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

Facial nerve palsy is the most common significant complication after parotid surgery or parotidectomy, occurring in approximately 27% of cases temporarily and 2.5% permanently in patients with normal preoperative function. 1

Complications of Parotid Surgery

Facial Nerve Complications

• Temporary facial weakness: Occurs in approximately 27% of cases 1
• Permanent facial weakness: Occurs in approximately 2.5% of patients with normal preoperative function 1
• Risk factors for facial nerve injury:
  • Extensive surgery
  • Tumor size and location
  • Revision surgery
  • Surgeon experience

Frey's Syndrome

• Develops in almost all patients who undergo parotidectomy to some extent, but only a minority become symptomatic 2
• Characterized by gustatory sweating, flushing, and warming over preauricular and temporal areas
• Clinically significant (symptomatic) Frey's syndrome occurs in:
  • 23.5% of patients after an average of 12 months post-surgery 3
  • Only 44% of patients with Frey's syndrome report symptoms that affect daily life 3
  • Higher incidence (18.18%) after superficial parotidectomy compared to extracapsular dissection (3.37%) 4

Skin Flap Anesthesia/Hypoesthesia

• Hypo-anesthesia of the skin occurs in approximately 71% of patients 5
• Often involves the distribution of the great auricular nerve
• Usually improves over time but can be permanent

Other Complications

• Hematoma formation
• Salivary fistula (6.18-8.58%) 4
• Sialocele (3.53-4.77%) 4
• Wound dehiscence (10.6-12.64%) 4
• Pathological scarring/keloid (7.57-7.86%) 4
• First Bite Syndrome (11%) 5

Risk Factors for Complications

For Facial Nerve Injury

• More extensive resections
• Revision surgery
• Tumor proximity to facial nerve
• Surgeon experience (lower complication rates with surgeons performing >100 thyroidectomies per year) 6

For Frey's Syndrome

• Tumor size (significant predictor - incidence nearly doubles in patients with tumors ≥4 cm) 7
• Type of surgery (higher in superficial parotidectomy vs. extracapsular dissection) 4

Prevention Strategies

For Facial Nerve Injury

• Meticulous surgical technique
• Careful identification and preservation of facial nerve
• Use of facial nerve monitoring during surgery

For Frey's Syndrome

• Maintaining thick skin flaps when oncologically appropriate 1
• Free abdominal fat graft (associated with lower incidence) 5
• Partial superficial parotidectomy when appropriate 2

Management of Complications

For Facial Nerve Injury

• Physical therapy
• Eye protection measures for incomplete eye closure
• Nerve grafting in severe cases

For Frey's Syndrome

• Intracutaneous injection of botulinum toxin A (effective, long-lasting, and well-tolerated) 1, 2
• Treatment can be repeated if symptoms recur 2

Clinical Implications

The high incidence of facial nerve palsy, even if temporary, highlights the importance of:

1. Proper patient counseling regarding potential complications
2. Meticulous surgical technique with careful identification and preservation of the facial nerve
3. Consideration of surgeon experience and volume when referring patients for parotid surgery
4. Early recognition and management of complications to prevent long-term sequelae

While Frey's syndrome and skin flap anesthesia are common, they typically have less impact on quality of life compared to facial nerve dysfunction, which can significantly affect facial expression, eye protection, and social interactions.