complications of parotidectomy.docx

8/10/2019 COMPLICATIONS OF PAROTIDECTOMY.docx

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COMPLICATIONS OF PAROTIDECTOMYComplications of parotidectomy can e di!ided into early complications "incl#din$t%ose t%at occ#r intraoperati!ely and d#rin$ t%e immediate postoperati!e period& andlate postoperati!e complications "'o( )*+,&- Eac% complication of parotidectomy isdisc#ssed separately- E(pected se.#elae of parotidectomy s%o#ld e differentiated

from complications and are also presented-BOX 20-1

Complications of Parotidectomy

EARLY COMPLICATIONS

Facial nerve injury

Hemorrhage

Hemaoma

In!ecion

E"ernal oii#

Sialocele Seroma

Salivary !i#ula

LATE COMPLICATIONS

Frey #yn$rome

Tri#mu#

Am%uaion neuroma &greaer auricular nerve'

Tumor recurrence

Co#meic $e!ormiy

Hy%erro%hic #car

(eloi$

Earlo)e mal%o#iioning

Early ComplicationsFacial Ner!e In/#ry

Facial ner!e paralysis represents t%e ma/or complication of parotid s#r$ery- T%e ris0 oft%is complication can e minimi1ed 2it% proper and caref#l s#r$ical tec%ni.#es-

At t%e time of s#r$ery3 paralysis a$ents "e(cept for s%ort+actin$ a$ents s#c% as

s#ccinylc%oline at t%e time of anest%esia ind#ction& s%o#ld e a!oided- If t%e localin/ection of epinep%rine alon$ t%e proposed incision is #sed for !asoconstriction3 t%ent%e in/ection sol#tion s%o#ld contain no local anest%etic "e-$-3 lidocaine&3 2%ic% mayca#se temporary ne#ral loc0ade- T%e facial s0in flap s%o#ld e caref#lly raised toa!oid in/#ry to t%e perip%eral facial ner!e ranc%es eyond t%e anterior order of t%e$land- Intraoperati!ely3 t%e facial ner!e s%o#ld e caref#lly identified 2it% t%e aid ofanatomic landmar0s "'o( )*+)&- 4ide s#r$ical e(pos#re is recommended to allo2 fort%e ade.#ate !is#ali1ation of t%ese landmar0s- Ade.#ate operati!e e(pos#re red#ces
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t%e ris0 of inad!ertent ner!e in/#ry d#rin$ t%e dissection for facial ner!e identificationand allo2s for safe %emostasis if leedin$ occ#rs d#rin$ dissection near t%e facialner!e-

BOX 20-2

Anatomic Landmarks for Facial Nerve Identification

1. Tragal %oiner &The nerve i# a%%ro"imaely *+cm me$ial an$ aneroin!erior o he i% o!he %oiner,'

2. Tym%anoma#oi$ #uure &The nerve i# a%%ro"imaely -./+mm me$ial o he #uure,'

3. 0iga#ric mu#cle aachmen o $iga#ric groove &The nerve i# ju# #u%erior o an$ on he

#ame %lane a# he mu#cle aachmen,'

4. Nerve 1ihin he ma#oi$ )one

5. Rerogra$e $i##ecion o! he %eri%heral !acial nerve )ranch

A disposale nonp#lsed direct c#rrent ner!e stim#lator s%o#ld e #sed /#dicio#sly forfacial ner!e stim#lation- 5o2e!er3 t%is c#rrent can dama$e ner!es3 eca#se it istransmitted to t%e ner!e for t%e d#ration of stim#lator tip contact 2it% t%e ner!e- 6,7386,98Prolon$ed ner!e contact 2it% t%is type of stim#lator may res#lt in e(cessi!e c#rrentdeli!ery to t%e ner!e- Repeated ner!e stim#lation 2it% s#c% a stim#lator may eresponsile for temporary ner!e paresis postoperati!ely-Intraoperati!e ner!e monitorin$ 2it% commercially a!ailale electromyo$rap% #nits canpro!ide !al#ale intraoperati!e information re$ardin$ facial ner!e identity and inte$rity-S#c% monitorin$ can e partic#larly #sef#l for reoperation- In a retrospecti!e re!ie2 of:; patients 2%o recei!ed facial ner!e monitorin$ d#rin$ parotidectomy and of ;,patients 2%o did not3 a si$nificant red#ction in temporary facial paresis 2as oser!ed int%e monitored $ro#p as compared 2it% t%e #nmonitored $ro#p "99< !s- ;))78T%e
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facial ner!e ranc% t%at is most at ris0 for temporary paralysis is t%e mar$inalmandi#lar ranc%-6,@>),3)78T%is is t%o#$%t to e t%e res#lt of t%e %i$% len$t%+to+diameterratio of t%is ner!e ranc% and of t%e relati!e lac0 of interconnections 2it% ot%erranc%es of t%e facial ner!e as compared 2it% ot%er facial ner!e ranc%es "e-$-3 t%e#ccal and 1y$omatic ranc%es&- Paralysis of t%e mar$inal mandi#lar ranc% res#ltsin a loss of ipsilateral lo2er lip depressor f#nction "Fi$#re )*+:&- Reco!ery fromtemporary facial paresis occ#rs 2it%in ; mont%s in t%e ma/ority of patients-6,@386)*386)78

