What are the different types of parotidectomy?

Types of Parotidectomy

The main types of parotidectomy are partial superficial parotidectomy, superficial (lateral) parotidectomy, and total parotidectomy, with the choice determined by tumor grade, stage, and location relative to the facial nerve. 1, 2

Classification of Parotidectomy Types

Partial Superficial Parotidectomy

• This procedure removes only the tumor with a margin of surrounding parotid tissue while preserving uninvolved parotid parenchyma. 1, 2
• Indicated for T1-T2 low-grade salivary cancers that are appropriately located in the superficial lobe. 1
• For benign tumors confined to the superficial lobe, partial superficial parotidectomy is sufficient and associated with lower morbidity. 2, 3
• Additional excision of uninvolved parotid parenchyma beyond achieving negative margins (≥1 mm) is not necessary, as studies show 5-year disease-free survival of 90.6% with this approach. 1
• This limited approach reduces the incidence of transient postoperative facial nerve weakness by 2.7-fold compared to more extensive procedures. 4

Superficial (Lateral) Parotidectomy

• This procedure removes the entire superficial lobe of the parotid gland, which lies superficial to the plane of the facial nerve. 2, 3
• For high-grade or advanced-stage (T3-T4) parotid cancers, at least a superficial parotidectomy must be performed due to the risk of intraparotid nodal metastases. 1
• The facial nerve is identified at the stylomastoid foramen, and all parotid tissue superficial to the nerve branches is removed. 2
• This approach addresses occult lymph node involvement, which occurs in over 20% of high-grade histologies including salivary duct carcinoma and adenocarcinoma. 1

Total (Complete) Parotidectomy

• This procedure removes both the superficial and deep lobes of the parotid gland while preserving the facial nerve when oncologically feasible. 2, 3
• Consideration for total or subtotal parotidectomy should be given in high-grade or advanced-stage parotid cancers when additional parotid tissue removal is possible without placing the facial nerve at significant increased risk. 1
• Deep lobe involvement occurs in approximately 22% of parotid metastatic lesions, though more aggressive surgery has not been shown to improve survival or locoregional control when adjuvant therapy is used. 1
• Total parotidectomy is reserved for tumors of larger extent or deep-located tumors occupying the parapharyngeal space. 3

Radical Parotidectomy

• This procedure involves removal of all parotid tissue with intentional sacrifice of the facial nerve. 1
• Facial nerve resection should only be performed when branches are encased or grossly involved by confirmed malignancy, or when preoperative facial nerve weakness/paralysis is present. 1, 2
• The facial nerve should be preserved in patients with intact preoperative function when a dissection plane can be created between tumor and nerve, as nerve sacrifice does not clearly improve survival outcomes even in advanced tumors. 1
• Studies show no statistically significant difference in disease-free survival between total parotidectomy with nerve preservation versus radical parotidectomy with nerve sacrifice. 1

Key Clinical Decision Algorithm

For tumor selection:

• T1-T2 low-grade superficial tumors → Partial superficial parotidectomy 1, 2
• T3-T4 or high-grade tumors → At minimum superficial parotidectomy, consider total/subtotal 1
• Benign tumors → Partial superficial parotidectomy is sufficient 2, 3

For facial nerve management:

• Normal preoperative function + dissection plane possible → Preserve nerve 1, 2
• Preoperative weakness or nerve encasement → Resect involved branches 1, 2

Important Clinical Pitfalls

• Do not perform complete superficial parotidectomy routinely for all benign tumors—partial superficial parotidectomy achieves similar recurrence rates (0.8-3.0%) with significantly lower facial nerve morbidity. 3, 4
• Intraoperative frozen section has 98.5% sensitivity and 99% specificity for detecting malignancy, but decisions causing major harm (such as facial nerve sacrifice) should not be based on indeterminate diagnoses alone. 2
• More extensive surgery (superficial or total parotidectomy) increases temporary facial nerve weakness from baseline to 27% of cases, with permanent weakness occurring in 2.5% when nerve is preserved. 3, 4
• The extent of parotidectomy should be guided by tumor characteristics, not by arbitrary surgical dogma—narrow margins (≤5 mm but ≥1 mm) show excellent disease control in low/intermediate-grade tumors without adverse features. 1, 2