ducts; the main excretory duct, Stensen's duct, arises from the anterior aspect of the superficial lobe, courses over the masseter muscle for about 7 cm, pierces the buccinator muscle, and opens into the oral cavity opposite the upper second molar tooth.^[10] Arterial blood supply to the parotid gland derives from branches of the external carotid artery, primarily the superficial temporal artery and its transverse facial branch, along with contributions from the maxillary artery. Venous drainage occurs via the retromandibular vein, which forms from the confluence of the superficial temporal and maxillary veins within the gland and descends to join the external jugular vein. Lymphatic drainage is unique among salivary glands, featuring intraparotid lymph nodes embedded within the superficial lobe and capsule that serve as the first echelon for lymphatic spread from the scalp, face, external auditory canal, and certain head and neck malignancies. These nodes ultimately drain into the superficial and deep cervical lymph node chains.^[10]

Facial Nerve and Adjacent Structures

The facial nerve, or cranial nerve VII, follows an extratemporal course after emerging from the stylomastoid foramen, entering the parotid gland approximately 1-2 cm inferior to the external auditory canal, where it divides into the temporofacial and cervicofacial trunks.^[12] These trunks further branch into the five main peripheral branches—temporal, zygomatic, buccal, marginal mandibular, and cervical—which fan out through the gland to innervate the muscles of facial expression.^[12] This branching occurs within the parotid substance, separating the superficial and deep lobes, and the nerve's arborization pattern is crucial for preserving facial function during surgical dissection.^[13] Surgical identification of the facial nerve relies on consistent anatomical landmarks to minimize injury risk. The tragal pointer, a cartilaginous prominence at the tragus base, lies approximately 1.6 cm anterior and deep to the main nerve trunk.^[13] The tympanomastoid suture, located posterior to the external auditory canal, marks the nerve about 3-4 mm deep and inferior along its line.^[13] Additionally, the posterior belly of the digastric muscle serves as a reliable inferior landmark, with the nerve trunk positioned superficial and slightly anterior to it at a mean distance of 5.5 mm.^[14] Adjacent structures to the parotid gland influence surgical approaches and potential complications. Anteriorly, the gland overlays the masseter muscle, while superiorly it abuts the external auditory canal and zygomatic arch.^[10] Inferiorly, it extends to the mandible's angle, and the deep lobe wraps around the styloid process, lying in close proximity to the internal carotid artery and internal jugular vein medially.^[10] Anatomical variations in the facial nerve occur, including early high branching, trunk duplication, or atypical arborization patterns such as the "anomalous temporozygomatic plexus."^[15] These anomalies, often classified by systems like Davis or Kopuz, underscore the need for preoperative imaging to map individual anatomy.^[16] The facial nerve provides motor innervation to the muscles of facial expression via its terminal branches, enabling movements like eye closure and smiling.^[12] Parasympathetic secretomotor fibers to the parotid gland originate from the glossopharyngeal nerve (cranial nerve IX) and are relayed through the lesser petrosal nerve to the otic ganglion, with postganglionic fibers traveling via the auriculotemporal nerve (a trigeminal branch) to stimulate serous saliva production.^[17]

Diagnosis and Assessment

Clinical Presentation

Patients with parotid gland pathology often present with a painless swelling or mass in the parotid region, which is the most frequent initial symptom prompting evaluation.^[8] This swelling typically develops gradually and may cause facial asymmetry due to the mass effect on surrounding tissues.^[18] In cases of inflammation or malignancy, pain may accompany the swelling, distinguishing it from the more common benign presentations.^[19] Additional symptoms can include difficulty swallowing, numbness, or muscle weakness in the face if the mass affects adjacent structures.^[19] On physical examination, the mass is often mobile and well-defined in benign conditions, whereas fixation to surrounding tissues suggests malignancy.^[8] Skin involvement, such as tethering or ulceration, is a sign of advanced malignant disease, while facial nerve invasion may manifest as weakness or paralysis on the affected side.^[8] In inflammatory processes like sialadenitis, the gland may appear erythematous and tender, mimicking otitis externa with ear pain and swelling near the auricle.^[20] Associated features vary by etiology; chronic sialadenitis can lead to xerostomia due to reduced salivary flow from glandular obstruction or inflammation.^[20] Differential diagnosis hinges on growth characteristics: slow, indolent progression favors benign tumors like pleomorphic adenoma, whereas rapid enlargement points to malignancy.^[8] Parotid pathologies leading to surgical consideration are more prevalent in adults over 50 years of age, with a median diagnosis around 56-64 years.^[21] Certain subtypes, such as Warthin's tumor, exhibit a slight male predominance.^[22]