Fi!re 2"#4 Righ !acial %araly#i# a!er %aroi$ecomy,

Fi!re 2"#5 Pare#i# o! he righ marginal man$i)ular )ranch o! he !acial nerve, Noe he

lac2 o! li% $e%re##or !uncion,

Permanent facial ner!e paralysis occ#rs less commonly t%an temporary paresis-Permanent paralysis after partial parotidectomy for eni$n t#mors is #ncommon and$enerally reported to occ#r in less t%an :< to ;< of cases- 6,@>))8A %i$%er incidence ofot% temporary and permanent facial paralysis occ#rs 2it% total parotidectomy ascompared 2it% s#perficial parotidectomy3 per%aps as a res#lt of t%e increased ner!emanip#lation t%at is necessary for complete $land remo!al- 6,B3)*>)78In addition3permanent facial paralysis is more common 2it% reoperation for rec#rrent t#mors- 6),386)9386):8T%e performance of a nec0 dissection at t%e time of parotidectomy is associated2it% a %i$%er incidence of permanent paralysis of t%e mar$inal mandi#lar ranc% of

t%e facial ner!e-6)*8Care m#st e ta0en to protect t%e e(posed facial ner!e ifparotidectomy is performed efore t%e nec0 dissection- Anot%er protecti!e option is toperform t%e nec0 dissection efore t%e parotidectomy-Per1i06);8reported a ,**< incidence of temporary facial paralysis 2it% parotidectomyfor c%ronic sialadenitis- T%is is not t%e e(perience of t%e a#t%ors3 and ot%er reports%a!e s%o2n no %i$%er incidence of paralysis for parotidectomies performed for c%ronicinflammation t%an 2it% t%ose performed for eni$n neoplasms-6,B386)?386)B8In addition3 totalparotidectomy does not appear to e associated 2it% a %i$%er incidence of permanentparalysis t%an s#perficial parotidectomy 2%en s#r$ery is performed for c%ronicparotitis-6)B8

Facial paralysis in!ol!in$ t%e oric#laris oc#li m#scle often res#lts in incomplete eyeclos#re- Con/#ncti!itis3 0eratitis3 and corneal #lceration can res#lt from eye e(pos#re-Epip%ora res#lts from t%e loss of t%e normal p#mpin$ action of t%e eyelids and lo2er+lidla(ity or ectropion "Fi$#re )*+;&- 4it% facial paralysis in!ol!in$ t%e oric#laris oc#li3eye+protection meas#res s%o#ld e instit#ted immediately and s%o#ld incl#de t%efre.#ent instillation of artificial tears d#rin$ t%e day and l#ricant op%t%almic ointmentand eyelid clos#re 2it% tape or t%e application of a moist#re c%amer "Fi$#re )*+?& atni$%t- If prolon$ed or permanent paralysis is anticipated3 #pper+lid $old+2ei$%timplantation is a #sef#l tec%ni.#e to pro!ide ade.#ate eye clos#re-6)@8In addition3lo2er+lid ti$%tenin$ proced#res may e eneficial- T%e patient s%o#ld e .#estioned
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periodically ao#t eye symptoms and e(amined for si$ns of eye in/#ry- Op%t%almolo$iccons#ltation s%o#ld e otained immediately if any eye complication is s#spected-

Fi!re 2"#$ Ecro%ion o! he lo1er eyeli$ a!er inenional #acri!ice o! he !acial nerve !or a

malignan %aroi$ neo%la#m,

Fi!re 2"#% Eye+moi#ure cham)er !or nocurnal eye %roecion,

T%e mana$ement of permanent facial paralysis is eyond t%e scope of t%is c%apter-

Facial reanimation proced#res incl#de ner!e crosso!er tec%ni.#es s#c% as facial>%ypo$lossal anastomosis3 cross+face ner!e transplantation3 masseter or temporalism#scle transfer3 and free+tiss#e transfer- 'ro2 lift3 r%ytidectomy3 lep%aroplasty3c%eiloplasty3 contralateral frontal ne#rectomy3 and ot#lin#m to(in in/ections to ac%ie!efore%ead symmetry for frontal paralysis are some of t%e ot%er reconstr#cti!etec%ni.#es t%at may %elp to impro!e t%e cosmetic deformities associated 2it% facialparalysis-

