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 Frey's syndrome (gustatory sweating), which occurs in approximately 62-85% of patients when including subclinical cases. 1

Complications of Parotidectomy: Prevalence and Impact

Parotidectomy is associated with several potential complications:

1. Frey's syndrome (gustatory sweating):

   • Occurs in 23.5% of patients clinically 2
   • Up to 85% of patients have subclinical manifestation when tested 1
   • Typically develops around 12 months post-surgery 2
   • Only 44% of patients with Frey's syndrome report being symptomatic 2

2. Facial nerve weakness:

   • Temporary facial weakness: occurs in approximately 27% of cases 3
   • Permanent facial weakness: occurs in about 2.5% of patients with normal preoperative function 3

3. Greater auricular nerve anesthesia/skin flap anesthesia:

   • Affects approximately 71% of patients 4
   • While common, it has less impact on quality of life compared to other complications 4

4. Other complications:

   • Hematoma formation
   • Salivary fistula
   • Seroma
   • Keloid formation
   • First Bite Syndrome (11% of patients) 4
   • Recurrent tumor (0.8% with appropriate technique) 3, 5

Risk Factors and Prevention

Risk Factors for Frey's Syndrome:

• Tumor size: The only statistically significant predictor, with tumors ≥4cm nearly doubling the risk (33% vs 18%) 6
• Disease pathology, type of resection, and previous treatments (radiotherapy or prior parotidectomy) do not appear to be significant predictors 6

Prevention Strategies:

• Surgical technique: Maintaining thick skin flaps when oncologically appropriate 3
• Barrier methods: Free abdominal fat grafts have been associated with lower incidence of Frey's syndrome 4
• Sternocleidomastoid flaps: No significant benefit observed in preventing Frey's syndrome 2

Management of Complications

For Frey's Syndrome:

• Intracutaneous injection of botulinum toxin A is effective and well-tolerated 3, 1
• Effects typically appear within one week of treatment 1
• Treatment can be repeated if symptoms recur 3

For Other Complications:

• Meticulous hemostasis and layered wound closure are essential to prevent hematoma, seroma, and salivary fistula 3
• Early detection and management are critical to preventing long-term sequelae 3

Clinical Pearls and Pitfalls

• Delayed onset: Patients should be educated that Frey's syndrome typically appears around 12 months after surgery 2
• Subclinical cases: Many patients have subclinical Frey's syndrome that can be detected with Minor's starch iodine test even when they report no symptoms 1
• Quality of life impact: First Bite Syndrome appears to have a greater negative impact on quality of life than Frey's syndrome or skin anesthesia 4
• Deep lobe surgery: Surgery of the deep lobe of the parotid is associated with higher risk of First Bite Syndrome 4

While facial nerve weakness and skin flap anesthesia are significant complications, the evidence clearly shows that Frey's syndrome is the most common complication after parotidectomy, especially when including subclinical cases detected through objective testing.