Diagnostic Investigations

Diagnostic investigations for parotid gland pathology primarily involve imaging and biopsy techniques to confirm the nature of lesions, assess extent, and guide surgical planning. Ultrasound serves as the initial imaging modality, providing real-time assessment of lesion size, location, and vascularity, with high sensitivity for detecting superficial parotid masses.^[23] Computed tomography (CT) is utilized when bony involvement or deeper extension is suspected, offering detailed evaluation of skull base erosion or adjacent structures.^[24] Magnetic resonance imaging (MRI) is the preferred modality for soft tissue characterization and facial nerve assessment, employing T1-weighted sequences for anatomical detail and T2-weighted sequences to highlight cystic components or perineural spread.^[25] Biopsy techniques are essential for histopathological confirmation. Fine-needle aspiration (FNA) cytology is the standard initial procedure, demonstrating approximately 96% accuracy (AUSROC 0.96) in distinguishing malignant from benign parotid lesions, though it may yield nondiagnostic results in up to 20% of cases.^[26] Results are typically reported using the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), a standardized framework that categorizes findings into six risk levels to guide management.^[27] Core needle biopsy is recommended if FNA is inconclusive, providing more tissue for analysis with improved diagnostic yield.^[28] Intraoperatively, frozen section analysis can be performed during parotidectomy to guide the extent of resection, particularly in cases of suspected malignancy.^[29] For malignant parotid tumors, staging follows the American Joint Committee on Cancer (AJCC) TNM system, which incorporates imaging findings to evaluate primary tumor size (T), regional nodal involvement (N), and distant metastasis (M), with MRI and CT crucial for assessing extraglandular extension and lymph node status.^[30] Adjunctive tests address specific etiologies. Sialography, involving contrast injection into the parotid duct, is used to identify ductal stones (sialoliths) and obstructions, revealing filling defects or dilatations with high diagnostic accuracy.^[31] In suspected high-grade malignancies, positron emission tomography-computed tomography (PET-CT) aids metastatic workup by detecting occult nodal or distant disease, improving staging accuracy over conventional imaging alone.^[32] Preoperative evaluation of facial nerve function includes electromyography (EMG) in patients with baseline weakness, quantifying nerve impairment and predicting postoperative outcomes to inform surgical approach.^[33]

Surgical Procedure

Types of Parotidectomy

Parotidectomy procedures are classified based on the extent of glandular resection, which is determined by the tumor's characteristics to balance oncologic control with preservation of facial nerve function and surrounding structures. The primary types include superficial, total, radical, and partial or limited approaches, with superficial parotidectomy being the most common, accounting for the majority of cases involving benign neoplasms that constitute 75-80% of parotid tumors.^[1]^[7] Superficial parotidectomy involves the removal of the superficial lobe of the parotid gland while identifying and preserving the main trunk and branches of the facial nerve. This approach is indicated for tumors confined to the superficial lobe, such as most benign lesions including pleomorphic adenomas and Warthin tumors. It represents 70-80% of parotidectomies due to the prevalence of superficially located benign pathology.^[1]^[7] Total parotidectomy entails excision of both the superficial and deep lobes with preservation of the facial nerve, often requiring mobilization of nerve branches to access deep extensions. It is performed for tumors involving the deep lobe, multifocal disease, or large neoplasms where lobe distinction is unclear, particularly in cases of aggressive benign or low-grade malignant tumors.^[1]^[7] Radical parotidectomy includes total gland removal along with sacrifice of the facial nerve and potential resection of adjacent skin, muscle, or bone if malignancy invades these structures. This is reserved for advanced malignant tumors with preoperative facial nerve paralysis or circumferential nerve involvement, prioritizing oncologic clearance over nerve function.^[1] Partial or limited parotidectomy, encompassing techniques like enucleation or extracapsular dissection, removes the tumor with a minimal cuff of surrounding tissue without routine identification of the main facial nerve trunk, often aided by nerve monitoring. It is considered for small, mobile benign lesions excluding pleomorphic adenomas, though it remains controversial due to higher recurrence risks—up to 45% historically with enucleation—compared to more extensive resections.^[1]^[34] Selection of the parotidectomy type relies on preoperative imaging (e.g., MRI or CT) to assess tumor location relative to the facial nerve plane, size (with larger tumors >4 cm often necessitating total resection), histological diagnosis via fine-needle aspiration, and evidence of nerve involvement such as paralysis or enhancement on imaging. Benign histology favors nerve-preserving approaches, while malignancy may escalate to radical if invasion is confirmed.^[1]^[7]^[35]

