2. Indications
• Benign tumours
• Malignant tumours
• Rarely sialadenitis
• Parotid abscess drainage
• As a part of lateral skull base procedure
• Skin malignancy(melanoma of skin)
6. 4 critical steps
• Flap elevation
Subplatysmal
Sub SMAS
• Identification of facial nerve
Digastric
Tragal pointer
tympanomastoid suture line
• TLC(Handling the nerve)
• Delivery and closure
7. procedure
• Once the skin is drapped(covered) the wound
is cleaned with betadine solution
• Face and eyes are kept exposed
• Modified blair incision made
• For infilteration 1;100000 xylocaine with
adrenaline
• The incision is deepened along the marked
area
8.
9. procedure
• Once the skin incision is done, hemostasis is
achieved
• in the neck we prefer to be in subplatysmal
plane (avascular plane)
• in the parotid region it should be subSMAS
• Traction and countertraction is given to
elevate the skin flap and monopolar cautery is
used to raise the flap
10.
11. procedure
• An inch of flap should be anterior to tumor
margin
• once the anterior flap is raised we ought to
elevate the posterior flap
• and make sure that the greater auricular nerve is
identified.We sometimes need it for nerve
anastomosis
• It is difficult to preserve the anterior branch of
greater auricular nerve however posterior branch
can be preserved
12. procedure
• The second step, is commenced by identifying
the sternocleidomastoid
• Now a plane is created between the parotid
tissue and the SCM muscle and superiorly
between the tragal cartilage and the parotid
• This groove is widened with bipolar cautery
and henceforth most of the dissection is done
with scissors and bipolars
13. procedure
• The parotid is reflected anteriorly so that a broad
plane is achieved to reach the facial nerve
• Bit of parotid tissue adherent to the
sternocleidomastoid is elevated with cautery .As
we elevate it digastrics muscle is seen
• They are generally in the opposite direction to
the muscle fibers of SCM
• This is very important landmark. Once this is
identified it will tell us the plane of dissection
15. procedure
• As we go along the lower border of digastrics,be
careful about the marginal mandibular nerve Which
might actually exit just along the lower border of the
parotid
• Hemostasis achieved as hemostasis is critical from
now on avascular field should be maintained
• Once the tragal pointer is identified and the digastric is
identified the next step which is step 2 is to identify the
facial nerve
• This is done by careful dissection with an artery forcep
while your assistant retracts the parotid tissue
• The dissection should be along the exit pathway of the
facial nerve not diagonally
16. procedure
• The superior attachments of the parotid is
released from the tragal cartilage
• The nerve is slowly carefully and slowly dissected
and almost one centimeter of nerve is visible
• After identifying the facial nerve the third step of
parotidectomy is tunnelling ,lifting and cutting
• What you just saw was tunneling we lifted the
parotid tissue from the nerve bed and cut with
bipolar
17. procedure
• So slowly and steadily the parotid tissue is separated
from the deep lobe and the nerve
separates the deep lobe and superficial lobe
• cauterize bleeding with bipolar
• a nerve stimulator is good tool to have and this will
identify the nerve when there is issue regarding
identification or if you think that there is an anomalous
course
• so here again we do the same maneuver which is
tunneling the parotid tissue lifting it from the facial
nerve course and coagulating and cutting it.(TLC
MANEUVER)
18. procedure
• once the parotid is marked atleast one
centimeter as circumferential margin is taken for
benign tumor
• The retromandibular vein which radiologically
separates the superficial lobe from deep lobe is
seen
• The temporozygomatic branch is identified and
just above the nerve an artery forcep is put for
Tunneling,lifting it from the bed and bipolar
cautery is done
19. procedure
• As you keep repeating this manever again and
again ,the parotid slowly opens like a book
• Any blood vessel has to be cauterised and if
the vessel is of bigger diameter it is better to
tie or apply a ligar clip
• sometimes the parotid tissue is very firm so
you might need to cut it with scissor or
monopolar when the tissue is very thick
• tunneling lifting and cutting done
20. procedure
• so we complete the dissection by 360 degree
approach and remove the parotid from its
attachments to the skin,subcutaneous tissue
• all the time keep a watch on the nerves for
any twitching
• now the tumour is dissected from the deep
lobe
• the last structure to be cut would be stensons
duct.you an identify and tie it
21. procedure
• Identify and check the facial nerve branches
• Complete hemostasis achieved
• Every structure is again identified
• The wound is then closed in layers
• 2 layer closure and single drain placed.
22. RISKS AND COMPLICATIONS OF
PAROTIDECTOMY
• Bleeding
• Infection
• Facial nerve palsy 5%
• Gustatory sweating
• Scar/keloid
• Recurrence
• Need for further treatment
• Cosmetic deformity