2 head and neck
6 PAROTIDECTOMY
Kathryn T. Chen, MD, Shannon H. Allen, MD, and John A. Ridge, MD, PhD, FACS*
Anatomic Considerations
The parotid (“near the ear”) gland, the largest of the
salivary glands, occupies the space immediately anterior to
the ear, overlying the angle of the mandible. It drains into
the oral cavity via the Stensen duct, which enters the oral
vestibule opposite the upper molars. The gland is invested
by a strong fascia, and its “parotid space” is bounded supe-
riorly by the zygomatic arch, anteriorly by the masseter
muscle, posteriorly by the external auditory canal and the
mastoid process, and inferiorly by the sternocleidomastoid
muscle. The masseter muscle, the styloid muscles, the pos-
terior belly of the digastric muscle, and a portion of the ster-
nocleidomastoid muscle lie deep to the parotid [see Figure 1].
The parotid gland is separated from the submandibular
gland by the stylomandibular ligament, which is a continu-
ation of the investing fascia between the styloid process and
the angle of the mandible.
Terminal branches of the external carotid artery, the facial
vein, and the facial nerve are found within the gland.
Parasympathetic innervation to the parotid is via the otic
ganglion, which gives fibers to the auriculotemporal branch
of the trigeminal nerve. Sympathetic innervation to the
gland originates in the sympathetic ganglia and reaches
the auriculotemporal nerve by way of the plexus around the
middle meningeal artery.1
Lymphatic channels and nodes may be found within the
parotid space. The majority of lymph nodes are found in the
superficial layer between the gland and fascial layer, but a
second lymphatic system exists in the deep space as well.
Lymph drainage is to the cervical nodes.
The facial nerve trunk exits the stylomastoid foramen and
courses toward the parotid. Once inside the gland, it com-
monly bifurcates into superior (temporofrontal) and inferior
(cervicomarginal) divisions before giving rise to its terminal
branches, which innervate the muscles of facial expression.
The variations of facial nerve anatomy within the parotid
can be complex, but the common patterns are well known
and their relative frequencies well established.2,3 They
have little to no impact on the conduct of parotidectomy.
The portion of the parotid gland lateral and superficial to the
facial nerve (about 80% of the gland) is designated as the
superficial lobe; the portion medial and deep to the facial
nerve (the remaining 20%) is designated as the deep lobe.
Deep lobe tumors often present clinically as retromandibu-
lar or parapharyngeal masses, sometimes with displacement
of the tonsil or the soft palate appreciated in the pharynx.
* The authors and editors gratefully acknowledge the contribu-
tions of the previous author, Leonard R. Henry, MD, to the
development and writing of this chapter.
Financial disclosure information is located at the end of this chapter
before the references.
© 2013 Decker Intellectual Properties
Preoperative Evaluation
When a patient presents with a mass at the angle of the
mandible, a neoplasm within the parotid is a strong consid-
eration. The type of resection performed depends on on
preoperative clinical suspicion for benign versus malignant
disease.
A thorough history should be secured and a complete
head and neck examination undertaken. Clinical findings
worrisome for malignancy include facial pain, facial nerve
palsy, a fixed or nonmobile mass, and cervical lymphade-
nopathy and should be documented.4 Ultrasound evaluation
cannot adequately demonstrate the deep lobe of the parotid.5
For parotid masses clinically suspicious for malignancy,
computed tomography (CT) with intravenous contrast or
magnetic resonance imaging (MRI) with gadolinium encom-
passing the skull base to clavicle is warranted. Involvement
of bone, muscle, or pharyngeal mucosa will require extend-
ed resection and may (rarely) necessitate mandibulectomy
or maxillectomy. If involvement is suspected, the surgeon
should also be prepared to resect the facial nerve, and
appropriate counseling regarding anticipated deficits should
be provided to the patient. Consultation with a reconstruc-
tive surgeon may be prudent if resection will include the
mandible or create a substantial cutaneous defect.