Preoperative Preparation

Preoperative preparation for parotidectomy involves a thorough multidisciplinary evaluation to optimize patient outcomes and minimize surgical risks. A team typically comprising an otolaryngologist-head and neck surgeon, oncologist, radiologist, and pathologist assesses the patient's overall health, tumor characteristics, and potential for facial nerve involvement based on prior diagnostic imaging and biopsy results.^[1]^[36] Informed consent is obtained after detailed discussion of procedure-specific risks, including transient facial nerve paresis, which occurs in 16.6-34% of cases, with most recovering within weeks to months.^[1] Permanent paralysis is rarer, affecting less than 1-2% in non-malignant cases.^[37] Anesthesia planning emphasizes general anesthesia with endotracheal intubation, often nasotracheal to facilitate surgical access, while avoiding muscle relaxants to preserve facial nerve responsiveness during monitoring.^[1] Airway evaluation is critical due to the parotid gland's proximity to pharyngeal structures, with fiberoptic intubation or preoperative tracheostomy considered for patients with deep-lobe tumors or anticipated difficult airways.^[1] Prophylactic antibiotics, such as cefazolin, are administered intravenously upon induction to prevent surgical site infections, particularly in clean-contaminated head and neck procedures.^[38]^[39] Perioperative steroids are not routinely recommended for swelling reduction, as evidence does not support their efficacy in improving facial nerve outcomes or reducing edema in standard parotidectomy cases.^[40] Adjunctive measures include setup for intraoperative facial nerve monitoring using electromyography to aid nerve identification and reduce injury risk, which is employed in most centers for both benign and malignant resections.^[1] Preoperative marking of the incision line, typically a modified Blair incision extending from preauricular to the cervical crease, ensures optimal cosmetic and functional results while accommodating potential extensions.^[1]^[38] For tumor-specific preparation, concurrent neck dissection is planned if preoperative imaging or fine-needle aspiration indicates cervical nodal involvement, particularly in high-grade malignancies involving levels I-III.^[1] Malnourished patients, common in advanced head and neck cases with up to 40% prevalence, receive preoperative nutritional support through oral supplements or enteral feeding to improve perioperative tolerance and wound healing.^[41]

