Parotidectomy
What the Examiner Expects
Surgical removal of the parotid gland, either superficial (lateral to the facial nerve) or total (both superficial and deep lobes). The examiner expects you to work up a parotid mass (FNA biopsy, CT/MRI for deep lobe extent and cervical lymph node assessment), know that pleomorphic adenoma is the most common parotid tumor (benign), Warthin's tumor is the second most common (benign), and mucoepidermoid carcinoma is the most common malignant parotid tumor. The critical intraoperative step is identification and preservation of the facial nerve (CN VII), found at its main trunk as it exits the stylomastoid foramen, and traced distally through its five branches (temporal, zygomatic, buccal, marginal mandibular, cervical).
Key Examiner Focus Points
- Superficial parotidectomy for benign tumors (pleomorphic adenoma — most common parotid tumor)
- Total parotidectomy for malignant tumors — preserve facial nerve if not directly invaded
- Facial nerve (CN VII): identified at its main trunk emerging from the stylomastoid foramen
- Frey's syndrome (gustatory sweating): most common long-term complication
- FNA before surgery to differentiate benign vs malignant
Common Curveballs
Postop the patient has weakness of the ipsilateral lower lip (cannot smile fully)
Marginal mandibular branch injury of CN VII. If the nerve was preserved anatomically but stretched, expect recovery over weeks to months (neuropraxia). If the nerve was divided, primary neurorrhaphy or nerve grafting should have been performed intraoperatively. Temporary weakness from traction is the most common postop facial nerve issue.
Pleomorphic adenoma recurs after inadequate initial excision
Recurrent pleomorphic adenoma is challenging due to multinodular recurrence pattern in the scarred operative bed, with the facial nerve at increased risk. Revision surgery should be performed by an experienced head and neck surgeon. There is a risk of malignant transformation (carcinoma ex-pleomorphic adenoma) in long-standing recurrences.