The parotid glands are salivary glands that lie in the cheek area just in front of the ear. When a benign or malignant tumor develops a lump is most often noted in front of or below the ear The majority of parotid tumors are benign but may be locally aggressive. Malignant tumors may cause facial nerve weakness, lymph node enlargement or pain at the site of the tumor.
Parotid Tumors In Depth
by Monica Tadros, M.D., F.A.C.S.
Most parotid tumors lie in the portion of the gland above the nerve. Identification of the nerve allows for safe removal of the tumor by a procedure called a Superfical Parotidectomy. When the tumor requires dissection both above and below the facial nerve, the procedure is called a Total Parotidectomy.
Aesthetic Approach to Parotid Surgery:
Dr. Tadros utilizes a ‘post-tragal rhytidectomy’ approach to expose the parotid for resection. This approach is similar to that used for face-lifts to hide incisions behind the tragus of the ear, around the ear lobe and behind the back of the ear. Once the tumor is removed, the area is reconstructed and face-lift techniques are used to camouflage the incisions and reconstruct the face.
Facial Restoration in Parotid Surgery & Frey’s Syndrome:
Large tumors tend to excavate the cheek area by pressure. Upon tumor removal, restoration is often performed using the patient’s own fat to graft and recontour the cheek area. The advantage of this is two-fold:
- Soft tissue in the cheek area is restored to prevent a post-operative sunken appearance to the cheek
- Fat placed between the defect and skin serves as a protective barrier to prevent Frey’s syndrome.
Frey’s syndrome is a very common complication of parotidectomy caused by the regeneration of salivary nerve fibers to the sweat glands of the skin. Patients may notice sweating of the cheek on the operated side while eating, also known as gustatory sweating. The incidence of Frey’s syndrome reported in the literature is variable, but may be as high as 50% in patients treated without reconstruction.
Management of the Facial Nerve in Parotid Surgery:
The most critical structure that runs through the parotid gland is the facial nerve. Every effort is made to preserve the facial nerve, including meticulous dissection, intra-operative medications to minimize inflammation and intra-operative EMG facial nerve monitoring.
The facial nerve exits the skull deep to the ear canal, and travels through the parotid gland to innervate the muscles of the face. There are five main branches and significant arborization of the facial nerve responsible for each nuance of facial expression including raising our eyebrows, closing our eyes, puckering our lips and smiling. Identification and protection of the facial nerve is an important part of parotid surgery.
Branches of the facial nerve, or even the main trunk of the nerve, may be surrounded or invaded by tumor and removal of all tumor tissue may require sacrifice of a portion of the nerve. This situation is rare with benign tumors. Usually, facial nerve sacrifice is considered for patients who have a malignant tumor and facial nerve invasion.
Circumstances requiring Facial Nerve sacrifice are immediately treated by Dr. Tadros who is highly experienced in Facial Nerve rehabilitation and grafting. Upon completion of tumor removal, Dr. Tadros utilizes EMG facial nerve stimulation to confirm the integrity of facial nerve function and each of the branches. If tumor removal requires sacrifice of the facial nerve or any of its branches, mobilization of the nerve ends may permit direct re-approximation of the tumor-free branches. More commonly donor nerve grafts are taken from the neck (greater auricular nerve) or leg (sural nerve) to serve as an extension cord to reunite the remaining tumor-free portions of nerve. Immediate nerve grafting permits the best possible outcome for nerve regeneration and rehabilitation of facial movement over the ensuing months to one year.
Read more on the management of Facial Nerve Paralysis.