Intraoperative Techniques

The intraoperative phase of parotidectomy begins with the patient under general anesthesia, positioned supine with the head turned away from the surgical side to facilitate access. A modified Blair S-shaped incision is commonly employed, starting in the preauricular crease, curving around the earlobe, and extending into the upper cervical skin crease for optimal cosmesis and exposure.^[1] This incision allows elevation of an anterior skin flap in the sub-superficial musculoaponeurotic system (SMAS) plane, extending beyond the tumor margins to expose the parotid capsule while preserving the greater auricular nerve posteriorly when possible.^[7] The flap is raised meticulously to maintain its thickness, reducing the risk of postoperative complications such as Frey syndrome.^[1] Identification of the facial nerve is a critical step to preserve its function, typically initiated via an anterograde approach using anatomical landmarks such as the tragal pointer, where the main trunk emerges approximately 1 cm inferior and anterior to this pointer, and the tympanomastoid suture line.^[1]^[7] If the anterograde method is obscured by tumor involvement, a retrograde dissection from peripheral branches may be employed, starting from the uppermost or lowermost branch and tracing proximally.^[42] Intraoperative nerve monitoring with a facial nerve stimulator is standard in many centers, delivering low-intensity pulses (e.g., 0.5 mA) to confirm nerve integrity and differentiate motor from sensory fibers, often supplemented by electromyography for real-time feedback.^[1]^[42] Loupe magnification (typically 2.5x to 4x) aids in precise dissection, with an operating microscope reserved for intricate nerve branching in complex cases.^[43] Resection of the parotid gland proceeds following nerve delineation, mobilizing the superficial lobe by incising the capsule and ligating vessels with fine ties or bipolar cautery to achieve hemostasis while sparing the nerve branches.^[1] For superficial parotidectomy, the lobe is removed en bloc with the tumor and a margin of normal tissue; if deep lobe involvement is present, the mandible is retracted anteriorly to access this portion, reflecting the superficial lobe superiorly or using a transcervical approach for delivery.^[7] The specimen is oriented intraoperatively with marking sutures for pathological evaluation to assess margins and nerve involvement.^[1] Advanced tools like LigaSure may be used for vessel sealing to expedite hemostasis and reduce operative time.^[1] Closure involves layered suturing of the SMAS and platysma, followed by platysmal approximation over the surgical defect to prevent contour irregularities, with skin edges closed in a tension-free manner using subcuticular sutures.^[7] A closed-suction drain is routinely placed to manage seroma formation, exiting through a separate stab incision and secured.^[1] Hemostasis is meticulously ensured throughout with bipolar electrocautery to avoid thermal injury to adjacent structures.^[7] The procedure typically lasts 2 to 4 hours, depending on tumor complexity and extent of resection.^[2]

Postoperative Management

Following parotidectomy, patients are transferred to the post-anesthesia care unit (PACU) for initial monitoring of vital signs, assessment for bleeding or hematoma formation, and evaluation of airway patency to ensure stable recovery from anesthesia.^[2] Facial nerve function is promptly checked by observing the patient's ability to smile, frown, and close their eyes, with any immediate weakness noted for ongoing surveillance.^[2] Pain is managed with a multimodal approach, including intravenous or oral opioids for moderate to severe discomfort and nonsteroidal anti-inflammatory drugs (NSAIDs) for milder pain, titrated to patient response while monitoring for side effects such as nausea.^[44] Wound care begins in the PACU with sterile dressings applied over the incision site, kept dry for the first 24-48 hours to promote healing and reduce infection risk.^[44] A suction drain is typically placed during surgery to prevent seroma or hematoma accumulation and is managed by emptying and measuring output every 8-12 hours; prophylactic antibiotics are continued postoperatively, often intravenously for 24-48 hours, to minimize surgical site infections.^[45] The drain is removed when output falls below 25-30 mL per 24 hours, usually within 1-2 days, after which the incision is monitored for signs of drainage or dehiscence.^[46] Facial nerve assessment continues daily through bedside evaluations using standardized scales like the House-Brackmann grading system to detect evolving paresis or paralysis.^[1] If facial nerve injury results in lagophthalmos (incomplete eyelid closure), immediate eye protection measures are instituted, including lubricating ointments, moisture chamber goggles, or eyelid taping at night to prevent corneal exposure and ulceration.^[47] Nutrition is advanced gradually, starting with clear liquids in the PACU to assess swallowing tolerance, progressing to a soft diet by postoperative day 1 while avoiding acidic or spicy foods that may irritate the surgical site.^[44] Early mobilization is encouraged within 24 hours of surgery, with assisted ambulation to reduce the risk of deep vein thrombosis (DVT), often supplemented by sequential compression devices as mechanical prophylaxis.^[48] The typical hospital stay lasts 1-3 days, depending on the extent of surgery and patient factors such as drain output and pain control.^[49] Discharge criteria include stable vital signs, drain removal or output less than 30 mL per day, adequate pain management with oral medications, and the ability to tolerate oral intake without complications.^[2] Vigilance for early signs of acute complications, such as expanding hematoma or infection, is maintained throughout the inpatient period.

