What is the most common complication after parotid (salivary gland) surgery or parotidectomy?

Most Common Complication After Parotidectomy

The most common complication after parotid surgery or parotidectomy is skin flap anesthesia (greater auricular nerve anesthesia), which occurs in approximately 71% of patients. 1

Complications of Parotidectomy by Frequency

1. Skin Flap Anesthesia (71%) 1

   • Caused by sacrifice or injury to the greater auricular nerve
   • Results in numbness in the earlobe and surrounding skin
   • Often unavoidable due to surgical approach

2. Frey's Syndrome (23.5-85%) 2, 3

   • Clinical incidence: 23.5% of patients develop symptomatic Frey's syndrome
   • Subclinical incidence: Up to 85% of patients have a positive Minor's starch iodine test even without symptoms
   • Typically develops after an average of 12 months post-surgery
   • Only 44% of patients with Frey's syndrome report being symptomatic

3. Facial Nerve Weakness 4

   • Temporary facial weakness: 27% of cases
   • Permanent facial weakness: 2.5% of patients with normal preoperative function

Risk Factors and Prevention

For Frey's Syndrome:

• Tumor size is a significant predictor - Tumors ≥4cm nearly double the risk (33% vs 18%) 5
• Preventive measures:
  • Maintaining thick skin flaps when oncologically appropriate 4
  • Free abdominal fat grafts have been associated with lower incidence 1
  • Sternocleidomastoid muscle flaps have not shown significant benefit 2

For Facial Nerve Injury:

• Meticulous surgical technique and careful nerve identification
• Surgeon experience (those performing >100 procedures annually have lower complication rates) 4

Management of Complications

1. Skin Flap Anesthesia:

   • Usually permanent but may improve partially over time
   • Patient education and reassurance are key

2. Frey's Syndrome:

   • Intracutaneous botulinum toxin A injections are effective for symptomatic cases 4, 3
   • Treatment can be repeated if symptoms recur
   • Results are typically seen within one week of injection 3

3. Facial Nerve Weakness:

   • Most cases are temporary and resolve within weeks to months
   • Early detection and management are critical to prevent long-term sequelae 4

Impact on Quality of Life

First Bite Syndrome appears to have a greater negative impact on patients' quality of life compared to both Frey's syndrome and skin flap anesthesia 1. However, it occurs less frequently (11% of cases).

Clinical Pearls

• Despite the high frequency of skin flap anesthesia, it is often not emphasized in preoperative counseling compared to more visible complications like facial weakness
• Frey's syndrome is present in almost all patients following parotidectomy when tested objectively, though many remain asymptomatic 3
• Deep lobe parotid surgery carries a higher risk for First Bite Syndrome 1
• Careful preoperative counseling about these potential complications is essential for patient satisfaction