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Acs0206 Parotidectomy


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Acs0206 Parotidectomy

  1. 1. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 1 6 PAROTIDECTOMY Leonard R. Henry, MD, and John A. Ridge, MD, PhD, FACS Anatomic Considerations the surgical anatomy are essential in parotid surgery. The The parotid (“near the ear”) gland, the largest of the salivary use of magnifying loupes and headlights is recommended. glands, occupies the space immediately anterior to the ear, General anesthesia without muscle relaxation should be overlying the angle of the mandible. It drains into the oral employed. cavity via Stensen’s duct, which enters the oral vestibule The patient is placed in the supine position, with the head opposite the upper molars. The gland is invested by a strong elevated and turned away from the side undergoing operation fascia and is bounded superiorly by the zygomatic arch, ante- and with the neck slightly extended. The table is positioned riorly by the masseter muscle, posteriorly by the external to allow the first assistant to stand directly above the patient’s auditory canal and the mastoid process, and inferiorly by the head, while the surgeon faces the operative field. A small sternocleidomastoid muscle. The masseter muscle, the styloid cottonoid sponge is placed in the external auditory canal, muscles, the posterior belly of the digastric muscle, and a where it remains for the duration of the procedure to prevent portion of the sternocleidomastoid muscle lie deep to the otitis externa from blood clots in the external auditory parotid. Terminal branches of the external carotid artery, the canal. The skin is painted with an antiseptic agent. A single facial vein, and the facial nerve are found within the gland. perioperative dose of an antibiotic is administered. Parasympathetic innervation to the parotid is via the otic The patient is draped in a fashion that permits the operat- ganglion, which gives fibers to the auriculotemporal branch of ing team to see all of the muscle groups innervated by the trigeminal nerve. Sympathetic innervation to the gland the facial nerve. To this end, we employ a head drape that originates in the sympathetic ganglia and reaches the auricu- incorporates the endotracheal tube and hose. This drape lotemporal nerve by way of the plexus around the middle secures the airway, keeps the tube from interfering with the meningeal artery.1 surgeon, and permits rotation of the head without tension The facial nerve trunk exits the stylomastoid foramen and on the endotracheal tube. The skin of the upper chest and courses toward the parotid. Once inside the gland, it com- neck is widely painted and draped with a split sheet to allow monly bifurcates into superior (temporal-frontal) and inferior additional exposure in the unlikely event that a neck dissec- (cervicomarginal) divisions before giving rise to its terminal tion or a tracheostomy becomes necessary. The nose, the lips, branches. The nerve branching within the parotid can be and the eyes are covered with a sterile transparent drape that quite complex, but the common patterns are well known and allows observation of movement during the procedure and their relative frequencies well established.2,3 The portion of permits access to the oral cavity (if desired) [see Figure 1]. the parotid gland lateral to the facial nerve (about 80% of the gland) is designated as the superficial lobe; the portion medial to the facial nerve (the remaining 20%) is designated as the Operative Technique deep lobe. Deep-lobe tumors often present clinically as retro- step 1: incision and skin flaps mandibular or parapharyngeal masses, with displacement of the tonsil or the soft palate appreciated in the throat. The incision is planned so as to permit excellent exposure with good cosmetic results. It begins immediately anterior to the ear, continues downward past the tragus, curves back Operative Planning under the ear (staying close to the earlobe), and finally turns Obtaining informed consent for parotidectomy entails downward to descend along the sternocleidomastoid muscle discussing both the features and the potential complications [see Figure 1]. Either all or part of this incision may be used, of the procedure. It is appropriate to address the possibility depending on circumstances. The incision is marked before of facial nerve injury, but in doing so, the surgeon should not draping. Skin creases typically help conceal the resulting neglect other, far more common sequelae, such as cosmetic scar. deformity, earlobe numbness, and Frey syndrome. Even con- Skin flaps are then created to expose the parotid gland. A ditions that are expected beforehand may prove distressing tacking suture is placed within the dermis of the earlobe so or debilitating for the patient. The risk of complications that it can be retracted posteriorly. Skin hooks are used to such as nerve injury is greater in cases involving reoperation apply vertical traction. The anterior flap is created superficial or resection of malignant or deep-lobe tumors. The over- to the parotid fascia to afford access to the appropriate dis- whelming majority of parotid tumors, however, are benign section plane. Vertically oriented blunt dissection minimizes and lateral to the facial nerve. Accordingly, in what follows, the risk of injury to the distal branches of the facial nerve [see we focus primarily on superficial parotidectomy, referring to Figure 2]. The face is observed for muscle motion. The flap variants of the procedure where relevant. is raised until the anterior border of the gland is identified. Excellent lighting, correctly applied traction and The facial nerve branches are rarely encountered during flap countertraction, adequate exposure, and clear definition of elevation until they emerge from the parenchyma of the DOI 10.2310/7800.S02C06 07/08