Complications

Acute Complications

Acute complications of parotidectomy encompass short-term risks that typically manifest within days to weeks following surgery and are often reversible with prompt intervention. These include hematoma or seroma formation, infection, facial nerve paresis, salivary leakage leading to sialocele or fistula, and rare instances of airway compromise due to swelling. The vulnerability of the facial nerve, which traverses the parotid gland, contributes to some of these risks during dissection.^[1] Hematoma and seroma are among the most common acute issues, occurring in approximately 1-3% of cases, with pooled incidence rates of 2.9% for hematoma (95% CI: 2.4-3.5%) from systematic reviews of parotidectomies primarily for benign tumors. These collections of blood or fluid can cause localized swelling and pain, potentially expanding the surgical site if not addressed. Management involves prompt surgical evacuation for hematomas to control bleeding sources, while seromas may require aspiration or closed suction drainage to prevent accumulation; prophylactic drains are routinely placed intraoperatively to mitigate risk.^[50]^[1]^[51] Infection rates, including wound infections and salivary fistulas, range from 1-5%, with wound infections at 2.3% (95% CI: 1.8-2.9%) and salivary fistulas at 3.1% (95% CI: 2.6-3.7%) in aggregated data from benign parotid surgeries. Wound infections present as erythema, induration, or purulent discharge, while salivary fistulas involve persistent leakage of saliva through the incision, often linked to incomplete ductal ligation. Treatment typically includes intravenous antibiotics for confirmed infections, with surgical drainage or irrigation for abscesses; fistulas may initially respond to conservative measures like pressure dressings before escalating to aspiration. Perioperative antibiotics further reduce incidence in high-risk cases.^[50]^[45]^[52] Facial nerve paresis is a frequent acute concern, with temporary dysfunction reported in 10-30% of benign parotidectomy cases and permanent paresis in 1-5%, based on subsite analyses and multicenter reviews. Temporary paresis, often due to edema, traction, or thermal injury during nerve identification, manifests as partial facial weakness within the first week and usually resolves within 6 months through spontaneous recovery aided by corticosteroids or observation. Permanent cases, rarer in benign tumors, may necessitate nerve grafting if identified intraoperatively, though most acute presentations are managed expectantly with eye protection to prevent corneal exposure. Intraoperative nerve monitoring helps minimize but does not eliminate this risk.^[53]^[54] Salivary leakage, resulting in sialocele formation, occurs in 2-6% of procedures, typically 7-14 days postoperatively, presenting as a painless fluctuant swelling from accumulated saliva. Sialoceles often resolve spontaneously or with conservative management, including serial aspiration, compression dressings, and anticholinergics to reduce saliva production; botulinum toxin injection into the gland achieves 70-100% success in refractory cases by temporarily paralyzing secretory function. Distinction from seroma is key, as sialocele fluid shows high amylase levels.^[55]^[56] Airway compromise is a rare but serious acute complication, with incidence below 1%, arising from extensive postoperative swelling, hematoma expansion, or sialadenitis that obstructs the upper airway. It may require emergent intubation or reintubation for airway protection, particularly in cases of massive edema; close monitoring in a recovery setting with elevation of the head and steroids can prevent progression. Such events are more likely in extensive resections but resolve with supportive care.^[57]^[58]

