What is Parotidectomy?
Parotidectomy is a surgical operation to remove the parotid which is a large salivary gland located in front of the ear and slightly below it. The most common reasons for removing all or part of this gland are a tumor, chronic infection, or obstruction of the saliva outflow causing chronic enlargement of the gland. Surgeons describe the parotid gland as having two lobes, superficial and deep, separated by the facial nerve that makes the face move and the eye close. Parotidectomy is usually performed under general anesthesia. The amount of parotid gland to be removed is often determined at the time of surgery, based on the size and location of the diseased parotid tissue. The extent of surgery may also depend on pathological examination of tissues removed during the surgery.
Most parotid tumors (80%) are benign. The remaining 20% are malignant. The most common tests to determine the nature of a parotid tumor include a CT scan (an x-ray test that helps to determine the size and position of the parotid tissues), and MRI scan (an imaging test that uses powerful magnets instead of x-rays). FNA (fine needle aspiration biopsy), may also be helpful. During this procedure, a small amount of fluid is withdrawn from the parotid to see if malignant cells are present,
What happens before surgery?
We will schedule a pre-operative visit during which the doctor will fill-out hospital forms, go over your medical history, current medications, allergies etc. and perform a complete physical examination. You will also be given the opportunity to ask questions about the procedure, hospitalization, complications, etc. You will sign the pre-operative surgical consent form and receive your post-operative instructions, and prescriptions for antibiotics, pain killers and other medications you may need after surgery.
What is pre-operative assessment?
After you finish with the doctor, you will then go to the hospital for pre-operative registration and assessment. This is where pre-operative blood tests, EKG, chest x-rays, etc. are carried out. You will also have the opportunity to talk to the anesthesiologist and ask questions or express concerns about anesthesia. Here also, you will be informed of the time of the operation and given instructions about when to take your medications and what to wear. You may also be asked to sign consent forms for surgery, anesthesia and blood transfusions. Sometimes, this assessment may not be necessary and may be carried out on the telephone.
What time do I show up on the day of surgery?
The assessment nurse will tell you the exact time of your operation and when to come to the hospital. In general, you are expected to be in the hospital, an hour and a half prior to your scheduled procedure.
What happens on the day of surgery?
If you have been assigned a room and have been admitted to a hospital bed, then you will be transported to the pre-operative holding area about 30 minutes prior to your operation. Your family may remain in your room or wait in the Surgery waiting area on the second floor. It would be helpful if family members or friends notify the nurses’ desk or the waiting room receptionist of their whereabouts, so that we can find them to let them know that your surgery is over.
If you have not been assigned a room, you would be asked to go to the second floor registration and from there, you would be directed to Day Surgery pre-op holding.
In pre-op holding, the nurses will start an intravenous line and review your history and medications. They will ask you questions to make sure you understand what is going to be done and that you have consented. They may make you sign the consent forms if you have not signed them during assessment. They will also mark the operative site with ink and if applicable, write on your neck LEFT or RIGHT so that there will be no confusion as to which side is being operated on. You may request a tranquilizer if you are very anxious.
What happens during surgery?
When the tumor is removed, it is sent for frozen section. This means that the pathologist will freeze a piece, slice it very thin and color it with various dyes that help in deciding what kind of tumor it is and if it is malignant or benign.
When superficial, benign tumors are treated with excision of the superficial lobe of the parotid gland. Deep tumors may require a total parotidectomy or excision of the portion of the tumor that is deep to the facial nerve. Every effort is made to preserve the facial nerve.
For malignancies, surgical excision is the preferred treatment, with superficial or total parotidectomy depending on the stage and histology of the tumor. Small low-grade tumors are treated with a superficial parotidectomy when possible. Neck dissection should be considered when evaluating node positive disease. A locally invasive tumor may require resection of the facial nerve, skull base, or mandible. Postoperative radiation therapy is recommended when surgical margins are positive, tumors are high grade or larger than 4 cm, or local extension is noted. Chemotherapy has not been proven effective.
In rare instances, the pathologist may be unable to make a diagnosis on frozen section and the diagnosis is postponed until the tissue has been permanently processed in the laboratory. This may take a few days. It is therefore possible for a patient to go home and be called back for more surgery if a cancer is discovered in the permanent preparation.
What happens after surgery?
When you wake up from surgery, you will be transported to the recovery room (PACU), where would spend about 30 minutes to an hour, until you are fully awake and stable for transportation to your room.
You will be asked to move your face, smile or pout to check on the movement of your face.
You will notice a drain tube attached to your clothes or a necklace. This is usually removed the next day. Please do not pull on the drain or try to empty the attached plastic bulb.
For 2 – 3 days after the surgery, it is not unusual to have pain or difficulty on swallowing.
The nurses have standing orders to give you antibiotics, pain killers and medications for nausea and vomiting. If there are no contraindications, you will also receive your usual home medications.
If you feel up to it, you are allowed to stand up, walk and go to the bathroom, with assistance and always, with someone present in the room. Do not attempt at walking or going to the bathroom if you are alone in the room. You may be too groggy from the pain killers or you may pass-out and fall down.
The day after surgery, the doctor will remove the drain. In general, the wound is sealed with a thin clear acrylic layer (Dermabond) and the sutures are buried under the skin. There is no need to apply antibiotic ointment on the wound. You are allowed to take a shower without covering the wound. This acrylic film will peal off in a couple of weeks. When you go home, please keep the wound exposed and do not hide it with a dressing or scarf. A little antibiotic ointment may be used at the site of the drain for a day or two. In general the drain wound heals and stops oozing in 24 hours.
When do I go home?
In general, most patients are discharged the day after the operation. By then, they should be able to eat, walk and go to the bathroom.
Occasionally, however, some patients may run a temperature or continue to have nausea or excessive drainage. It is not uncommon for older men, especially those with large prostates, to develop urinary retention after general anesthesia. In all these instances, discharge is delayed a day or two, until the problem is resolved.
What are the possible complications?
Possible short term complications include bleeding and infection. Although rare in parotid surgery, some patients may develop a thick scar or keloid. . In some patients, a depression or a "dent" occurs at the site of the removed tumor. Many patients experience numbness of the earlobe and outer edge of the ear after parotid surgery. This generally resolves slowly over time. In a small proportion of patients the face on the side of the parotidectomy sweats while eating ("Frey’s syndrome / gustatory sweating")Most often, this goes essentially unnoticed, however, if it should become bothersome medication and sometimes surgery are available. Very rarely, a salivary fistula may occur, with saliva draining from a small opening in the incision.
Why is the facial nerve important?
The nerve that controls motion to the face (the facial nerve) runs through the parotid gland. This nerve is important in closing the eyes, wrinkling the nose, and moving the lips. Most often the parotid gland can be removed without permanent damage to the nerve, however, the size and position of the diseased tissue may require that the nerve, or small branches of the nerve, be cut to assure complete removal. Even if the nerve is not permanently injured, there may be decreased motion of the facial muscles as the nerve recovers from the surgical procedure. If facial motion does not fully return, there are ways to rehabilitate facial movement.