  2. 2. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 2 a b Figure 1 Parotidectomy. (a) Shown are the recommended head position and incision. A transparent drape is placed over the eyes, the lip and oral cavity. (b) The head drape incorporates the hose from the endotracheal tube. parotid. If muscle movement occurs, the flap has been more branches of this nerve should be preserved if possible to pre- than adequately developed. The anterior flap is retracted with vent postoperative numbness of the earlobe.4,5 The parotid a suture through the dermis. tail is dissected away from the sternocleidomastoid muscle. The posterior-inferior skin flap is then elevated in a similar Vertical traction is applied to the gland surface with clamps manner. Careful dissection is performed to define the rela- to facilitate exposure. tionship of the parotid tail to the anterior border of the ster- nocleidomastoid. During this portion of the procedure, the Troubleshooting great auricular nerve is identified coursing cephalad and A favorable skin crease, if available, may be used for superficial to the sternocleidomastoid muscle. Uninvolved the incision to improve the postoperative cosmetic result; a b Figure 2 Parotidectomy. (a) Shown is the creation of the anterior skin flap superficial to the parotid gland. (b) Vertically oriented blunt dissection minimizes the risk of injury to facial nerve branches as they exit the gland. 07/08
  3. 3. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 3 however, it is important to keep the incision a few millimeters deep-lobe tumors may displace the nerve from its normal from the earlobe itself. A wound at the junction of the earlobe location. For appropriate and safe exposure of the nerve with the facial skin will distort the earlobe and create a visible trunk, it is necessary to mobilize several centimeters of the contour change. An incision behind the tragus may lead to parotid, thereby creating a trough rather than a deep hole. similar problems. Small arteries run superficial and parallel to the facial nerve; these must be divided. Use of the electrocautery this close to step 2: identification of facial nerve the nerve is potentially hazardous. Bleeding is typically minor Once the skin flaps have been developed and retracted, the but nonetheless must be controlled. next step is to identify the facial nerve. Usually, the nerve may be identified either at its main trunk (the antegrade approach) Retrograde Approach or at one of the distal branches, with subsequent dissection As noted, when the main trunk cannot be exposed, the back toward the main trunk (the retrograde approach). For a most common alternative method of identifying the facial lateral parotidectomy, our preference is to identify the main nerve is to find a peripheral branch and then dissect proxi- trunk first (unless it is thoroughly obscured by tumor or mally toward the main trunk. Which branch is sought may scar). depend on factors such as the surgeon’s comfort with the anatomy and the known consistency of the nerve branch’s Antegrade Approach location. In this setting, tumor bulk is often the deciding The dissection plane is immediately anterior to the factor. cartilage of the external auditory canal. The gland is mobi- The anatomic relationships between the nerve branches lized anteriorly by means of blunt dissection. To reduce the and various landmarks can be exploited for more efficient risk of a traction injury, tissue is spread in a direction that is identification. For example, the marginal mandibular branch perpendicular to the incision and thus parallel to the direction of the facial nerve characteristically lies below the horizontal of the main trunk of the nerve [see Figure 3]. The nerve trunk ramus of the mandible.7 Often, the facial vein can be traced can usually be located underlying a point about halfway toward the parotid on the submandibular gland; the nerve between the tip of the mastoid process and the ear canal. In branch can then be found coursing perpendicular and super- addition, there are several anatomic landmarks that facilitate ficial to the vein. The buccal branch of the facial nerve has a identification of the nerve, including the tragal pointer, the typical location in the so-called buccal pocket—the area infe- posterior belly of the digastric muscle, and the tympanomas- rior to the zygoma and deep to the superficial musculoapo- toid suture. Of these, the tympanomastoid suture is closest to neurotic layer, which contains the buccal fat pad and Stensen’s the main trunk of the facial nerve.6 The clinical utility of this duct in addition to the buccal branch.7 The zygomatic branch landmark is limited, however, because the tympanomastoid of the facial nerve lies roughly 3 cm anterior to the tragus, suture is not easily appreciated in every case. In addition, and the temporal-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 dissected with particular care: even transient weakness of these branches may have a significant impact on morbidity. 