Chronic Complications

Chronic complications of parotidectomy encompass delayed or persistent effects that can significantly impact patients' quality of life, often emerging months to years post-surgery due to anatomical changes, nerve disruptions, or tumor biology. These sequelae arise from the removal of parotid gland tissue and associated structures, leading to functional and aesthetic deficits that may require ongoing management. Frey syndrome, also known as gustatory sweating, is a common chronic complication characterized by facial flushing, sweating, and sometimes warmth in the preauricular region during eating, resulting from aberrant regeneration of parasympathetic nerve fibers following disruption of the auriculotemporal nerve and overlying skin innervation during surgery.^[59] The clinical incidence varies widely, reported from 4% to 96% depending on diagnostic methods, with symptomatic cases affecting approximately 10-50% of patients, though many are mild and self-limiting.^[59] Treatment options include topical anticholinergics for mild cases, intradermal botulinum toxin injections to inhibit sweat gland activity (effective for 6-12 months with repeat dosing), or surgical interventions like interposition grafts using sternocleidomastoid muscle or acellular dermis to prevent nerve regrowth in severe, refractory instances.^[60] Facial asymmetry and scarring represent aesthetic chronic sequelae from the loss of parotid gland volume, creating a contour defect or "hollowing" in the cheek and preauricular area, which can persist indefinitely and contribute to psychosocial distress.^[61] This defect occurs due to the resection of substantial glandular tissue, often exacerbated by postoperative atrophy or scarring from the surgical incision, with visible asymmetry noted in up to 20-30% of cases without reconstructive measures.^[62] Management strategies focus on volume restoration and scar revision; techniques include autologous fat transfer for natural filling (with 50-70% graft survival and improved symmetry in long-term follow-up), dermal-fat grafts from the abdomen or thigh to replace lost volume, or alloplastic fillers like hyaluronic acid for temporary correction.^[62] In select cases, superficial musculoaponeurotic system (SMAS) flaps or facelift approaches during initial surgery can minimize asymmetry by preserving or repositioning native tissues.^[61] First-bite syndrome is a rare but distressing chronic pain condition involving sharp, cramping pain in the parotid region triggered by the initial bite of a meal, typically resolving with subsequent chews, attributed to sympathetic denervation of the parotid gland following surgical disruption of the external carotid sympathetic plexus.^[63] Incidence is low, estimated at 1-10% after parotidectomy involving deep lobe or parapharyngeal space dissection, with symptoms often appearing within weeks to months postoperatively and potentially lasting years if untreated.^[64] Conservative management includes dietary modifications (e.g., avoiding acidic foods) and analgesics, while botulinum toxin injections into the parotid gland provide relief by modulating neural activity in 70-80% of cases, with surgical sympathectomy reserved for refractory symptoms.^[65] Sensory loss, manifesting as numbness or hypoesthesia in the earlobe, lower ear, and cheek, is a frequent chronic outcome from sacrifice or injury to the great auricular nerve (GAN), which supplies sensation to these areas and is commonly transected during superficial parotidectomy to access the gland.^[66] This leads to permanent or slowly recovering deficits in 40-80% of cases where the GAN is not preserved, with the posterior branch often divided to facilitate tumor exposure, resulting in dysesthesia that peaks at 3-6 months and improves over 1-2 years via collateral nerve sprouting.^[66]^[67] Preservation of the GAN, when oncologically feasible, can reduce long-term sensory impairment (e.g., 41% hypoesthesia at 12 months with preservation versus 76% without in one multicenter study), though residual deficits may still occur and affect quality of life.^[66] Tumor recurrence, while primarily a disease-related sequela rather than a direct surgical complication, poses a chronic risk following parotidectomy, influenced by surgical margins, tumor histology, and adjuvant therapies, with benign tumors like pleomorphic adenoma recurring in 1-5% of cases over 5-10 years due to incomplete excision or multifocal growth.^[68] For malignant parotid tumors, recurrence rates are higher, ranging from 10-30%, often involving the parotid bed or regional nodes within 2-5 years, necessitating vigilant imaging surveillance to detect and resect early for improved outcomes.^[69]