5emorr%a$e and 5ematoma

5emorr%a$e is an #ncommon intraoperati!e complication- Patients s%o#ld einstr#cted to a!oid aspirin and nonsteroidal anti+inflammatory medications for se!eral2ee0s efore s#r$ery- Patients ta0in$ clopido$rel and 2arfarin s%o#ld %a!e medical

clearance to stop t%ese medications at least , 2ee0 efore s#r$ery- If t%esemedications cannot e safely discontin#ed3 t%en replacement 2it% lo2+molec#lar+2ei$%t %eparin t%erapy is recommended- 5eparin can e stopped immediately efores#r$ery and res#med after all san$#ino#s 2o#nd draina$e %as ceased- T%e properidentification3 di!ision3 and li$ation of lood !essels d#rin$ s#r$ical dissection #s#allypre!ents si$nificant intraoperati!e leedin$- D#rin$ total parotidectomy and t%eremo!al of t%e deep loe3 t%e internal ma(illary artery and its ranc%es are t%e primary!essels of concern for si$nificant leedin$-

D#rin$ t%e remo!al of t#mors of t%e s#perficial loe3 t%e posterior facial !ein3 2%ic%co#rses deep to t%e facial ner!e3 can #s#ally e preser!ed- T%e li$ation of t%is !esselcan contri#te to t%e !eno#s con$estion of t%e $land and to increased !eno#s leedin$

from t%e c#t s#rface of t%e $land d#rin$ dissection-

Intraoperati!e leedin$ s%o#ld e controlled 2it% caref#l tec%ni.#e #sin$ li$at#res oripolar electroca#tery- Care s%o#ld e ta0en to a!oid s#ction or clamp compressionin/#ry to t%e facial ner!e d#rin$ attempts at %emostasis- nipolar electroca#tery s%o#lde #sed 2it% e(treme care eca#se of t%e ris0 of electrical c#rrent transmission to t%efacial ner!e- T%ere contin#es to e interest amon$ parotid s#r$eons to identify s#r$icalinstr#ments t%at pro!ide %emostasis 2it%o#t e(cessi!e facial ner!e stim#lation d#rin$


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parotidectomy- A retrospecti!e re!ie2 comparin$ 99 patients 2%o #nder2entparotidectomy 2it% t%e 5armonic Scalpel "Et%icon Endo+S#r$ery3 Inc-3 Cincinnati3 O%io&2it% 9, patients 2%o %ad con!entional parotidectomy oser!ed si$nificantly lessintraoperati!e lood loss and a red#ced incidence of facial ner!e paresis in t%e5armonic Scalpel $ro#p-67*8Similarly3 a retrospecti!e series of :* patients 2%o#nder2ent parotidectomy 2it% t%e 5emostati( Scalpel "5emostati( MedicalTec%nolo$ies3 'artlett3 TN& 2ere fo#nd to %a!e si$nificantly s%orter operati!e times andless intraoperati!e lood loss as compared 2it% patients #nder$oin$ con!entionalparotidectomy-67,8Anot%er st#dy of ?? parotidectomy patients asserted t%at t%e5emostati( Scalpel 2as an independent ris0 factor for facial ner!e paralysis- 5o2e!er3t%e lar$er 5emostati( ,* lade 2as #sed in t%is series rat%er t%an t%e more 2idelyaccepted ,: lade-67)8

Postoperati!e %ematoma formation is #n#s#al3 and it is reported to occ#r in 7< to ?9B %o#rs&- T%is is follo2ed y a co#rse of oralantiiotics- Ascess formation re.#ires incision and draina$e as 2ell as appropriateantiiotics-

Fi!re 2"#' Cellulii# a!er %aroi$ecomy,

o%nson and 4a$ner6778e(amined t%e enefit of prop%ylactic antiiotics forparotidectomy for cases in 2%ic% no infection e(isted efore s#r$ery and fo#nd no
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difference in infection rates 2it% or 2it%o#t perioperati!e antiiotics- 5o2e!er3perioperati!e prop%ylactic antiiotics are recommended for patients 2%o %a!e %adrecent parotid $land infection or recent s#r$ery-

