What is the most common complication after parotid (parotid gland) surgery or parotidectomy (surgical removal of the parotid gland)?

Most Common Complication After Parotid Surgery or Parotidectomy

The most common complication after parotid surgery or parotidectomy is Frey's syndrome (gustatory sweating), which develops in approximately 23.5% of patients following parotidectomy. 1

Understanding Frey's Syndrome

Frey's syndrome (auriculotemporal syndrome or gustatory sweating) occurs due to:

• Aberrant regeneration of damaged parasympathetic nerve fibers that inappropriately reinnervate sweat glands in the overlying skin
• Results in gustatory sweating and flushing when stimulated by eating 2
• Typically develops after an average of 12 months following surgery 1
• Almost all patients who undergo parotidectomy will develop some degree of Frey syndrome, though only a minority become symptomatic 3

Incidence Rates of Major Complications

1. Frey's syndrome: 23.5% overall incidence 1, with higher rates (up to 18.18%) after superficial parotidectomy compared to extracapsular dissection (3.37%) 4

2. Facial nerve palsy:

   • Temporary facial weakness: 4.49% with extracapsular dissection, 17.67% with superficial parotidectomy 4
   • Permanent facial weakness: 2.25% with extracapsular dissection, 6.56% with superficial parotidectomy 4

3. Skin flap anesthesia: While specific rates aren't provided in the evidence, this is less common than Frey's syndrome based on the available data

Risk Factors for Frey's Syndrome

• Tumor size: The only statistically significant clinical predictor, with larger tumors increasing risk
  • Tumors ≥4 cm have nearly double the incidence (33%) compared to tumors <4 cm (18%) 5
• Extent of surgery: More extensive resections increase risk 2
  • Risk ratios compared to tail lumpectomy:
    • Pre-auricular lumpectomy: 4.378
    • Superficial parotidectomy: 8.040
    • Total parotidectomy: 8.174 6
• Repeat parotidectomy: Increases risk by 3.214 times 6

Prevention and Management

• Surgical techniques to reduce risk:

  • Maintaining thick skin flaps when oncologically appropriate 2
  • Partial superficial parotidectomy for appropriate cases 2
  • Meticulous hemostasis and layered wound closure 2

• Treatment options:

  • Intracutaneous injection of botulinum toxin A is effective, long-lasting, and well-tolerated
  • Treatment can be repeated if symptoms recur 3

Clinical Implications

It's important to note that while Frey's syndrome is the most common complication, only about 44% of patients who develop it are actually symptomatic 1. This means that while the condition occurs frequently, it may not always require intervention.

For high-risk patients (large tumors, extensive surgery), preventive interventions such as acellular dermal matrix, dermofat grafts, or muscle flaps should be considered 5.