Variations of Parotidectomy – Indications and Technique€¦ · Variations of Parotidectomy –...
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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