E(ternal OtitisE(ternal otitis can occ#r postoperati!ely3 and it is related to lood collection in t%ee(ternal a#ditory canal intraoperati!ely- 'lood pro!ides an e(cellent medi#m foracterial $ro2t% in t%e ear canal- E(ternal otitis can e pre!ented y caref#lly placin$ apetrolat#m $a#1e pac0 in t%e ear canal at t%e e$innin$ of t%e proced#re to pre!ent t%eentry of lood "Fi$#re )*+,*&- If lood enters t%e ear canal intraoperati!ely3 salineirri$ation and caref#l s#ctionin$ of t%e ear canal are performed at t%e completion ofs#r$ery- T%e treatment of postoperati!e e(ternal otitis consists of t%e caref#l remo!al oflood and deris from t%e e(ternal a#ditory canal and t%e instillation of antiioticeardrops-

Fi!re 2"#1" Perolaum gau3e %ac2 %lace$ in he e"ernal au$iory canal o %reven he

enry o! )loo$,

Flap NecrosisFlap necrosis is an #ncommon complication of parotidectomy-6,@8Necrosis occ#rs mostcommonly in t%e distal tip of t%e inframastoid portion of t%e parotid flap "Fi$#re )*+,,&-Proper flap desi$n and plane of ele!ation3 caref#l %andlin$ of t%e flap3 and t%ea!oidance of flap desiccation intraoperati!ely are all important factors for t%epre!ention of t%is complication- Ot%er factors t%at may e responsile for t%ede!elopment of t%is complication incl#de t%e impairment of t%e flaps lood s#pply as ares#lt of smo0in$3 diaetes mellit#s3 or prior radiation t%erapy- Patients 2%o smo0es%o#ld e stron$ly enco#ra$ed to .#it smo0in$ se!eral 2ee0s efore s#r$ery to red#ce

t%e ris0 of s0in+flap necrosis-6793867:8eno#s con$estion of cer!icofacial rotation flaps cane red#ced 2it% t%e rapid instit#tion of leec% t%erapy for flap sal!a$e "Fi$#re )*+,)&-

Fi!re 2"#11 Paroi$ !la% necro#i# in a %aien 1ih $ia)ee# melliu#,

Fi!re 2"#12 4enou# conge#ion in a cervical !acial roaion !la% o! a heavy #mo2er reae$

1ih leech hera%y,

T%e treatment of parotid flap necrosis incl#des t%e deridement of necrotic tiss#e in t%e2o#nd- Dependin$ on t%e si1e of t%e defect3 secondary 2o#nd clos#re3 clos#re ysecondary intention3 or split+t%ic0ness s0in $raftin$ are options for 2o#nd clos#re-

Sialocele and Seroma
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Sialocele represents a collection of sali!a #nder t%e parotid flap and presents as anontender3 cystic mass "Fi$#re )*+,73 A&- Sialocele occ#rs after partial parotidectomyrelated to sali!ary lea0a$e from t%e c#t s#rface of t%e $land remnant- T%is complicationocc#rs in appro(imately :< to ,*< of patients after partial parotidectomy-6,B386,@386))8

Fi!re 2"#13 A(Sialocele a!er %arial %aroi$ecomy, )(Nee$le a#%irae o! #ialocele !lui$,

Seroma is clinically similar to sialocele #t differs in t%at it %as lo2er amylase contenton fl#id analysis- 5o2e!er3 s#c% differentiation %as little practical importance for t%emana$ement of t%ese t2o #ncommon complications- Postoperati!e seroma is #n#s#alif closeds#ction draina$e is employed #ntil t%e 2o#nd draina$e falls elo2 7* cc in a)9+%o#r period- 5o2e!er3 a red#ction in drain o#tp#t of t%is de$ree may ta0e se!eraldays and res#lt in a prolon$ed %ospital stay in patients 2%o #nder2ent e(tensi!edissection or 2%o %a!e partic#larly lar$e parotid $lands- A recent randomi1ed3controlled st#dy fo#nd si$nificantly less postoperati!e draina$e !ol#me and fe2er

postoperati!e seromas amon$ 7* patients treated 2it% a firin tiss#e $l#e to t%e 2o#nded efore clos#re as compared 2it% 7* patients 2%o #nder2ent standard clos#realone-67;8T%e #se of tiss#e sealants d#rin$ parotidectomy may increase in t%e f#t#re toallo2 for s%orter %ospital stays-T%e mana$ement of sialocele and seroma incl#des needle aspiration of t%e fl#idcollection after caref#l antiacterial s0in preparation- Aspirated fl#id is #s#ally clear andyello2 "Fi$#re )*+,73 '&- Press#re dressin$s are of little !al#e for t%is prolem3 andt%ey are c#mersome to t%e patient- Patients s%o#ld e co#nseled re$ardin$ potentialreocc#rrence after needle aspiration #t reass#red t%at sialoceles are rarely a c%ronicprolem- Alternati!ely3 t%e fl#id collection may e oser!ed3 and fl#id reasorption 2illoften occ#r spontaneo#sly- Lar$e3 persistent fl#id collections may necessitate Penroseor s#ction drain replacement-