Operative Planning
In general, there are three types of operations undertaken
for the parotid gland: subtotal, superficial, or total paroti-
dectomy. The term subtotal parotidectomy has sometimes
been interchangeably used with superficial parotidectomy
in the literature but might be considered as any parotid
resection less than a total parotidectomy. Obtaining
informed consent for parotidectomy entails discussing both
the features and the potential complications of the proce-
dure. It is appropriate to address the possibility of facial
nerve injury, but in doing so, the surgeon should not
neglect other, far more common sequelae, such as cosmetic
deformity, earlobe numbness secondary to division of the
posterior auricular nerve, and Frey syndrome (gustatory
sweating). Even conditions that are expected beforehand
may prove distressing or debilitating for the patient. The
risk of complications such as nerve injury is greater in cases
involving reoperation or resection of malignant or deep
lobe tumors. However, the overwhelming majority of
parotid tumors are benign and lateral to the facial nerve.
Accordingly, in what follows, we focus primarily on super-
ficial parotidectomy, referring to variants of the procedure
where relevant.
Excellent lighting, correctly applied traction and counter-
traction, adequate exposure, and clear definition of the
surgical anatomy are essential in parotid surgery. The use of
magnifying loupes and headlights is recommended. General
anesthesia without muscle relaxation should be employed.
ACS Surgery: Principles and Practice
DOI 10.2310/7800.2030
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2 head and neck
Zygomatic arch
Mastoid
Sternoclediomastoid muscle
Posterior digastric muscle
Stylohyoid muscle
Masseter muscle
The use of electromyography (EMG)-based facial nerve
monitoring has not been found to be associated with a
lower incidence of long-term permanent facial nerve injury6,7
and, as such, is not routinely used. However, it may be
useful in reoperative cases, where the anatomy of the facial
nerve may be distorted and its location obscured by scar.
The patient is placed in the supine position, with the head
elevated and turned away from the side undergoing opera-
tion and with the neck slightly extended. The table is posi-
tioned to allow the first assistant to stand directly above the
patient’s head while the surgeon faces the operative field. A
small cottonoid sponge is placed in the external auditory
canal, where it remains for the duration of the procedure to
prevent otitis externa from blood clot in the external audi-
tory canal. The skin is painted with an antiseptic agent. A
single perioperative dose of an antibiotic is administered.
The patient is draped in a fashion that permits the operat-
ing team to see all of the muscle groups innervated by the
facial nerve and to move the head if necessary. To this end,
we employ a head drape that incorporates the endotracheal
tube and anesthesia circuit. This drape secures the airway,
keeps the tube from interfering with the surgeon, and
permits rotation of the head without tension on the endotra-
cheal tube. The skin of the upper chest and neck is widely
painted and draped with a split sheet to allow additional
exposure in the unlikely event that a neck dissection or a
tracheotomy becomes necessary. The nose, the lips, and the
eyes are covered with a sterile transparent drape that allows
observation of movement during the procedure and permits
access to the oral cavity (if desired) [see Figure 2].
Operative Technique
step 1: incision and skin flaps
The incision is planned so as to permit excellent exposure
with good cosmetic results. It may usually be placed in a
skin crease to help conceal the resulting scar. The incision
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6 parotidectomy — 2
Figure 1 Anatomic boundaries of parotid space. The
parotid space is bounded by the zygomatic arch supe-
riorly, the external auditory canal and mastoid process
posteriorly, and the sternocleidomastoid muscle inferi-
orly. Additionally, the masseter muscle, the styloid
muscles, and the posterior belly of the digastric muscle
lie deep to the gland.
begins immediately anterior to the ear, continues downward
past the tragus, curves back under the ear (staying close to
the earlobe), and finally turns downward to descend along
the sternocleidomastoid muscle [see Figure 2]. All or part of
this incision may be used, depending on the circumstances.
The incision is marked before draping.
Skin flaps are then created to expose the parotid gland. A
tacking suture is placed within the dermis of the earlobe so
that it can be retracted posteriorly. Skin hooks are used to
apply vertical traction. The anterior flap is created superfi-
cial to the parotid fascia to afford access to the appropriate
dissection plane. Vertically oriented blunt dissection mini-
mizes the risk of injury to the distal branches of the facial
nerve, which become more superficial than the proximal
origins [see Figure 3]. The face is observed for muscle motion.
