Parotid gland removal (parotidectomy) at Wessex Hospital

What is parotid gland removal?

Parotidectomy is an operation to remove all or part of your parotid gland, the largest of the glands that produce saliva, found just in front of your ear. It's most often done to remove a lump, whether that turns out to be non-cancerous or cancerous.

What conditions does it treat?

This operation most often treats a lump in the parotid gland: around 8 in 10 are benign (non-cancerous), commonly a type called a pleomorphic adenoma, while around 2 in 10 are or become cancerous. Sometimes the lump turns out to be an enlarged lymph node rather than a growth of the gland itself.

It's also used to treat chronic infection of the gland, or a blockage of saliva outflow, for example caused by a stone, that leads to persistent, uncomfortable swelling.

What are the benefits?

Removing and examining the whole lump under a microscope is the only way to know for certain whether it's benign or cancerous. Left alone, a lump will keep growing, sometimes slowly and sometimes quickly, may look unsightly, and may start to affect the facial nerve.

Notably, nearly 1 in 10 of the most common benign parotid lumps turn cancerous after 15 years, which is why removing them is often recommended even when they aren't causing problems yet. If a lump is already cancerous, or likely to become so, removal forms part of the treatment itself.

Removing one parotid gland doesn't affect your overall saliva production, since the many other salivary glands in and around your mouth continue to keep it moist.

Are there different types or surgical approaches?

A partial, or superficial, parotidectomy removes the part of the gland that sits between the skin and the facial nerve. A total parotidectomy removes the whole gland, both above and below the nerve.

Some surgeons also offer a more limited, tailored technique for smaller, suitable tumours, sometimes called micro-parotidectomy, removing just the tumour and a narrow margin of tissue rather than the whole superficial lobe. This can mean a smaller scar and faster recovery, though it isn't suitable for every tumour, and reconstructive techniques are sometimes used alongside it to fill the resulting defect and improve facial symmetry.

If you're unfit for surgery, for example because of age or other health conditions, the alternative is regular monitoring with examination and scans rather than removal, though the lump will continue to be there and may keep growing.

What happens before the procedure?

Beforehand, you'll usually have an ultrasound scan and a fine needle aspiration, where a few cells are taken with a small needle to help identify what's causing the lump. A CT or MRI scan may also be arranged if more detail is needed, particularly if the lump is close to the facial nerve, and a core biopsy using a larger needle is occasionally used instead.

Sometimes it isn't possible to be sure whether a lump is benign or cancerous even after these tests. When this happens, removing the lump and part of the gland for examination under a microscope gives the definitive answer.

General preparation includes:

• stopping smoking if you can
• telling your surgeon about any medicines or supplements you take, in case anything needs pausing beforehand
• following fasting instructions given to you
• arranging for someone to drive you home and help for the first day or so afterwards.

What happens during the procedure?

1. You're given a general anaesthetic, so you're asleep throughout.
2. A cut is made just in front of your ear, extending down towards your neck or behind your ear.
3. The skin is lifted to expose the parotid gland; a nerve-monitoring device is often used to help the surgeon identify and protect the facial nerve running through it.
4. All or part of the gland is removed, along with any nearby lymph nodes known or suspected to contain cancer.
5. The facial nerve is tested to confirm it's working normally.
6. The cut is closed with stitches, and a small drainage tube is often left under the skin for a day or so to stop blood or fluid collecting.

The operation typically takes around 2 hours, though more complex cases can take up to 4.

What does recovery look like?

In hospital

You're cared for in a recovery area, then taken to a ward or day-surgery unit once fully awake. Staff may ask you to smile or close your eyes so they can check your facial nerve is working as expected.

A drainage tube, if used, is often left in overnight and removed the following morning once the surgeon is happy with how much fluid is draining. Partial parotidectomy is sometimes done as a day case, so you go home the same day, while most people stay 1 to 2 nights; you'll need to stay longer if a blood clot under the skin or a wound infection develops.

At home

Keep the wound dry for the first week, taking care when washing or shaving, and take regular painkillers if needed, though it's not usually very sore. Swelling tends to be minimal, though the area can feel dented and your face may look a little less full on that side, since part of the gland has been removed; this is more noticeable if the lump was large or the whole gland removed.

Non-dissolvable stitches are usually removed after about a week. Plan for 1 to 2 weeks off work and avoid strenuous activity during this time.

The scar usually fades over several months and blends into the natural creases of the face. Thickened (keloid) scarring is uncommon overall but is more common in people of Afro-Caribbean or Indian subcontinent descent, so mention this to your surgeon beforehand if you've had thickened scars elsewhere on your body.

What are the risks and complications?

Risks vary depending on whether part or all of the gland is removed. Reported rates from UK data include:

• numbness of the ear and side of the face: very common, affecting up to 80 in 100 people; it usually improves with time but can be permanent in up to 5 in 100 partial operations and around 10 in 100 total operations
• a blood clot under the skin (haematoma): 7 to 12 in 100; occasionally needs a further small operation to remove it
• wound infection: uncommon, 1 to 2 in 100; usually settles with antibiotics
• saliva collecting under the skin: up to 16 in 100 after partial removal or 26 in 100 after total removal; usually managed by draining with a needle, sometimes more than once
• saliva leaking through the wound (a fistula): uncommon overall, up to 2 in 100 (partial) or 11 in 100 (total); usually settles by itself
• sweating and flushing of the skin when eating (Frey's syndrome): very common, affecting up to 67 in 100 (partial) or 94 in 100 (total); usually mild and treatable with an antiperspirant, occasionally Botox
• weakness of the facial muscles: temporary in around 20 in 100 (partial) or 40 in 100 (total) operations, usually from bruising rather than cutting of the nerve; permanent in up to 7 in 100 (partial) or 9 in 100 (total) operations, usually affecting only part of the face rather than all of it
• sharp pain on the first bite of food (first bite syndrome): up to 11 in 100, more likely after removal of the whole gland; often eases over months to a year
• moderate to severe change in the contour or fullness of the face: 7 to 40 in 100, depending mainly on the size of the lump removed
• risks related to the general anaesthetic itself, which your anaesthetist will discuss with you.

In rare cases involving cancers that have grown into the facial nerve, part of the nerve may need to be removed to fully clear the tumour; if this happens, nerve reconstruction, such as a nerve graft, can restore some facial function, though results vary with the extent of the damage.