The document provides information on the operative technique of parotidectomy. It discusses the embryology, surgical anatomy, types (partial, superficial, total, radical), procedure, and complications of parotidectomy. The procedure involves raising skin flaps and identifying landmarks like the facial nerve to fully expose and dissect the parotid gland from surrounding tissues. The main steps are identification and preservation of the facial nerve branches, ligation of duct and vessels, and removal of the gland. Complications can include hematoma, facial nerve injury, salivary fistula, cosmetic deformity, and Frey's syndrome.

1. Operative Technique :
Parotidectomy
By: Dr Sangamesh S K
Mod: Col VP Singh

2. Contents
• Introduction
• Embryology
• Surgical Anatomy
• Types of parotidectomy
• Procedure
• Complications

3. Introduction
• Parotid is the largest salivary gland
• Pre auricular region both sides of cheek
• Weighs : 15-30 gms
• 2 lobes: superficial and deep
• Divided by facial nerve traversing within
• Accessory parotid gland may be present

4. Embryology
• 6 to 8 week : Outpouching
of oral ectoderm
• As it grows posteriorly,
facial nerve advances
anteriorly toward midline
• Facial nerve becomes
surrounded by glandular
tissue
• Lymph nodes are
encapsulated by
mesenchymal capsule :
Iintraparotid lymph node

5. Surgical anatomy
• It lies in a recess bounded by ramus of mandible,
base of skull and mastoid process
• It lies on carotid sheath, CNs XI and XII and extends
forward over the masseter muscle

6. Capsule
• Enclosed in a sheath of
dense deep cervical fascia
• Its upper pole extends
just below the zygoma
and its lower pole (tail)
into the neck

7. Surgical relations
• Posterior:
– Cartilage of EAC
– Tympanic bone
– Mastoid process
– SCM muscle
• Deep:
– Styloid process
– Stylomandibular tunnel
– Parapharyneal space
• Superior:
– Zygomatic arch
– TMJ

8. Structures running in parotid

9. Structures running in parotid
• ● Facial nerve trunk : divides into its major five
branches
• ● Terminal branch of External carotid artery :
divides into maxillary & superficial temporal
artery
• ● Retromandibular vein
• ● Intraparotid lymph nodes.
• Gland is arbitrarily divided into deep and
superficial lobes: by facial nerve.
• 80% : superficial and 20% : deep to the nerve.

10. Facial nerve & branches

11. Autonomic nerve supply

12. External Carotid Artery & Retromandibular Vein

13. Stenson duct
• Runs over masster muscle
anteriorly and downwards
• Turn inwards pierce
– Buccal pad of fat
– Buccopharyngeal fascia
– Buccinator muscle
• Opens opposite 2nd
maxillary molar teeth
• Accessory lobe is
occasionally present
• Along duct on masseter
muscle

14. Types of parotidectomy
• Partial parotidectomy:
– Resection of pathology with a margin of normal
parotid tissue (1cm)
– Benign pathology & low grade malignancies
• Superficial Parotidectomy:
– Entire superficial lobe resection
– Mets to parotid lymph node e.g from skin cancers
and high grade malignant parotid

15. Types of parotidectomy
• Total parotidectomy:
– Resection of entire parotid gland
– Preservation of facial nerve
• Radical parotidectomy
– Superficial & deep parotid gland
– Extended to involve adjacent structures

16. Position
• Patient in 450 reverse trendelenburg position
with head higher than heart
• Head turned to opposite side of lesion
• Neck extended by rolled sheet below chest
and doughnut pillow head
• Ipsilateral shoulder : corner of bed
– Surgeon : Ipsilateral gland to be dissected
– Assistant : at head & opposite the surgeon
– Scrub technician : side of surgeon

17. Draping
• Sterile scrub
• Ipsilateral visible
– Ear
– Lateral corner of eye
– Oral commisure
– Entire ipsilateral neck

18. Incisions
• Modified Blair incision
or lazy S incision
• Initially “L” shaped
incision
• Bailey modified with
cervical extension
• Exposes : posterior part
and tail of parotid

19. Incisions
Y Shaped incision

20. Flaps raising : anterior extent
• Skin flap developed : anterior border of gland
• Anteriorly flap is raised till terminal branches
of facial nerve visualised

21. Posterior extent of dissection
• Greater auricular nerve & facial vein are identified, ligated &
divided to expose : tail of the parotid and SCM muscle
• Posterior belly of digastric muscle is exposed beyond its
attachment to temporal bone

22. Superficial Muscular Aponeurotic
System (SMAS)
• Fibrous network that
invests facial muscles, &
connects them with
dermis
• Platysma inferiorly
• Zygomatic Arch
Superiorly
• Facial nerve courses deep
to SMAS & Platysma
• Parotid fascia

