Introduction

The most devastating complication of parotid surgery is facial paralysis (see Chapter 50 ) and therefore preoperative counseling is generally centered around it. Early postoperative complications include sialoceles/salivary fistula, skin anesthesia, and “wound complications” such as infection, bleeding, hematoma, seroma, and skin flap necrosis. Late complications include adverse scarring, Frey syndrome, local deformity with skin depression (see Chapter 40 ), as well as tumor recurrence (see Chapter 41 ).

Wound Complications

Although the incidence of surgical site infection after parotidectomy is poorly documented, it seems close to the average incidence of 2.6% found in surgical site infections from other sites. In one publication specifically interested in post-parotidectomy infections (a retrospective study over 17 years), an alarming rate of 20% was found and the variables associated with an infection were concomitant neck dissection and drain output >50 cc. Treatment should include wound opening and rinsing. Antibiotics are indicated in cases with erythema and induration extending >5 cm from the wound edge or with severe systemic manifestations (temperature >38.5°C, heart rate >110/min, or white blood cell count >12,000/µL).

Because vessels are close to facial nerve branches, hemostasis during parotidectomy is sometimes difficult to achieve and could result in postoperative hematoma. When specifically sought, the incidence could be as high as 18%, but the average incidence is probably below 5%. Possible factors contributing to postoperative hematoma have not been formally investigated but could include anticoagulant medications, rebound hypertension and coughing during extubation, as well as extensive procedures. Treatment depends on the amount of parotid swelling, with large hematoma requiring return to the operating theater for wound opening, clot evacuation, and bleeding control. Hematoma could lead to further wound complications, being the nidus of infection and probably favoring the development of skin flap necrosis and seroma/sialocele.

Skin flap necrosis after parotidectomy is rare (<1% ) and not well studied. Contributing factors include smoking, prior radiation, diabetes, lengthy procedures, and not keeping the flap moist. Skin necrosis usually occurs at the distal end of the flap, i.e., its retroauricular portion. Treatment consists of debridement of the necrotic skin and wound care.

Sialocele, Salivary Fistula, and Seroma

True cystic salivary lesions are lined by an epithelium, while pseudocysts such as mucoceles and sialoceles lack such a lining and consist of poorly circumscribed mucus pools. Saliva tends to induce a local inflammatory response, which with time could lead to a pseudocapsule formation made of macrophages and other inflammatory cells. In salivary fistula ( Fig. 39.1 ), the liquid collection is no longer contained subcutaneously and drains through a skin opening. Seroma is a clear liquid collection that develops after surgery and is made of plasma and inflammatory cells. Seroma could occur after parotidectomy but is rarely considered as such, and any clear liquid collection in the parotidectomy bed is generally called a sialocele ( Fig. 39.2 ).

Salivary fistula and unaesthetic scarring.

Sialocele.

The incidence of sialoceles after parotidectomy is not insignificant, ranging from 10% to 40%. In a large series of 771 parotidectomies, numerous prognostic variables were sought but only limited parotidectomy was found as significant. Despite conflicting results, an association of higher rates of sialoceles with limited parotid resections has been confirmed in prospective studies. Foreign body placement in the surgical field, usually to prevent other parotidectomy complications, is associated with an increased incidence of sialoceles.

Unless there is a suspicion of a laceration of Stenson’s duct, there are only two theoretical options: pressure and decrease of salivary output. Pressure dressings are probably the most frequent treatment of sialoceles, but there is no evidence of their efficacy. If the parotid swelling is moderate, we avoid initial aspiration of the collection, since it constitutes a pressure system in itself, echoing Witt’s findings that most sialoceles will resolve within 1 month without active treatment. In large post-parotidectomy swellings, needle aspiration might be warranted to exclude hematoma and to prevent salivary fistula. Another option, derived from traumatic cases, might be the creation of a transoral drainage path, which could be maintained patent by a stent.

About 30–40% of patients with sialoceles will develop a salivary fistula ( Fig. 39.1 ). Here again, pressure dressings are probably ineffective and probably the only management option is to decrease salivary gland output with infiltration of the gland with botulinum toxin or the administration of a somatostatin analogue, as demonstrated in pancreatic surgery.

Cutaneous Anesthesia

The great auricular nerve carries sensory fibers from the cervical plexus towards the lower lateral face, ear pinna, and postauricular skin. It courses on the lateral aspect of sternocleidomastoid muscle and divides into an anterior and a posterior branch. Since parotidectomy requires the gland to be separated from the sternocleidomastoid muscle, the nerve historically was sacrificed. Over the last 20 years, the deficits and problems associated with great auricular nerve sacrifice, such as paresthesia, difficulty using the telephone, shaving, combing hair, wearing earrings, and sleeping on the operative side, have been recognized. Brown and Ord showed that: (1) the anterior branch entered the parotid gland and could not be spared; and (2) sparing the posterior branch resulted in smaller surfaces of cutaneous anesthesia. Although the literature is not unanimous, a systemic review favors these findings. However, the results are not clear cut because even patients with a sectioned great auricular trunk progressively recover sensation, and patients with the entire nerve preserved demonstrate some anesthesia. A possible explanation is the variability of the branching pattern of the great auricular nerve and its anastomosis with other cutaneous nerves, including the posterior auricular, auriculotemporal, and facial nerve.