The flap is raised until the anterior border of the gland is
identified. The facial nerve branches are rarely encountered
during flap elevation until they emerge from the parenchyma
of the parotid. If muscle movement occurs, the flap has
been more than adequately developed. The anterior flap is
retracted with a suture through the dermis.
The posteroinferior skin flap is then elevated in a similar
manner. Careful dissection is performed to define the
relationship of the parotid tail to the anterior border of the
sternocleidomastoid. During this portion of the procedure,
the great auricular nerve is identified coursing cephalad and
superficial to the sternocleidomastoid muscle. Uninvolved
branches of this nerve should be preserved, if possible, to
prevent postoperative numbness of the earlobe.8,9 The
parotid tail is dissected from the sternocleidomastoid muscle
and should not be violated. Vertical traction is applied to the
gland surface with clamps to facilitate exposure.
A favorable skin crease, if available, may be used for
the incision to improve the postoperative cosmetic result;
however, it is important to keep the incision a few millime-
ters from the earlobe itself. A wound at the junction of the
2 head and neck
a
earlobe with the facial skin will distort the earlobe and
create a visible contour change. An incision behind the
tragus may lead to similar problems.
step 2: identification of facial nerve
Once the skin flaps have been developed and retracted,
the next step is to identify the facial nerve. Usually, the
nerve may be identified either at its main trunk (the ante-
grade approach) or at one of the distal branches, with
6 parotidectomy — 3
b
Figure 2 Parotidectomy. (a) The recommended head position and
incision. A transparent drape is placed over the eyes, the lip, and the
oral cavity. (b and c) The head drape incorporates the hose from the
endotracheal tube.
subsequent dissection back toward the main trunk (the
retrograde approach). For a superficial parotidectomy, our
preference is to identify the main trunk first (unless it is
thoroughly obscured by tumor or scar).
Antegrade Approach
The dissection plane is immediately anterior to the carti-
lage of the external auditory canal. The gland is mobilized
anteriorly by means of blunt dissection. To reduce the
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2 head and neck
b
Upper
Temporal division
Zygomatic
Lower division
Buccal
Marginal
Figure 3 Parotidectomy. (a) The creation of the anterior skin flap
superficial to the parotid gland. (b) Branches of the facial nerve,
including superior and inferior divisions and distal branches.
risk of a traction injury, tissue is spread in a direction that
is perpendicular to the incision and thus parallel to the
direction of the main trunk of the nerve [see Figure 4]. The
nerve trunk can usually be located underlying a point about
halfway between the tip of the mastoid process and the
ear canal.
Another commonly employed method is to identify the
tragal pointer, or the tip of the external canal cartilage. The
dictum is that the nerve is typically found slightly anterior
and inferior to this landmark and 1.0 to 1.5 cm deep,
although distance can vary considerably.10,11 Other anatomic
landmarks that facilitate identification of the nerve include
the posterior belly of the digastric muscle and the tympano-
mastoid suture. Of these, the tympanomastoid suture is
closest to the main trunk of the facial nerve.12 The clinical
utility of this landmark is limited, however, because the
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6 parotidectomy — 4
Figure 4 Parotidectomy. Dissection of the gland parenchyma is
carried out over the branches of the facial nerve to minimize the risk
of nerve injury. Each division of the substance of the gland should
reveal more of the facial nerve.
tympanomastoid suture is not easily appreciated in every
case. In addition, deep lobe tumors may displace the nerve
from its normal location. For appropriate and safe exposure
of the nerve trunk, it is preferable to mobilize several centi-
meters of the parotid, thereby creating a trough rather than
a deep hole. Small arteries run superficial and parallel to
the facial nerve; these must be divided. In particular, the
stylomandibular artery enters the stylomastoid foramen
alongside and superficial to the nerve. Use of the electrocau-
tery this close to the nerve is potentially hazardous, and
bipolar current or suture ligation is preferred. Bleeding is
typically minor but nonetheless must be controlled.
Retrograde Approach
As noted, when the main trunk cannot be exposed, the
most common alternative method of identifying the facial
nerve is to find a peripheral branch and then dissect proxi-
mally toward the main trunk. Which branch is sought may
depend on factors such as the surgeon’s comfort with the
anatomy and the known consistency of the nerve branch’s
location. In this setting, tumor bulk is often the deciding
factor.
