Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

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Parotid Surgery

There are two parotids, on either side of the face and both secrete saliva.  They are situated just inside the cheek and in front of the ear and occasionally surgery may be required because of either a tendency for recurrent painful swelling (sialadenitis) or because of the development of an isolated swelling in the gland.

Swellings occur in the parotid either due to abnormal overgrowth of some part of the salivary glands (a parotid gland tumour) or associated lymphoid tissue within the capsule of the parotid gland. Most tumours are benign: hence, not cancerous (malignant) not having a risk of spread to other parts of the body. Rarely, malignant tumours can also affect the parotid. The histological diagnosis of the type of tumour is established by collecting a needle sample from the swelling, often under ultrasound guidance.

Investigations such as ultrasound and possibly a fine needle aspirate may help with the diagnosis but if the recurrent swelling is particularly severe, and if there is also a lesion which it is felt better to remove, then parotidectomy may be required.  Although 90% of parotid swellings are benign, generally it is recommended that they are removed since they typically continue to grow and can become unattractive, and – after many years – a benign lump can, rarely, turn malignant. The difficulty of surgical removal, and associated complications, increases with size of the swelling.  Concern may also persist about the precise diagnosis until it has been removed.

The surgical procedure is typically a superficial parotidectomy, which is an operation to remove the superficial lobe of the parotid and it is relatively unusual for the whole gland, including the deeper lobe, to need to be removed unless the swelling involves this also.  Whilst 90% of overall parotid swellings are benign, around 90% of benign parotid tumours are pleomorphic adenomas.  These are benign growths which develop from myoepithelial cells which surround the ducts along which the saliva passes.  If this is the problem then surgery is generally advisable, as they do tend to slowly become larger, which as discussed above – can make the operation a little more difficult, and very occasionally there is a possibility of malignant change.

The incision required is relatively long; it extends anteriorly, in front of the ear, and then turns posteriorly and then antero-inferiorly, forwards and downwards along the neck.  It does however generally heal very well and does not leave too much of a cosmetic deformity, although the area of operation may be slightly less full after the gland has been removed if it has been particularly large there.  This does produce an area of numbness over the skin, particularly as a sensory nerve also often needs to be divided.  A drain will be inserted and kept in place for at least 24 hours after the operation and discharge home occurs around 6 to 24 hours after this is removed.  Typically it is necessary to be off work for around 10 days to 2 weeks.

The principal complication is possible weakness of the facial nerve.  This motor nerve runs through the middle of the gland and there is a small incidence of risk of damaging this nerve during the dissection.  This may lead to a weakness of the muscles of the face which may be temporary (occurring in 5 to 15% of cases), if there was bruising, or just occasionally this can be permanent (around 1 to 5% of cases, depending on pre-operative size and the nature of the pathology).

Numbness of the face and ear has been mentioned above and occasionally it is possible to develop Frey’s syndrome. This occurs when after the removal of the gland, secreto-motor nerves, which have previously directed salivary glands to release saliva, instead grow into the skin and then activate sweat glands to produce sweat.  Typically then stimuli which would normally produce saliva can produce an area of sweating of an area of skin supplied and this can produce some soreness.  Occasionally aluminium based antiperspirant preparations can help with this.

Local collections of serum, clot or saliva under the skin flap may require evacuation and this can sometimes necessitate a return to theatre.

The risk of recurrence of a benign swelling is less than 0.5%.