Steps of Parotidectomy
The key steps of parotidectomy should include facial nerve identification and preservation when possible, with the extent of surgery determined by tumor characteristics including grade, size, and location. 1
Preoperative Assessment
- Evaluate tumor characteristics (size, location, grade, histology)
- Assess facial nerve function preoperatively
- Determine appropriate extent of parotidectomy based on:
- Low-grade vs. high-grade malignancy
- Early-stage (T1-T2) vs. advanced-stage (T3-T4)
- Facial nerve involvement
Surgical Steps
1. Incision and Exposure
- Modified Blair or modified facelift incision
- Elevation of skin flaps to expose the parotid gland
- Identification of anatomical landmarks (tragus, mastoid tip, sternocleidomastoid muscle)
2. Facial Nerve Identification
- Locate the main trunk of the facial nerve at the stylomastoid foramen
- Key landmarks for facial nerve identification:
- Tragal pointer
- Digastric muscle (posterior belly)
- Tympanomastoid suture
3. Facial Nerve Dissection
- Careful antegrade dissection of the facial nerve and its branches
- Preserve facial nerve when:
- Preoperative facial nerve function is intact
- A dissection plane exists between tumor and nerve 1
- Resect facial nerve branches only when:
- Preoperative facial weakness is present
- Branches are encased or grossly involved by confirmed malignancy 1
4. Tumor Removal Based on Type
For Low-Grade, Early-Stage Tumors (T1-T2):
- Perform partial superficial parotidectomy
- Remove tumor with adequate margins
- Preserve uninvolved parotid parenchyma 1
For High-Grade or Advanced Tumors (T3-T4):
- Perform at least superficial parotidectomy
- Consider total or subtotal parotidectomy
- Remove additional parotid tissue when possible without compromising facial nerve 1
5. Management of the Neck
- For T3-T4 tumors and high-grade malignancies:
- Perform elective neck dissection for clinically negative neck 1
- For low-grade, early-stage tumors:
- Observation of the neck is appropriate
6. Hemostasis and Closure
- Meticulous hemostasis to prevent hematoma formation
- Consider placement of drain
- Layered closure of the wound
Considerations for Specific Scenarios
Deep Lobe Involvement
- Deep lobe involvement is present in approximately 22% of metastatic lesions 1
- Complete parotidectomy may be considered but must balance with facial nerve risk
Facial Nerve Management
- Facial nerve preservation is critical for quality of life
- Early-stage, low-grade tumors have excellent disease control even with close margins 1
- For advanced/high-grade tumors with nerve involvement, resection of involved branches may be necessary
Potential Complications
- Facial nerve injury (temporary or permanent)
- Hemorrhage
- Infection
- Salivary fistula
- Seroma
- Greater auricular nerve anesthesia
- Frey syndrome (gustatory sweating) 2
Key Surgical Principles
- Adequate exposure is essential for safe parotidectomy 3
- Careful identification and protection of the facial nerve is paramount 3
- The extent of surgery should be tailored to tumor characteristics
- Achieving negative surgical margins improves overall survival 1
The surgical approach should balance complete tumor removal with preservation of facial nerve function whenever possible, as this significantly impacts patient quality of life and functional outcomes.