The anatomic relationships between the nerve branches
and various landmarks can be exploited for more efficient
identification. For example, the marginal mandibular branch
of the facial nerve characteristically lies below the horizontal
ramus of the mandible.13 Often the facial vein can be traced
superiorly toward the parotid on the submandibular gland;
the nerve branch can then be found coursing perpendicu-
larly across and superficial to the vein [see Figure 5]. The
buccal branch of the facial nerve has a typical location in the
so-called buccal pocket—the area inferior to the zygoma and
deep to the superficial musculoaponeurotic layer, which
contains the buccal fat pad and Stensen duct in addition to
the buccal branch.13 The zygomatic branch of the facial nerve
lies roughly 3 cm anterior to the tragus, and the temporo-
frontal branch lies at the midpoint between the outer
canthus of the eye and the junction of the ear’s helix with the
preauricular skin.7 Nerve branches to the eye should be dis-
sected with particular care: even transient weakness of these
branches may be associated with substantial morbidity.
2 head and neck
Tragal pointer
Mastoid process
Tympanomastoid
suture
Facial nerve
Posterior belly a
digastric muscle
Marginal branch VII
Figure 5 Dissection of the facial nerve. (a) Antegrade approach. Shown are the relationships between the main trunk of the facial nerve,
mastoid process, tragal pointer, posterior belly of the digastric muscle, and tympanomastoid suture. (b) Retrograde approach. Shown are the
relationships between the distal branches of the facial nerve and the horizontal mandibular ramus, facial vein, and buccal fat pad.
Troubleshooting
Special efforts should be made to ensure that the cartilage
of the ear canal is not injured during exposure of the facial
nerve trunk. Any injury to this cartilage must be avoided, or
else the patient will hear an intense whistling as air enters
the closed-suction drain after operation.
The anxiety associated within isolation of the nerve trunk
may be alleviated somewhat by keeping in mind that the
nerve typically lies deeper than one might expect. In a study
of 46 cadaver dissections, the facial nerve was found to lie
at a median depth of 22.4 mm from the skin at the stylomas-
toid foramen (range 16 to 27 mm). The diameter of the nerve
trunk was found to range from 1.1 to 3.4 mm.14 In our
experience, the facial nerve trunk is slightly larger than the
nearby deep vessels, but their presence limits identification
unless they are divided.
Some surgeons advocate the use of a nerve stimulator
to aid in identifying the facial nerve trunk or its branches;
however, we have substantial reservations about whether
this measure should be employed on a regular basis [see
Complications, Facial Nerve Injury, below]. Knowledge of
the anatomy and sound surgical technique are the keys to a
safe parotidectomy; it is potentially hazardous to rely too
much on practices that may diminish them.
step 3: parenchymal dissection
Once identified, the plane of the facial nerve remains
uniform throughout the gland (unless the nerve is displaced
6 parotidectomy — 5
Buccal fat pad
b
Facial vein
Mandible
by a tumor) and serves to guide the parenchymal dissection.
Although some surgeons advocate the use of hemostatic
devices for parenchymal division,15,16 our practice is to
divide the substance of the parotid gland sharply and use
ligatures as appropriate when bleeding is encountered.
Usually, there is no significant hemorrhage: loss of more
than 30 mL of blood is rare.
The parenchymal dissection proceeds directly over the
facial nerve. We favor using fine curved clamps for this
portion of the procedure. To prevent trauma to the nerve,
care must be taken to resist the tendency to rest the blades
of the clamp on the nerve during dissection. Each division
of the gland should reveal more of the facial nerve [see
Figure 4]. When this is the case, the surgeon can continue the
parenchymal dissection with confidence that the nerve will
not be injured. As a rule, if a parenchymal division does
not immediately show more of the facial nerve, it is in an
improper (potentially unsafe) plane.