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 repaired, or else an intense whistling will be heard from 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 stylomastoid foramen (range, 16 to 27 mm). The diameter of the nerve trunk was found to range from 1.1 to 3.4 mm.8 In our expe- rience, the facial nerve trunk is slightly larger than the nearby deep vessels. Some surgeons advocate the use of a nerve stimulator to aid in identifying the facial nerve trunk or its branches; how- ever, we have substantial reservations about whether this Figure 3 Parotidectomy. Depicted is identification of the facial nerve at its trunk. A wide trough is created anterior to measure should be employed on a regular basis [see Compli- the external auditory canal and deepened by spreading a blunt cations, Facial Nerve Palsy, below]. Knowledge of the ana- curved instrument in a direction perpendicular to the incision tomy and sound surgical technique are the keys to a safe and parallel to the nerve trunk. Anatomic landmarks assist in parotidectomy; it may be hazardous to rely too much on identification of the nerve. practices that may diminish them. 07/08
  4. 4. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 4 step 3: parenchymal dissection The vertical portion of the dissection seldom poses a threat Once identified, the plane of the facial nerve remains uni- to the integrity of the facial nerve, but care must be taken to form throughout the gland (unless the nerve is displaced by maintain appropriate margins. If division of Stensen’s duct is a tumor) and serves to guide the parenchymal dissection. required, the distal remnant may be either left open12 or Although some surgeons advocate the use of hemostatic ligated. devices for parenchymal division,9,10 our practice is to divide Caution is appropriate in the resection of deep-lobe tumors. the substance of the parotid gland sharply and use ligatures Tumors medial to the facial nerve may displace this structure as appropriate when bleeding is encountered. Usually, there laterally. Thus, after establishing the plane of the facial nerve, is no significant hemorrhage: loss of more than 30 mL of the surgeon must remain careful when dissecting near the blood is rare. tumor to keep from injuring the nerve. Once the substance of The parenchymal dissection proceeds directly over the the gland obscuring the tumor has been removed, the nerve facial nerve. We favor using fine curved clamps for this branches in the area of the tumor are retracted to allow expo- portion of the procedure. To prevent trauma to the nerve, sure of the deep portion of the gland and facilitate resection. care must be taken to resist the tendency to rest the blades of Traction injury to the nerve may still result in transient facial the clamp on the nerve during dissection. Each division of the weakness. gland should reveal more of the facial nerve [see Figure 4]. Troubleshooting When this is the case, the surgeon can continue the paren- chymal dissection with confidence that the nerve will not Complete superficial parotidectomy with full dissection of be injured. As a rule, if a parenchymal division does not all facial nerve branches is seldom necessary, though in some immediately show more of the facial nerve, it is in an improper cases it is mandated by tumor size or histologic findings. plane. Removal of the entire superficial lobe with the intention of We do not regularly resect the entire lateral lobe of the obtaining a larger lateral margin is rarely useful, because the parotid unless the tumor is large and such resection is required closest margin is usually where the tumor is nearest the facial on oncologic grounds. The goal in resecting the substance of nerve. Even temporary paresis of the temporal-frontal branch the parotid is to obtain sound margins while preserving the of the facial nerve may have devastating consequences, and remainder of the gland. This so-called partial superficial dissection near this branch is usually unnecessary in treating parotidectomy has been shown to reduce the incidence of a benign tumor in the parotid tail. Any close margins remain- Frey syndrome without increasing the rate of recurrence of ing after nerve-preserving cancer treatment can be addressed pleomorphic adenoma.11 The plane of dissection is developed by means of postoperative radiation therapy, usually with along facial nerve branches until the lateral margins have excellent results.13 been secured. This is the portion of the procedure during The question of whether to sacrifice the facial nerve almost which the risk of nerve injury is highest. Once the