technique of superficial parotidectomy

1. Parotidectomy
Jameel kifayatullah

2. Indications
• Benign tumours
• Malignant tumours
• Rarely sialadenitis
• Parotid abscess drainage
• As a part of lateral skull base procedure
• Skin malignancy(melanoma of skin)

3. Tests
• FNAC
• U/S
• CT NECK
• MRI
• Siaogram(special situation)

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

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

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

14. Surgical landmarks for identification of
the main trunk of the facial nerve

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