We do not regularly resect the entire lateral lobe of the
parotid unless the tumor is large and such resection is
required on oncologic grounds. The goal in resecting the
substance of the parotid is to obtain sound margins while
preserving the remainder of the gland and limiting manipu-
lation of the nerve it harbors. This so-called partial superfi-
cial parotidectomy, or subtotal parotidectomy, has been
shown to reduce the incidence of Frey syndrome without
increasing the rate of recurrence of pleomorphic adenoma.17
The plane of dissection is developed along facial nerve
ACS Surgery: Principles and Practice
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2 head and neck
branches until the lateral margins have been secured. This
is the portion of the procedure during which the risk of
nerve injury is highest. Once the lateral margins have been
secured, the parenchymal dissection can proceed from deep
to superficial for the excision of the tumor. The vertical
portion of the dissection (perpendicular to the plane of the
nerve branches) seldom poses a threat to the integrity of the
facial nerve, but care must be taken to maintain appropriate
margins. If division of the Stensen duct is required, the distal
remnant may be either left open18 or ligated.
Caution is appropriate in the resection of deep lobe
tumors. Tumors medial to the facial nerve may displace it
laterally. Thus, after establishing the plane of the facial
nerve, the surgeon must remain vigilant when dissecting
near the tumor to keep from injuring the nerve. Once the
substance of the gland obscuring the tumor has been
removed, the nerve branches in the area of the tumor are
retracted to allow exposure of the deep portion of the gland
and facilitate resection. Traction injury to the nerve may still
result in transient facial weakness.
Troubleshooting
Complete superficial parotidectomy with full dissection
of all facial nerve branches is seldom necessary, although
in some cases, it is mandated by tumor size or histologic
findings. Removal of the entire superficial lobe with the
intention of obtaining a larger lateral margin is rarely useful
because the closest margin is usually where the tumor is
nearest the facial nerve. Even temporary paresis of the tem-
porofrontal branch of the facial nerve may have devastating
consequences, and dissection near this branch is usually
unnecessary in treating a benign tumor in the parotid tail.
After complete resection of cancer, any close margins
remaining after nerve-preserving resection can be addressed
by means of postoperative radiation therapy, usually with
excellent results.19
The question of whether to sacrifice the facial nerve
almost invariably arises in the setting of malignancy. In our
view, this measure is seldom necessary. Benign tumors tend
to displace the nerve, not invade it. Sacrifice of the nerve
probably does not enhance survival.20,21 Although this issue
remains a subject of debate, our practice, like that of others,22
is to sacrifice only those branches intimately involved
with tumor. Repair, if feasible, should be performed [see
Complications, Facial Nerve Injury, below].
step 4: drainage and closure
Before closure, absolute hemostasis is confirmed (includ-
ing hemostasis during the Valsalva maneuver, which is
approximated by transiently increasing airway pressure to
30 cm H2O1). We sometimes then confirm the integrity of the
facial nerve with a nerve stimulator. A 5 mm closed-suction
drain is placed through a stab incision posterior to the infe-
rior aspect of the ear in a hair-bearing area. The tip of the
drain is loosely tacked to the sternocleidomastoid muscle,
with care taken to avoid direct contact with the facial nerve.
The wound is closed with the drain placed on continuous
suction. The skin is closed with interrupted 5-0 nylon
sutures. Bacitracin is applied to the wound. No additional
dressing is necessary or desirable [see Figure 6].
ACS Surgery: Principles and Practice
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6 parotidectomy — 6
The use of interrupted skin sutures instead of a continu-
ous suture allows the surgeon to perform directed suture
removal to drain the rare postoperative hematoma or fluid
collection instead of reopening the entire wound. We main-
tain gentle pressure over the surgical bed with an unfolded
surgical sponge during extubation to limit bleeding that
may be engendered by coughing during extubation.
Postoperative Care
Facial nerve function is evaluated in the recovery room,
with particular attention paid to whether the patient is able
to close the eyelid. The patient resumes eating when nausea
(if any) abates. Pain is generally well controlled by means of
oral agents. At discharge, the patient should be warned to
protect the numb earlobe against cold injury. The closed-
suction drain is kept in place for 5 to 7 days (until the first
postoperative visit) to minimize the risk of salivary fistula.