lateral invariably arises in the setting of malignancy. In our view, this margins have been secured, the parenchymal dissection can measure is seldom necessary. Benign tumors tend to displace proceed from deep to superficial for the excision of the tumor. the nerve, not invade it. Sacrifice of the nerve probably does not enhance survival.14,15 Although this issue remains a sub- ject of debate, our practice, like that of others,16 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 (including hemostasis during the Valsalva maneuver, which is approxi- mated by transiently increasing airway pressure to 30 cm H2O1). We may then assess 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 inferior 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 5]. Troubleshooting Figure 4 Parotidectomy. Dissection of the gland The use of interrupted skin sutures instead of a continuous parenchyma is carried out over the branches of the facial nerve to minimize the risk of nerve injury. Each division of suture allows the surgeon to perform directed suture removal the substance of the gland should reveal more of the facial to drain the rare postoperative hematoma or fluid collection nerve. instead of reopening the entire wound. 07/08
  5. 5. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 5 a b Figure 5 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 additional dressings are used. Postoperative Care Complications Facial nerve function is evaluated in the recovery room, facial nerve injury with particular attention paid to whether the patient is able to close the eyelid. The patient resumes eating when nausea Studies have found that transient paralysis of all or part of (if any) abates. Pain is generally well controlled by means of the facial nerve occurs in 17 to 100% of patients undergoing oral agents. At discharge, the patient should be warned to parotidectomy,17–20 depending on the extent of the resection protect the numb earlobe against cold injury. The closed and the location of the tumor. Fortunately, permanent paral- suction drain is kept in place for 5 to 7 days (until the ysis is uncommon, occurring in fewer than 5% of cases.19,21 first postoperative visit) to minimize the risk of salivary Nerve monitoring has been advocated to reduce the fistula. incidence or severity of facial nerve injury, particularly in the 07/08
  6. 6. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 6 setting of surgery for a recurrent parotid tumor.22 To date, iodine test is employed, the incidence of Frey syndrome however, no randomized trial has demonstrated that intra- may reach 95% at 1 year after operation.25 Fortunately, the operative facial nerve monitoring or nerve stimulators yield majority of patients have only subclinical findings, and only a any significant reduction in the incidence of facial nerve small fraction complain of debilitating symptoms.25 Most paralysis after either primary parotidectomy or recurrence symptomatic patients are adequately treated with topical surgery. Indeed, indiscriminate use of nerve monitoring and antiperspirants; eventually, however, they tend to become nerve stimulators may imbue the surgeon with a false sense noncompliant with such measures, preferring simply to dab of security and cause him or her to pay insufficient attention the face with a napkin while eating.25 Despite the relatively to the appearance of nerve tissue. Transient nerve dysfunc- low incidence of clinically significant Frey syndrome, there is tion may follow inappropriate (or even appropriate and an extensive literature addressing prevention and additional unavoidable) trauma to or traction and pressure on nerve treatment of this condition.11,21,26–34 trunks. Nerve monitoring does not prevent such problems; sialocele (salivary fistula) moreover, it adds to the cost of the procedure and lengthens the operating time.23 Some, in fact, have suggested that Sialocele, or salivary fistula, has been reported to occur nerve stimulators may actually increase transient dysfunction. after 1 to 15% of parotidectomies.11,35 Although this condi- Accordingly, our use of nerve stimulators is selective. tion is generally minor and self-limited, it may nonetheless be The management of facial nerve injury depends on when embarrassing for the patient. We believe that the incidence of the injury is discovered and on how sure the surgeon is of the sialocele can be reduced by maintaining closed suction drain- anatomic integrity of the nerve. If the injury is discovered age for 5 to 7 days (to facilitate adhesion of the skin flaps to intraoperatively, it should be repaired if posssible. Primary the underlying parotid parenchyma). Postparotidectomy sali- repair—performed with interrupted fine permanent monofila- vary fistula is usually attributable to gland disruption rather ment sutures under magnification24—is preferred if sufficient than to duct transection and therefore tends to resolve with- nerve is available for a tension-free anastomosis. If both tran- out difficulty.36 Compression dressings are generally effec- sected nerve ends are identified but tension-free repair is not tive.35 Anticholinergic agents have been used in this setting as