Sali!ary Fist#laSali!ary fist#la is manifested y sali!ary draina$e from t%e 2o#nd "Fi$#re )*+,9&- It isan #ncommon complication of s#total parotidectomy3 occ#rrin$ in less t%an 7< ofcases-6,B386),8Sali!ary fist#las are $enerally selflimited and #s#ally close spontaneo#sly2it% local care 2it%in se!eral 2ee0s- A fist#la 2ill rarely persist for mont%s orc%ronically- T%e s0in s#rro#ndin$ a c%ronic fist#la is often e(coriated and scarred as ares#lt of t%e irritati!e effect of sali!a-67?8

Fi!re 2"#14 Salivary !i#ula a!er %arial %aroi$ecomy,

A c%ronic sali!ary fist#la #s#ally re.#ires additional treatment to effect clos#re-Completion total parotidectomy is c#rati!e for c%ronic sali!ary fist#la #t in!ol!es t%eris0 of facial ner!e in/#ry-67B8Antic%oliner$ic medications %a!e een reported to %a!e aeneficial effect on t%e red#ction of sali!ary flo2 2it% res#ltant fist#la resol#tion- 67@3869*8Transdermal scopolamine may %a!e a similar effect on sali!ary flo2 red#ction-69,8Tympanic ne#rectomy3 2%ic% interr#pts t%e parasympat%etic inner!ation to t%eparotid $land3 %as also een ad!ocated as a s#ccessf#l met%od for t%e clos#re of
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c%ronic sali!ary fist#las-67?3869)8Recent reports %a!e s%o2n enefit 2it% t%e #se ofot#lin#m to(in for sali!ary fist#la- 697386998ltrasono$rap%y is #sef#l for proper in/ectioninto t%e remainin$ parotid $land parenc%yma "Fi$#re )*+,:&-

Fi!re 2"#15 5lra#oun$+gui$e$ )oulinum o"in injecion !or %o#%aroi$ecomy #alivary

!i#ula,

Late ComplicationsFrey Syndrome

Frey syndrome "$#statory s2eatin$3 a#ric#lotemporal syndrome& is a relati!elycommon late complication of parotidectomy- T%is complication is t%o#$%t to occ#r inrelation to t%e aerrant re$eneration of t%e post$an$lionic secretomotorparasympat%etic ner!e fiers3 2%ic% are carried in t%e a#ric#lotemporal ner!e from t%eotic $an$lion to t%e parotid to t%e se!ered post$an$lionic sympat%etic fiers t%at s#pplyt%e s2eat $lands of t%e s0in "Fi$#re )*+,;&- As a res#lt3 s2eatin$3 dermal fl#s%3 or ot%occ#r in t%e distri#tion of t%e a#ric#lotemporal ner!e d#rin$ sali!ary stim#lation-

Fi!re 2"#1$ Pro%o#e$ a)erran regeneraion mechani#m o! Frey #yn$rome, A(Normal

%aroi$ glan$ an$ #1ea glan$ %ara#ym%aheic an$ #ym%aheic innervaion, )(A)erran

regeneraion o! #evere$ %aroi$ %o#ganglionic %ara#ym%aheic nerve !i)er# o #evere$ #1ea

glan$ %o#ganglionic #ym%aheic !i)er#,

T%e Minor starc%>iodine test 2ill o/ecti!ely demonstrate t%e area affected y Freysyndrome-69:8An iodine sol#tion consistin$ of 7 $ of iodine3 )* $ of castor oil3 and )**ml of asol#te alco%ol is applied to t%e s0in of t%e face and nec0- After t%e sol#tiondries3 t%e face is d#sted 2it% starc% po2der- T%e patient is $i!en a sialo$o$#e s#c% aslemon candy- In areas of s2eatin$3 t%e starc% and iodine react3 prod#cin$ a dar0+l#ediscoloration "Fi$#re )*+,?&- An alternati!e simple met%od for t%e o/ecti!e assessmentof Frey syndrome is to apply one ply of a t2o+ply tiss#e to t%e patients face after t%epatient %as een $i!en a sialo$o$#e- T%e tiss#e 2ill ad%ere to areas of perspiration"Fi$#re )*+,B&-

