What is the anesthetic management for superficial parotidectomy (superficial removal of the parotid gland)?

From the Guidelines

Anesthetic management for superficial parotidectomy requires general anesthesia with endotracheal intubation, prioritizing facial nerve monitoring and multimodal analgesia to minimize complications and promote smooth recovery. Begin with standard preoperative assessment focusing on airway evaluation and comorbidities, as recommended by various guidelines 1. Premedicate with midazolam 1-2mg IV for anxiolysis and glycopyrrolate 0.2mg IV to reduce secretions. Induction should include propofol 1.5-2.5 mg/kg, fentanyl 1-2 mcg/kg, and rocuronium 0.6 mg/kg for muscle relaxation. Maintain anesthesia with sevoflurane or desflurane at 1-1.2 MAC in oxygen/air mixture, supplemented with remifentanil infusion (0.05-0.2 mcg/kg/min) for stable hemodynamics.

Some key considerations for superficial parotidectomy include:

• Positioning the patient supine with head turned to the opposite side, ensuring eye protection and careful padding of pressure points
• Intraoperative facial nerve monitoring, which requires avoiding long-acting neuromuscular blockers after intubation and maintaining TOF counts of at least 2 twitches
• Administering dexamethasone 8-10mg IV to reduce edema and ondansetron 4mg IV for antiemesis, as recommended by 1
• Providing multimodal analgesia with paracetamol 1g IV, ketorolac 30mg IV (if not contraindicated), and local anesthetic infiltration by the surgeon, in line with guidelines from 1 and 1

For emergence, reverse neuromuscular blockade with sugammadex 2-4 mg/kg, extubate when fully awake, and transfer to PACU with oxygen supplementation. This approach ensures stable intraoperative conditions while facilitating facial nerve monitoring and promoting smooth recovery with minimal complications, ultimately prioritizing morbidity, mortality, and quality of life outcomes. The management of salivary gland malignancy, as outlined in 1, also supports the importance of careful surgical planning and execution to minimize risks and optimize patient outcomes.

From the Research

Anaesthetic Management for Superficial Parotidectomy

• The choice of anaesthetic technique for superficial parotidectomy depends on various factors, including the patient's overall health, the surgeon's preference, and the specific requirements of the procedure 2, 3.
• Total intravenous anesthesia (TIVA) with propofol and inhalation anesthesia with sevoflurane are two common techniques used for superficial parotidectomy 2.
• A study comparing TIVA with propofol and inhalation anesthesia with sevoflurane found that both techniques were safe and effective, but TIVA was associated with a longer recovery time 2.
• Another study found that coadministration of propofol and sevoflurane provided faster awakening and extubation with a low incidence of emergence coughing and agitation compared to sevoflurane maintenance alone 3.
• The choice of anaesthetic agent can also affect the glottic opening area during general anesthesia, with desflurane narrowing the glottic opening area and increasing peak inspiratory pressure compared to sevoflurane and propofol 4.

Considerations for Anaesthetic Management

• The anaesthetic management plan should take into account the patient's medical history, current medications, and any potential allergies or sensitivities 5, 6.
• The use of a supraglottic airway device may be associated with a higher risk of glottic stenosis during desflurane-remifentanil anesthesia, and clinicians should be aware of this possibility 4.
• The anaesthetic technique should be tailored to the individual patient's needs and the specific requirements of the procedure, with consideration given to factors such as pain management, nausea and vomiting, and recovery time 2, 3.

Postoperative Care

• Postoperative care for patients undergoing superficial parotidectomy should include monitoring for potential complications such as bleeding, infection, and facial nerve weakness 5, 6.
• The use of analgesics and antiemetics may be necessary to manage postoperative pain and nausea, and the choice of these medications should be tailored to the individual patient's needs 2, 3.
• Patients should be closely monitored during the postoperative period, with regular assessments of their vital signs, pain levels, and overall condition 5, 6.