feasible, interposition nerve grafts may be used. A sensory well.37–40 Low-dose radiation,41 completion parotidectomy, nerve harvested from the neck (e.g., the great auricular nerve) and tympanic neurectomy42 have all been employed in is often employed for this purpose. If the nerve is injured refractory cases. (or deliberately sacrificed) in conjunction with treatment cosmetic changes of malignancy, use of nerve grafts from distant sites may be indicated.24 Parotidectomy creates a hollow anterior and inferior to the If unexpected facial nerve dysfunction is identified in the ear, which may extend behind the mandible and may reach a postanesthesia care unit and if the surgeon is unsure of the significant size in patients with large or recurrent tumors. anatomic integrity of the nerve (ideally, a rare occurrence), This cosmetic change is a necessary feature of the procedure, the patient should be returned to the operating room for not a complication; nonetheless, it should be discussed with wound exploration so that either the continuity of the nerve the patient before operation. Many augmentation methods, can be confirmed or the injury to the nerve can be identified using a wide variety of techniques, have been devised for and, if possible, repaired. When the surgeon is certain that improving postoperative appearance (as well as alleviating the nerve is intact, facial nerve dysfunction can be managed Frey syndrome).27–31,43,44 All of these methods have limitations without reoperation, in anticipation of recovery24; however, or drawbacks that have kept them from being widely applied this may take many months. and accepted. Management of enduring facial nerve paralysis (from any cause) is beyond the scope of our discussion and constitutes Outcome Evaluation a surgical subspecialty in itself.24 With proper surgical technique, superficial or partial super- ficial parotidectomy can be performed safely and within a gustatory sweating (frey syndrome) reasonable operating time. The requirement for blood trans- Gustatory sweating, or Frey syndrome, occurs in most fusions should be vanishingly rare. Given adequate exposure, patients after parotidectomy; it has been seen after good knowledge of the relevant anatomy, limited trauma to submandibular gland resection as well. The symptom com- the nerve, and appropriate use of closed suction drains (see plex includes sweating, skin warmth, and flushing after above), complications should be uncommon. Although chewing food and is caused by cross-innervation of the para- patients may tolerate parotidectomy on an outpatient basis, sympathetic and sympathetic fibers supplying the parotid we prefer to keep them in the hospital overnight. Patients gland and the overlying skin. The reported incidence of should be able to leave the hospital with minimal pain, com- Frey syndrome varies greatly, apparently depending on the fortable with their drain care, by the morning of postoperative sensitivity of the test used to elicit it. When Minor’s starch day 1. References 1. Berkovitz BKG, Moxham BJ. A textbook of cervicofacial halves. 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  7. 7. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 2 HEAD AND NECK 6 PAROTIDECTOMY — 7 great auricular nerve. J Laryngol Otol 1997; possible etiologic factors and results with 33. Beerens AJ, Snow GB. Botulinum toxin A in 111:556–9. routine facial nerve monitoring. Laryngo- the treatment of patients with Frey syndrome. 6. de Ru JA, van Benthem PP, Bleys RL, et al. scope 1999;109:754–62. Br J Surg 2002;89:116–9. Landmarks for parotid gland surgery. 20. Bron LP, O’Brien CJ. Facial nerve function 34. Marchese-Ragona R, De Filippis C, Marioni J Laryngol Otol 2001;115:122–5. after parotidectomy. Arch Otolaryngol Head G, Staffieri A. Treatment of complications of 7. Peterson RA, Johnston DL. Facile identifica- Neck Surg 1997;123:1091–6. parotid gland surgery. Acta Otorhinolaryngol tion of the facial nerve branches. Clin Plast 21. Debets JMH, Munting JDK. Parotidectomy Ital 2005;25:174–8. Surg 1987;14:785–8. for parotid tumours: 19-year experience 35. Wax M, Tarshis L. 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World J The use of acellular dermis in the prevention parotidectomy soft tissue defects: a prelimi- Surg, 2003;27:863–7. of Frey’s syndrome. Laryngoscope 2001;111: 17. Witt RL. Facial nerve monitoring in parotid 1993–8. nary experience. Int Online J Otorhinolaryn- surgery: the standard of care? Otolaryngol 31. Nosan DK, Ochi JW, Davidson TM. Preser- gol Head Neck Surg 2000;2(5). Head Neck Surg 1998;119:468–70. vation of facial contour during parotidectomy. 18. Reilly J, Myssiorek D. Facial nerve stimula- Otolaryngol Head Neck Surg 1991;104: tion and postparotidectomy facial paresis. 293–8. Acknowledgment Otolaryngol Head Neck Surg 2003;128: 32. Sinha UK, Saadat D, Doherty CM, Rice DH. 530–3. Use of AlloDerm implant to prevent Frey The authors wish to thank Veronica Levin for her 19. Dulguerov P, Marchal F, Lehmann W. syndrome after parotidectomy. Arch Facial assistance in the preparation of this chapter. Postparotidectomy facial nerve paralysis: Plast Surg 2003;5:109–12. Figures 1a, 2b, 3, 4 Tom Moore. 07/08