Fi!re 2"#1% Minor #arch.io$ine e# !or Frey #yn$rome, 0i#coloraion occur# in he a!!ece$

area a!er gu#aory #imulaion,

Fi!re 2"#1& Sim%le a##e##men o! Frey #yn$rome 1ih !acial i##ue, The a!!ece$ area i#$emarcae$ )y he 1e area on he i##ue,

T%e reported incidence of Frey syndrome after parotidectomy !aries $reatly dependin$on %o2 closely patients are .#estioned and e(amined for t%e condition- T%e incidence
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of o/ecti!ely doc#mented Frey syndrome y t%e Minor starc%>iodine test approac%es@:< to ,**:78Reports indicate incidences of patient a2areness of t%is prolem ofet2een )*< and ;:9@8Symptomatic Frey syndrome3 %o2e!er3 occ#rs in onlyappro(imately ,*< to ,:< of patients-6,B3869;386:*8Symptoms #s#ally de!elop after a latentperiod of many mont%s to a year or more after s#r$ery-6,B386:,8T%e delayed de!elopmentof symptoms of #p to B-: years after s#r$ery %as een reported- 69@8

Frey syndrome may e pre!entale y t%e ele!ation of a t%ic0 s0in flap at t%e time ofparotid e(pos#re- Sin$leton and Cassisi6:)8reported only a )-;< incidence of t%iscomplication 2it% t%ic0+flap ele!ation as compared 2it% a ,)-:< incidence 2it% at%inner flap- T%e #se of a sternocleidomastoid m#scle flap for t%e pre!ention of Freysyndrome %as een s%o2n to e ineffecti!e-6:7386:98Ot%er reports %a!e e(amined t%e #seof arriers placed at t%e time of parotidectomy to pre!ent Frey syndrome- ario#siolo$ic arriers placed et2een t%e parotid ed and t%e s0in3 incl#din$ lyop%ili1edd#ra3 poly$lactin @,*+polydio(ane3 and e(panded polytetrafl#oroet%ylene3 may red#cet%e incidence of Frey syndrome3 #t t%ey %a!e not een 2idely accepted as a res#lt ofan oser!ed increase in postoperati!e seroma and sali!ary fist#la 2it% t%eir #se-6::8Acell#lar dermis %as also een reported to si$nificantly red#ce t%e incidence of Frey

syndrome 2%ile impro!in$ postoperati!e facial conto#r- 5o2e!er3 an increased rate ofpostoperati!e seroma formation %as also een noted 2it% its #se-6:;386:?8

After t%ey #nderstand t%e condition3 many patients c%oose to tolerate t%e symptoms ofFrey syndrome and do not opt for treatment-6,@386),8Some patients enefit from t%e dailyor t2ice+daily application of antiperspirants to t%e affected area- 69@386:B8Treatment 2it%antic%oliner$ic medications is ased on t%e fact t%at t%e post$an$lionic sympat%eticinner!ation to t%e s2eat $land is c%oliner$ic rat%er t%an adrener$ic- 5o2e!er3 systemicantic%oliner$ic medications are associated 2it% a %i$% incidence of side effects s#c% asdry mo#t% and l#rred !ision3 2%ic% are #s#ally #ndesirale-Topical ,< or )< $lycopyrrolate applied to t%e affected area of $#statory s2eatin$ %aseen s%o2n in do#le+lind st#dies to e an effecti!e treatment 2it% a lo2 incidence ofside effects-69@386:@8T%e relief of symptoms lasts for se!eral days after t%e application of

topical $lycopyrrolate- T%is medication is not a!ailale commercially as a topicalpreparation= t%erefore a lotion or cream m#st e made specially y a p%armacist-Contraindications to t%e #se of t%is medication incl#de $la#coma3 pyloric ostr#ction3and prostate %ypertrop%y-C#rrently a common and effecti!e met%od for t%e mana$ement of Frey syndrome isot#lin#m to(in in/ections- T%e recommended administration of ot#lin#m to(in A forFrey syndrome is )-: IG*-, ml in/ected s#c#taneo#sly into eac% ,-* cm)of affectedarea3 2it% total dosa$es ran$in$ from B* I to ,** I-6;*386;,8T%e ma/ority of patientstreated 2it% ot#lin#m to(in A 2ill %a!e an o/ecti!e ret#rn of $#statory s2eatin$ ystarc% iodine testin$ y ,B mont%s after t%e in/ection= %o2e!er3 s#/ecti!e symptomsare #s#ally reported to e less se!ere-6;*>;)8Patients 2it% a symptomatic rec#rrence of