Complications
facial nerve injury
Facial nerve injuries include both intraoperative transec-
tion and paralysis. Transection or partial resection of the
facial nerve may be intentional, as in the case of a locally
advanced cancer with preoperative nerve dysfunction or
direct invasion, but can also be inadvertent. If the injury is
discovered intraoperatively, it should be repaired if possi-
ble. Primary repair—performed with interrupted fine per-
manent monofilament sutures under magnification23—is
preferred if sufficient nerve is available for a tension-free
anastomosis. If both transected nerve ends are identified but
tension-free repair is not feasible, interposition nerve grafts
may be used. A sensory nerve harvested from the neck (e.g.,
the great auricular nerve) is often employed for this pur-
pose. If the nerve is injured (or deliberately sacrificed) in
conjunction with treatment of malignancy, use of nerve
grafts from distant sites may be indicated24 but is seldom
necessary because uninvolved sensory nerves are almost
invariably to be found in the neck Recovery of facial nerve
function following grafting occurs at a mean time of 6 to
7 months.23,25
Facial nerve function should be assessed immediately in
the postanesthesia care unit to establish a baseline as tran-
sient paralysis may worsen over time. However, if unex-
pected facial nerve dysfunction is identified immediately
following the operation and if the surgeon is unsure of the
anatomic integrity of the nerve (ideally, a rare occurrence),
the patient should be returned to the operating room for
exploration so that either the continuity of the nerve can be
confirmed or the injury to the nerve can be identified and, if
possible, repaired. When the surgeon is certain that the
nerve is intact, facial nerve dysfunction may be approached
expectantly, in anticipation of recovery24; however, this may
take many months.
Facial nerve paralysis is generally secondary to traction,
compression, or ischemic insult. Studies have found that
transient paralysis of all or part of the facial nerve occurs
in 17 to 100% of patients undergoing parotidectomy26–29
2 head and neck 6 parotidectomy — 7

c d

Figure 6 Parotidectomy. Shown is drainage and closure after parotidectomy. (a) A closed-suction drain is placed in the operative bed and
loosely tacked to the sternocleidomastoid muscle. (b) Interrupted monofilament sutures are used for the skin. Bacitracin is applied. No addi-
tional dressings are used. (c) Photograph of a patient’s wound being drained after parotidectomy. (d) Photograph of a patient’s wound being closed
after parotidectomy.

depending on the extent of the resection and the location of
the tumor. Factors predictive of facial nerve palsy following
parotidectomy include prolonged operative time and larger
tumor sizes.28,30 Recovery of nerve function can take between
6 months and 1 year29–31; fortunately, permanent paralysis is
uncommon, occurring in fewer than 5% of cases.28,32
Nerve monitoring has been advocated to reduce the inci-
dence or severity of facial nerve injury, particularly in the
setting of resection for a recurrent parotid tumor.33 To date,
however, no randomized trial has demonstrated that intra-
operative facial nerve monitoring or nerve stimulators yield
any significant reduction in the incidence of facial nerve
paralysis after either primary parotidectomy or recurrence
surgery. Indeed, indiscriminate use of nerve monitoring and
nerve stimulators may imbue the surgeon with a false sense
of security and cause him or her to pay insufficient attention
to the appearance of nerve tissue. There are grounds to fear
that reliance on the nerve monitor may limit the surgeon’s
ability to identify the appearance of the nerve or its branch-
ses. Transient nerve dysfunction may follow inappropriate
(or even appropriate and unavoidable) trauma to or traction
and pressure on nerve trunks. Nerve monitoring does not
prevent such problems; moreover, it adds to the cost of
the procedure and lengthens the operating time.6,7 Some,
in fact, have suggested that nerve stimulators may actually
increase transient dysfunction. Accordingly, our use of nerve

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2 head and neck
stimulators is selective and limited to reoperations. Manage-
ment of enduring facial nerve paralysis (from any cause)
is beyond the scope of our discussion and constitutes a
surgical subspecialty in itself.
hemorrhage
Hemorrhage is a rare event and is usually secondary to
inadequate intraoperative hemostasis. Additional factors
that may contribute to bleeding include antiplatelet medica-
tions and anticoagulants, which should be discontinued in
an appropriate time frame prior to surgery.