Prognosis and Follow-up

Treatment Outcomes

Parotidectomy for benign tumors, such as pleomorphic adenomas, achieves a cure rate exceeding 95% with superficial parotidectomy, primarily due to the low recurrence rates associated with complete excision while preserving the facial nerve.^[70] Recurrence occurs in only 2-5% of cases following superficial parotidectomy, with meta-analyses confirming rates as low as 0.7-2.4% for partial or superficial approaches in well-selected patients.^[71] These outcomes are supported by long-term studies showing 5-year overall survival rates of 100% and locoregional recurrence-free survival of over 92% for benign parotid lesions.^[72] For malignant parotid tumors, treatment outcomes vary significantly by histological grade, with 5-year survival rates ranging from 70-90% for low-grade malignancies like mucoepidermoid carcinoma and 30-50% for high-grade tumors such as salivary duct carcinoma.^[73] Adjuvant radiation therapy following parotidectomy improves local control rates, particularly in high-grade cases with adverse features, achieving locoregional control in up to 92% at 2 years and enhancing overall survival in retrospective analyses.^[74] Negative surgical margins, achieved in approximately 80% of cases through adequate resection, are a key prognostic factor, correlating with reduced local recurrence.^[75] Functional outcomes after parotidectomy emphasize facial nerve preservation, with over 90% of patients achieving good long-term facial symmetry and function in benign cases, as permanent paralysis rates remain below 6%.^[76] However, complications such as temporary paresis or Frey's syndrome can impact quality of life in about 20% of patients, though most recover fully within 6-12 months, leading to sustained satisfaction in the majority.^[77] Success is further influenced by tumor stage at diagnosis and intraoperative nerve preservation techniques, which minimize deficits and support favorable cosmetic and functional results. Meta-analyses demonstrate that more extensive resections, such as total parotidectomy versus partial, reduce recurrence rates for certain malignant or multifocal tumors, with total approaches yielding rates as low as 1% compared to 2-4% for limited excisions, without proportionally increasing morbidity.^[78] These findings underscore the importance of tailoring surgical extent to pathology while prioritizing oncologic clearance.^[79]

Long-term Monitoring

Long-term monitoring after parotidectomy focuses on detecting tumor recurrence, assessing functional recovery, and addressing quality-of-life impacts through structured surveillance protocols, particularly for patients with malignant salivary gland tumors. According to National Comprehensive Cancer Network (NCCN) guidelines, follow-up clinic visits are recommended every 1-3 months in the first year, every 2-6 months in the second year, every 4-8 months during years 3-5, and annually thereafter, extending up to 20 years due to the risk of late recurrences in tumors like adenoid cystic carcinoma.^[80] Imaging, such as contrast-enhanced MRI or CT of the primary site and chest CT, is typically performed every 6-12 months for the first 2 years post-treatment, with subsequent scans guided by symptoms or high-risk features like high-grade histology.^[81] These protocols aim to balance vigilant monitoring with minimizing unnecessary radiation exposure. Assessments during follow-up include comprehensive physical examinations of the head and neck to evaluate for new masses, lymphadenopathy, or changes in facial symmetry, alongside targeted evaluation of facial nerve function using scales like the House-Brackmann grading system.^[80] Patient-reported outcomes are incorporated to gauge quality of life, encompassing symptoms such as dry mouth (xerostomia), eating difficulties, or emotional distress related to cosmetic alterations.^[82] For high-risk cases, thyroid function tests may be conducted every 6-12 months if neck radiation was involved, to detect radiation-induced hypothyroidism.^[80] Recurrence detection relies on vigilance for symptoms such as progressive facial swelling, new lumps in the parotid bed, or neurological deficits like worsening facial weakness, with over 70% of recurrences occurring within the first 3 years.^[80] Suspicious findings prompt fine-needle aspiration biopsy or core biopsy for histopathological confirmation, often combined with advanced imaging like PET-CT if metastasis is suspected.^[81] Rehabilitation for persistent issues includes physical therapy emphasizing neuromuscular reeducation and facial exercises to improve muscle strength and symmetry in cases of facial nerve paresis, with evidence supporting protocols like mirror biofeedback or proprioceptive stimulation for functional recovery.^[83] Psychological support is recommended to manage cosmetic concerns and body image issues, particularly in younger patients or those with visible asymmetry.^[84] NCCN recommendations underscore multidisciplinary surveillance tailored to tumor histology and stage, integrating oncologic, rehabilitative, and supportive care to optimize long-term outcomes.^[80]