23. Techniques : Identify Facial nerve
Antegrade :
1. Inferior portion of the cartilaginous canal, Conley’s pointer -
Tragal pointer : lies 1 cm deep & inferior
2. Upper border of the posterior belly of the digastric muscle :
mobilise the parotid gland, & exposes an area superior :
nerve lies here
3. Squamotympanic fissure
4. Styloid process (the nerve is superficial to it)
5. Mastoid process can be drilled and the nerve identified
more proximally
Retrograde :
Any branch is identified and traced back till trunk

24. Identifying facial nerve
• Next the fascial attachments between EAC & parotid
tissue divided to identify : Tragal pointer
• Using the following landmarks the main trunk of the
facial nerve can be identified

25. Facial nerve mobilization
• No tissue is cut in this area
until the nerve is seen.
• Blunt dissection proceeds
posterior to anterior until
the surgeon identifies the
nerve as a white cord 2–3
mm wide
• Meticulously elevate
parotid tissue off nerve
blanches
• Bipolar cautery used near
nerve
• Parotid tissue overlying the
nerve is then divided

26. Branching of facial nerve
Nasser Nasse, British Journal of Oral and Maxillofacial Surgery, Volume 54, Issue 10, December 2016, Pages e61-e6

27. Superficial parotidectomy
• Faciovenous plane of Patey developed
• Duct is ligated and divided

28. Deep parotidectomy
• Small vessels around deep gland adjacent to
mastoid & trunk cauterized : bipolar cautery
• If needed extend incision : neck dissection

29. Facial nerve sacrifice
• If facial nerve function is normal preoperatively, even
malignancy : nerve can be preserved with careful
dissection
• If nerve is paretic or fully paralyzed preoperatively :
resected during tumor resection.
• Invaded by high-grade malignant tumor : resected with
specimen to negative margins.
• Peripheral branches, divisions, or even main trunk of
facial nerve may be sacrifice
• Intra- op nerve if infiltrated appears swollen & usually
darker than normal glistening white appearance

30. Repair
• Primary neurropahy or grafting
• Mastoidectomy and nerve mobilization :
length & free tension
• Grafts
– Ipsilateral Greater Auricular nerve
– Ipsilateral Sural nerve graft
– Proximal facial nerve
– Ipsilateral cranial nerve XI XII

31. Radical parotidectomy
• Radical parotidectomy : histological evidence of high-
grade malignant tumour with facial nerve invasion (e.g.
squamous cell carcinoma)
– All parotid gland tissue
– Elective division of the facial nerve, usually through the
main trunk
– Surgery inevitably removes ipsilateral masseter muscle
– May also require simultaneous neck dissection
• Particularly if clinical, radiological and cytological
evidence of lymph node metastases in the ipsilateral
neck

32. Complications
• Hematoma
• Facial nerve palsy
• Salivary fistula
• Gustatory sweating/ Frey’s syndrome
• Cosmetic deformity

33. Hematoma
• Inadequate haemostasis
before closure
• Suction drain reduce
post op hematoma
• Treatment
– Evacuation of hematoma

34. Facial nerve palsy
• Temporary or
permanent
• Partial or total
• Neuropraxia : nerve
stretching
• If nerve intact: recovers
with in weeks

35. Facial nerve palsy…
• If palsy severe and recovery prolonged:
transcutaneous nerve stimulation of facial
muscles
• Problems with eye closure : exposure keratitis
– Protective glasses or tape of eyelid
– Temporary tarsorrhapy
– Botulin toxin paralysis of upper eyelid
• When palsy : total loss of facial nerve
– Reconstruction & Rehabilitation of face

36. Salivary fistula
• Presents at suture line,
post to ear lobe
• Pressure dressing
• Drains
• Anticholinergic drugs

37. Cosmetic deformity
• Sunken cheek due to
loss of parotid gland
and fat
• Rotation of SCM muscle
flap
• Free flaps

38. Frey’s syndrome
• Damage to autonomic
innervations of salivary
gland
• Inappropriate regeneration :
Postanglionic
parasympathetic nerve
fibres of auriculotemporal
nerve
• Aberrantly stimulate the
sweat glands of overlying
skin
• Clinical features include
sweating and erythema
(flushing)

39. Cause of Frey’s syndrome
• Parasympathetic and
sympathetic
secretomotor stimuli
• Misdirected to
cholinergic receptors of
sweat glands during
healing

40. Iodine test
• Alcohol-iodine- oil
solution : starch powder
• Dry : lemon candy for
10 min

41. Treatment of Frey’s syndrome
• No effective treatment,
• Various options
– Injection of botulinum toxin
– Surgical transection of nerve fibres
– Application of ointment : anticholinergic drug
such as scopolamine

42. Thank you