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Variations of Parotidectomy –Indications and Technique

Variations of Parotidectomy –Indications and Technique

Kerry D. Olsen, M.D.

Professor and ChairHead and Neck Surgery

Mayo Clinic

Kerry D. Olsen, M.D.

Professor and ChairHead and Neck Surgery

Mayo Clinic

Parotidectomy

• 60 – 100 cases per year

• Variety of neoplasms and anatomic variations

• Minimal morbidity overall

• Recurrent neoplasms –challenging cases

Personal experience > 32 years

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Parotid Surgery - Challenges

Patient expectations

Variety of tumorsencountered

Relationship and sizeof the tumor to thenerve

Extend the operationas needed

Role of pathology

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Parotidectomy

Surgical options:

• Superficial parotidectomy

• Partial parotidectomy

• Deep lobe parotidectomy

• Total parotidectomy

• Extended parotidectomy

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Surgical Technique

Superficial parotidectomy

Deep lobe parotidectomy

Surgeons will spend their entire career trying to learn when it is safe or necessary to do more or less than a superficial parotidectomy

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Superficial Parotidectomy

Indications• Neoplasm• Risk of metastasis• Recurrent

infection/abscess• Surgical exposure –

deep lobe/parapharynx/infratemporal fossa

• Cosmesis

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Pre-operative Discussion

Individualized

• Goals – rational – risks

Goals – safe and complete removal with surroundingmargin of normaltissue andpreservation offacial nervefunction

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Facial Nerve Identification

Helpful:• Cartilaginous

pointer• Posterior belly

of the digastricmuscle

• Mastoid tipRetrograde dissectionMastoid dissection

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Superficial Parotidectomy

Surgical goals

• Avoid facial nerveinjury

• Remove tumorwith surrounding parotid tissue

• Minimize capsular dissection

• Avoid tumor spillage

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Partial Parotidectomy

Inferior parotidectomy

Posterior parotidectomy

Accessory parotidectomy

Deep lobe partial parotidectomy

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Deep Lobe of the Parotid Gland

Largest portion between ramus of mandible and mastoid process

Small amount deepto facial nerve andover massetermuscle

Smaller extensionretromandibularinto the parapharyngeal space

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Deep Lobe ParotidectomyIndications

To understand the indications one must know:

• Regional anatomy

• Embryology

• Lymphatic drainage of the parotid area

• Parotid tumor behavior

• Effective surgical technique

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Parotid Lymph NodesParotid Lymph Nodes

15-20 parotid regional nodes

Paraglandular – intraglandular

Number lymphnodessuperficiallobe > numberlymph nodesdeep lobe

15-20 parotid regional nodes

Paraglandular – intraglandular

Number lymphnodessuperficiallobe > numberlymph nodesdeep lobe

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Parotid Lymph NodesParotid Lymph Nodes

Mean ± SD Range

Superficial lobe 7.6±3.4 3-19

Deep lobe 2.3±1.8 0-9

Mean ± SD Range

Superficial lobe 7.6±3.4 3-19

Deep lobe 2.3±1.8 0-9

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Deep Lobe ParotidectomyIndications

Both benign and malignant tumors• Deep lobe parotidectomy alone –

usually benign disease• For malignant disease – deep lobe

parotidectomy generally done in conjunction with a superficial parotidectomy

Facial nerve preserved or removed depending on the individual case

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Deep Lobe Parotid SurgeryPartial Removal

Identification of facial nerve portion or all

Mobilization offacial nerve

Removal portiongland by tumor

Preservation mostdeep structures

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Deep Lobe RemovalTotal Parotidectomy

Concept lymphatic spread

• Primary parotid neoplasms

• Metastasis to superficial parotid nodes

Frequently misunderstood aspect of the treatment of parotid malignancy

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Case Report

Melanoma temple with

palpable mass lower

pole of parotid

PET scan / CT

negative except

for single parotid

node

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Case Report Treatment

• Excision of the primary• Superficial parotidectomy

One 2 x 2 cm node pos. 1 / 6 other nodes

positive• Deep lobe removed

1 / 3 nodes positive• Select neck dissection

1 / 8 upper nodes positive

0 / 10 mid 0 / 6 low

Treatment• Excision of the primary• Superficial parotidectomy

One 2 x 2 cm node pos. 1 / 6 other nodes

positive• Deep lobe removed

1 / 3 nodes positive• Select neck dissection

1 / 8 upper nodes positive

0 / 10 mid 0 / 6 low

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Deep Lobe RemovalPositive Superficial Parotid Nodes

66 year old male

Parotid gland adenocarcinoma

Pathology findings

• 8 of 9 superficial parotid nodes positive

• 5 of 6 deep lobe nodes positive

• 15 of 41 neck nodes positive

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Deep Lobe RemovalHigh Grade Parotid Malignancy

64 year old male Carcinoma Ex-pleomorphic – superficial

lobe Sarcomatoid salivary duct carcinoma type Pathology findings

• 3x3x2 cm parotid mass – sup. lobe• 4 parotid nodes negative• 42 neck nodes negative• 2 deep lobe nodes positive

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Deep Lobe ParotidectomyIndications

Actual or presumed metastasis to deep parotid nodes

• All cases of metastasis to superficial parotid nodes (Parotid and extra-parotid primaries)

• Any parotid malignancy with cervical metastasis

• High grade aggressive parotid malignancies

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Deep Lobe Parotid SurgeryTotal Removal

Deep Lobe Parotid SurgeryTotal Removal

Initial superficial parotidectomy

Complete facial nerve mobilization

Removal vessels – key step!

• External carotid

• Superficialtemporal

• Internalmaxillary

Initial superficial parotidectomy

Complete facial nerve mobilization

Removal vessels – key step!

• External carotid

• Superficialtemporal

• Internalmaxillary

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Deep Lobe ParotidectomyDeep Lobe Parotidectomy

En-bloc removal

Preserve facial nerve

Remove gland and deep parotid nodes

Safe and effective

En-bloc removal

Preserve facial nerve

Remove gland and deep parotid nodes

Safe and effective

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SummarySurgeon should be

able to match patient’sexpectations of a safesuccessful tumorremoval withpreservation of facialnerve function

Challenges – unknowns –unexpected – unusual