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

Facial nerve palsy is the most common complication after parotid surgery or parotidectomy. 1

Complications of Parotid Surgery

Parotid surgery carries several potential complications that can be categorized by their timing of onset:

Early Complications

• Facial nerve palsy/weakness:

  • Temporary facial weakness occurs in approximately 27% of cases 1
  • Permanent facial weakness occurs in about 2.5% of patients with normal preoperative function 1
  • Rates vary by surgical technique: 4.49% temporary facial paralysis with extracapsular dissection vs. 17.67% with superficial parotidectomy 2

• Other early complications:

  • Hematoma formation
  • Salivary fistula (6.18% with extracapsular dissection, 8.58% with superficial parotidectomy) 2
  • Sialocele (4.77% with extracapsular dissection, 3.53% with superficial parotidectomy) 2

Late Complications

• Frey's syndrome (gustatory sweating):

  • Occurs in 3.37% of extracapsular dissection cases and 18.18% of superficial parotidectomy cases 2
  • Some studies report higher incidence rates:
    • 23.5% of patients developed Frey's syndrome after an average of 12 months post-surgery 3
    • Up to 62% of patients may experience gustatory sweating following superficial parotidectomy 4
    • When using Minor's starch iodine test, 85% of patients who don't notice symptoms actually have subclinical manifestation 4

• Skin flap anesthesia (often due to greater auricular nerve injury)

• Wound complications:

  • Surgical wound dehiscence (12.64% with extracapsular dissection, 10.6% with superficial parotidectomy) 2
  • Pathological scarring/keloid (7.86% with extracapsular dissection, 7.57% with superficial parotidectomy) 2

Risk Factors for Complications

For Facial Nerve Palsy

• Extent of surgery (more extensive procedures carry higher risk)
• Surgical technique (superficial parotidectomy has higher rates than extracapsular dissection) 2
• Tumor characteristics (size, location, and relationship to facial nerve)

For Frey's Syndrome

• Tumor size (nearly double incidence with tumors ≥4cm compared to <4cm) 5
• Type of surgical procedure (risk ratios compared to lumpectomy of tail area) 6:
  • Pre-auricular lumpectomy: 4.378 times higher risk
  • Superficial parotidectomy: 8.040 times higher risk
  • Total parotidectomy: 8.174 times higher risk
• Repeat parotidectomy increases risk by 3.214 times 6
• Benign tumors carry higher risk than malignant tumors 6

Clinical Pearls and Pitfalls

• Important caveat: While Frey's syndrome is very common when tested objectively, many patients are asymptomatic or minimally symptomatic. Only 44% of patients with Frey's syndrome report being symptomatic 3

• Surgical technique considerations:

  • Maintaining thick skin flaps when oncologically appropriate can reduce complication risk 1
  • Meticulous hemostasis and layered wound closure are essential 1
  • The use of SMAS (superficial muscular aponeurotic system) flap has not been shown to significantly affect Frey's syndrome development 6

• Treatment options for Frey's syndrome:

  • Intracutaneous injection of botulinum toxin A is effective for severe cases 1, 4
  • Symptoms typically disappear within 1 week of treatment 4

• Follow-up considerations:

  • Educate patients about potential delayed onset of symptoms, as they may develop years after surgery 1
  • Long-term follow-up is important, as Frey's syndrome typically develops after an average of 12 months 3