Frey syndrome often enefit from repeat in/ections-6;,8

T%e s#r$ical correction of Frey syndrome incl#des fascial $raft interposition et2eenan ele!ated s0in flap and t%e $land-6;7386;98T%is tec%ni.#e %as een s%o2n to %a!e lon$+term enefit for some patients3 #t t%ere %a!e een fe2 reports of t%is proced#re-6;78E(treme care m#st e ta0en to a!oid facial ner!e in/#ry d#rin$ s0in+flap ele!ation2it% t%is approac%- As a res#lt of t%e efficacy of t%e nons#r$ical mana$ement of Freysyndrome3 s#r$ical mana$ement is presently an #ncommon remedy-H#statory r%inorr%ea %as occasionally een reported after parotidectomy-6;:>;?8Patientscomplain of ipsilateral r%inorr%ea 2it% eatin$- A proposed pat%2ay for t%is symptom is
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t%e re$eneration of dama$ed pre$an$lionic parasympat%etic fiers in t%e lessers#perficial petrosal ner!e t%ro#$% t%e $reater s#perficial petrosal ner!e to t%e idianner!e3 t%e sp%enopalatine $an$lion3 and t%e lon$ sp%enopalatine ner!e3 2%ic% s#ppliest%e nasal m#co#s $lands-6;:8

Trism#sTrism#s occ#rs rarely after parotidectomy3 and3 if it occ#rs3 it is #s#ally mild andtransient "Fi$#re )*+,@&- Trism#s is most li0ely related to masseter inflammation andfirosis or ot%er scarrin$- Radiation t%erapy may contri#te si$nificantly to t%is prolem-Trism#s #s#ally impro!es 2it% mo#t%+openin$ e(ercises- Some patients may enefitfrom p%ysical t%erapy or t%e #se of a commercially a!ailale mo#t%+openin$ de!ice"e-$-3 T%eraite 6Atos Medical3 5ry3 S2eden8&-

Fi!re 2"#1' Tri#mu# a!er oal %aroi$ecomy an$ %o#o%eraive ra$iaion hera%y !or an

a$enoi$ cy#ic carcinoma,

5ypertrop%ic Scar and JeloidFor t%e ma/ority of patients3 t%e parotidectomy incision %eals 2ell and is cosmeticallyacceptale as a res#lt of concealment in t%e nat#ral s0in creases- Care m#st e ta0end#rin$ 2o#nd clos#re to caref#lly reali$n t%e 2o#nd to a!oid t%e malpositionin$ of t%eearloe- 5ypertrop%ic scarrin$ or 0eloid 2ill rarely complicate %ealin$ "Fi$#re )*+)*&-Scar re!ision3 steroid in/ections3 and ot%er t%erapies are treatment options for t%emana$ement of %ypertrop%ic scars-

Fi!re 2"#2" A(Hy%erro%hic #car a!er %aroi$ecomy, )((eloi$ a!er %aroi$ecomy,

Amp#tation Ne#roma of t%e Hreater A#ric#lar Ner!eAn amp#tation ne#roma "Fi$#re )*+),& 2ill occasionally form at t%e se!ered end of t%e$reater a#ric#lar ner!e after parotidectomy-6;B386;@8T%e dia$nosis of an amp#tationne#roma is #s#ally clinical- Patients may complain of locali1ed or radiatin$ pain relatedto t%e mass- A tender nod#le #s#ally less t%an , cm in diameter is palpale o!er t%e#pper order of t%e sternocleidomastoid m#scle- Palpation of t%e mass #s#ally elicitstenderness and parest%esias-6;B8Eddey6:,8reported a 7-B< incidence of ne#romaformation after parotidectomy- 5osley6;B8reported se!en amp#tation ne#romas t%at2ere dia$nosed an a!era$e of 9 years after s#r$ery- T%e incidence of t%is prolem may

e red#ced 2it% recent trends to preser!e t%e $reater a#ric#lar ner!e d#rin$parotidectomy- Simple e(cision of t%e ne#roma is #s#ally c#rati!e-

Fi!re 2"#21 E"ci#e$ am%uaion neuroma o! he greaer auricular nerve,
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Expected SequelaeT%e e(pected se.#elae of parotidectomy are as follo2sK