Bleeding may manifest postoperatively as a hematoma or
persistent oozing at the surgical incision site and almost
always presents within the first 24 hours.34 Although hemo-
stasis may have been established intraoperatively, increased
venous return on emergence from anesthesia may disrupt
clotted or ligated vessels in the surgical bed (thus, pressure
is typically applied at the surgical site during extubation, as
noted above). It is important to remember that the parotid
space is not easily compressible given the skeletal and
muscular boundaries, and pressure is unlikely to resolve an
expanding hematoma once it develops. Thus, it is always
prudent to return to the operating room for hemostasis
when bleeding is suspected postoperatively.
gustatory sweating (frey syndrome)
Gustatory sweating, or Frey syndrome, occurs in most
patients after parotidectomy; it has been seen after subman-
dibular gland resection as well. The symptom complex
includes sweating, skin warmth, and flushing after chewing
food and is caused by cross-innervation of the parasympa-
thetic secretomotor fibers supplying the parotid gland and
cutaneous sympathetic receptors of the sweat glands and
blood vessels in the overlying skin. The reported incidence
of Frey syndrome varies greatly, apparently depending on
the sensitivity of the test used to elicit it. When Minor’s
starch iodine test is employed, the incidence of Frey
syndrome may reach 95% at 1 year after operation.35
Fortunately, the majority of patients have only subclinical
findings, and only a small fraction complain of debilitating
symptoms.35 Most symptomatic patients are adequately
treated with topical antiperspirants; eventually, however,
they tend to become noncompliant with such measures,
preferring simply to dab the face with a napkin while
eating.35 Despite the relatively low incidence of clinically
significant Frey syndrome, there is an extensive literature
addressing prevention and additional treatment of this
condition.17,32,36–44
sialocele (salivary fistula)
Sialocele, a collection of salivary fluid underneath the skin
flap, and salivary fistulae have been reported to occur after
1 to 15% of parotidectomies.17,45 Although both conditions
are generally minor and self-limited, they may nonetheless
be annoying and embarrassing for the patient. The diagnosis
is assigned with an increase in clear drainage during eating
or mastication or by aspiration of clear fluid with an amylase
level sent.45–47 The incidence of sialocele and fistula can be
reduced by maintaining closed-suction drainage for 5 to
ACS Surgery: Principles and Practice
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6 parotidectomy — 8
7 days (to facilitate adhesion of the skin flaps to the underly-
ing parotid parenchyma). Salivary leaks are usually attribut-
able to gland disruption rather than to duct transection
and therefore tend to resolve without difficulty.48 Once a
sialocele has formed, repeated aspiration and compression
dressings are generally effective for treatment and typically
resolve within 2 weeks.45 Anticholinergic agents have been
used in this setting as well.46,47,49,50 Low-dose radiation,51
completion parotidectomy, botulinum toxin injection,47,52
and tympanic neurectomy53 have all been employed in
refractory cases.
cosmetic changes
Parotidectomy creates a depression anterior and inferior
to the ear, which may extend behind the mandible and may
reach a significant size in patients with large or recurrent
tumors. This cosmetic change is a necessary feature of the
procedure, not a complication; nonetheless, it should be dis-
cussed with the patient before operation. Many augmenta-
tion methods, using a wide variety of techniques, have been
devised for improving postoperative appearance (as well
as alleviating Frey syndrome).37–41,54,55 All of these methods
have limitations or drawbacks that have kept them from
having wide application and acceptance. None has gained
overwhelming favor.
Outcome Evaluation
With proper surgical technique, superficial or partial
superficial parotidectomy can be performed safely and
within a reasonable operating time. The requirement for
blood transfusions should be vanishingly rare. Given ade-
quate exposure, good knowledge of the relevant anatomy,
limited trauma to the nerve, and appropriate use of closed-
suction drains (see above), complications should be uncom-
mon. Although patients may tolerate parotidectomy on
an outpatient basis, we prefer to keep them in the hospital
overnight. Patients should be able to leave the hospital with
minimal pain, comfortable with their drain care, by the
morning of postoperative day 1.
Financial Disclosures: None Reported
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Acknowledgment
Figures 1, 2a, 2b, 3b, 4, 5, 6a, 6b Shannon H. Allen, MD

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