Terminology

Etymology

The term "parotidectomy" combines "parotid," referring to the salivary gland located near the ear, with the suffix "-ectomy," denoting surgical removal. The root "parotid" derives from the New Latin "parotis," borrowed from the Greek "parōtis," meaning "tumor near the ear" or "gland beside the ear," formed by "pará" (beside or near) and "ôus" (ear), highlighting the gland's anatomical position anterior to the ear.^[85]^[86] The suffix "-ectomy" originates from the Greek "ektomḗ," a compound of "ek-" (out) and "tomḗ" (a cutting or incision), signifying the excision of an organ or tissue, a convention adopted in modern medical nomenclature during the 19th century. The full term "parotidectomy" was coined in the late 19th century, with its earliest recorded use in 1893 in a medical dictionary, reflecting the evolution of surgical terminology as parotid gland procedures became more defined.^[87] A related term, "parotitis," describes inflammation of the parotid gland and stems from the Greek "parōtîtis," combining "parōtís" (the parotid gland) with "-îtis" (inflammation), first appearing in English in 1796.^[88]^[89]

Surgical Nomenclature

Parotidectomy nomenclature encompasses standardized terminology for surgical procedures involving the parotid gland to ensure clarity in medical reporting and outcomes assessment. Key terms distinguish between conservative and more extensive resections, reflecting the balance between oncologic adequacy and functional preservation. These terms have evolved to address inconsistencies in historical descriptions, promoting uniformity across clinical studies and practice guidelines.^[90] Enucleation refers to the simple shelling out of a tumor from the parotid gland without formal identification or dissection of the facial nerve, typically reserved for select benign lesions to minimize morbidity.^[1] Extracapsular dissection extends beyond enucleation by removing the tumor with a margin of surrounding parotid tissue outside the tumor capsule, still avoiding complete facial nerve dissection, and is often employed for benign tumors aided by intraoperative nerve monitoring.^[1]^[91] Nerve-sparing parotidectomy involves meticulous dissection and preservation of the facial nerve during tumor excision, standard for benign conditions and most malignancies to maintain facial function.^[92] In contrast, nerve-sacrificing procedures entail resection of the facial nerve, indicated in cases of preoperative paralysis or advanced invasion, frequently followed by nerve grafting or reconstruction.^[1]^[92] Incision types in parotidectomy include the classic Blair incision, which follows the preauricular crease, extends around the earlobe, and curves into the cervical region for broad access.^[1] The retroparotid or facelift incision modifies this by extending posteriorly into the retroauricular crease, prioritizing cosmetic outcomes while providing adequate exposure.^[1] Cosmetically modified variants, such as limited Blair or rhytidectomy approaches, further adapt these to reduce visible scarring.^[7]^[91] For pathology-specific nomenclature, in low-grade parotid malignancies, close surgical margins (typically ≤5 mm) are considered adequate in early-stage cases, providing excellent outcomes without compromising prognosis, though wider margins may be aimed for to further minimize recurrence risk, especially near critical structures like the facial nerve. Major guidelines, such as those from ASCO (2021), define close margins as ≤5 mm for low- and intermediate-grade tumors, supporting their use in appropriate cases.^[81]^[93] Evolving terminology in combined procedures has shifted from "radical neck dissection," which removes multiple lymph node levels and non-lymphatic structures, to "selective neck dissection," targeting specific levels (e.g., II-IV) based on metastasis patterns in parotid cancers for reduced morbidity.^[94] Standardization efforts, such as those by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), emphasize consistent reporting of procedure types (e.g., superficial vs. total) and outcomes like margin status and nerve function to facilitate comparative research.^[92] The European Salivary Gland Society proposes limiting terms to "extracapsular dissection" for limited resections and "parotidectomy" for those involving facial nerve dissection and at least one glandular level, subdividing the gland into five levels for precise description.^[90] Similarly, revisions by Tweedie and Jacob advocate segmenting the gland into upper, middle, and lower portions per lobe to refine classifications beyond superficial/deep dichotomies.^[91]

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