* Some $egree o! #en#ory lo## in he $i#ri)uion o! he greaer auricular nerve

* So!+i##ue $e!ici in he area o! re#ecion

* Scar

Sensory Loss in t%e Distri#tion of t%e Hreater A#ric#lar Ner!eAll patients s%o#ld e informed t%at sensory loss in t%e distri#tion of t%e $reatera#ric#lar ner!e to some de$ree is an e(pected se.#ela of parotidectomy- T%e posteriorranc% of t%is ner!e can e preser!ed-6?*386?,8In t%e a#t%ors e(perience3 t%is is possilein more t%an :*< of cases "Fi$#re )*+))&- T%e area of sensory loss decreases3 and32it% time3 t%e sensory deficit ecomes less noticeale to t%e patient- 6?)8Onlyappro(imately ):< of patients complained of t%is symptom 2%en t%ey 2ere .#estionedpostoperati!ely in t%e series reported y Eddey-6:,8Patients 2it% a sensory deficits%o#ld e ca#tioned ao#t t%e possiility of #nnoticed in/#ry to t%e ear y t%ermal orot%er tra#ma "Fi$#re )*+)7&-6?78

Fi!re 2"#22 Pre#ervaion o! he %o#erior )ranch o! he greaer auricular nerve, A(Nerve $i##ece$

circum!erenially, )(Nerve un$ermine$ 1ih a cu!! o! %aroi$ i##ue, Thi# meho$ avoi$# nerve#rech injury an$ conri)ue# o im%rove$ !acial conour,

Fi!re 2"#23 A(6urn o he %inna a!er %aroi$ecomy, )(0og )ie o! %inna, The %aien

1a# una1are o! hi# injury7 1hich 1a# #u#aine$ 1hile %laying 1ih a !ri#2y %u%%y,

Soft+Tiss#e DeficitA soft+tiss#e deficit in t%e area of resection is anot%er e(pected se.#ela ofparotidectomy- Most patients are not dist#red y t%is3 and fe2 re.#est considerationfor reconstr#cti!e s#r$ery for its correction- T%is deformity is more se!ere after total orradical parotidectomy "Fi$#re )*+)9&3 and primary reconstr#ction may e eneficial torestore facial conto#r- M#ltiple reconstr#cti!e proced#res %a!e een proposed forcorrection 2%en t%e defect is si$nificant3 incl#din$ fat $raft3 6?9386?:8micro!asc#larm#sc#lar free flaps36?;8sternocleidomastoid m#scle rotational flaps3 6??386?B8and fillers "e-$-3

AlloDerm 6LifeCell3 'ranc%#r$3 N8&-

Fi!re 2"#24 So!+i##ue $e!ici a!er oal %aroi$ecomy, Noe he in!ra+auricular an$ !acial

$e%re##ion,

ScarAfter parotidectomy3 t%e 2o#nd $enerally %eals 2it% an inconspic#o#s scar- Caref#lplacement of t%e incision parallel to rela(ed s0in tension lines contri#tes to optimalscar concealment- For yo#n$ patients and 2omen 2it%o#t a prominent prea#ric#lar
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crease3 an incision e%ind t%e tra$#s may offer etter camo#fla$e for t%e scar line"Fi$#re )*+):&-

Fi!re 2"#25 Po#ragal inci#ion !or #car camou!lage !or a *8+year+ol$ girl re9uiring a

%aroi$ecomy !or a )enign #alivary neo%la#m,

Tumor RecurrenceRec#rrent t#mor is a dreaded late complication of parotidectomy- Some mali$nantparotid t#mors are 0no2n to %a!e a relati!ely %i$% rate of rec#rrence- Rec#rrences aremore li0ely 2it% %i$%er t#mor sta$e and %i$%er %istopat%olo$ic $rade and amon$ t%osepatients 2it% preoperati!e facial ner!e paralysis-6?@>B,8Lon$+term follo2 #p is necessary3partic#larly for adenoid cystic carcinoma and acinic cell carcinoma3 eca#se laterec#rrence can occ#r 2it% t%ese parotid mali$nancies- 6?@8Postoperati!e radiationt%erapy %as een s%o2n to red#ce t%e ris0 of local rec#rrence of select mali$nant

parotid neoplasms as compared 2it% s#r$ery alone-6B,>B78

T%e rec#rrence of pleomorp%ic adenoma occ#rs less t%an ,< of t%e time after formalparotidectomy-6B9386B:8Alternati!ely3 t%e en#cleation of pleomorp%ic adenomas res#lts inrec#rrence rates of 7*< to :*


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Postoperati!e radiation t%erapy appears to e eneficial after t%e resection of rec#rrentpleomorp%ic adenoma-6@9>@;8Radiation t%erapy %as een s%o2n to e effecti!e for t%osepatients 2it% microscopic resid#al pleomorp%ic adenoma after t%e s#r$ical resection ofrec#rrence #t not for patients 2it% resid#al $ross disease after e(cision-6@:8Patientsm#st e informed t%at radiation t%erapy carries 2it% it a lo2 ris0 of s#se.#entradiation+ind#ced mali$nancy-6@?8
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