The parotid gland is divided into lateral and medial lobes. Most tumors occur in the lateral lobe which is described below. However, tumors can occur in the medial lobe with definitive treatment requiring total parotidectomy. This is accomplished by first performing a lateral lobectomy to identify the facial nerve before the dissection to remove the medial lobe is initiated.

Indications

Tumors (benign) – the most common indication for parotidectomy or removal of the tumor are benign mixed tissue tumors that originate in the lateral lobe of the parotid. Definitive treatment is wide resection (removal) with a surrounding margin of normal tissue to decrease the likelihood of local recurrence. For these tumors, the facial nerve and its branches are generally not surgically removed.

Tumors (malignant) – While not common, malignant tumors of the parotid gland do exist. Definitive treatment is wide excision with inclusion of the facial nerve and its branches if they are involved.

Metastatic disease - Surgical treatment of malignancies (particularly melanoma) located on the face usually includes sentinel lymph node mapping with the typical drainage basin surveyed including the parotid gland. Presence of a positive node or signal in the parotid necessitates at least a partial resection of the gland.

Preoperative Workup and Preparation

The most important task to be accomplished preoperatively is thorough counseling of the patient about the risks and consequences of injury to the facial nerve. All facial hair should be removed the morning of surgery.

Incision

The patient is placed supine (face up) and the head is turned away from the side of the lesion, with the head being placed in slight extension. The head of the operating room table is elevated slightly to reduce venous pressure in the parotid gland and surrounding tissues.

The incision is made from the area immediately in front of the ear, traces the trajectory of the lower ear lobe , passes over the mastoid process, and then descends 2 cm below the angle of the mandible into the superior cervical crease. Care must be taken so that the skin that is pulled toward the side the head is turned is not incised in such a manner that the incision lies over the mandible when the head is straightened.

Surgical Details of the Procedure

1. The dissection is begun to expose the main trunk of the facial nerve.

2. Sharp dissection is used to incise the subcutaneous tissue.

3. The anterior border of the sternocleidomastoid, the greater auricular nerve, and the posterior facial vein with the overlying marginal mandibular branch of the facial nerve are all identified.

4. Dissection is done in a manner to avoid the above identified structures until the capsule of the parotid is identified.

5. The capsule of the parotid is then dissected free from the anterior border of the sternocleidomastoid.

6. Most surgeons then doubly ligate the posterior facial vein with 2-0 silk ties and transsect this with care taken to avoid injury to the adjoining nerves.

7. The dissection is then continued inferiorly and posteriorly to the external auditory canal.

8. The sternocleidomastoid is then retracted posteriorly and the parotid gland anteriorly.

9. The posterior belly of the digastric muscle is then identified along with the membranous portion of the external auditory canal.

10. The facial nerve is then identified lying anterior to the digastric muscle pushing up into the surgical field and inferior to the above membrane approximately 5 mm.

11. If the position of the tumor makes the visualization of the facial nerve difficult, the dissection can be completed in a distal to proximal fashion.

12. If a distal to proximal dissection strategy is performed care must be taken to identify and void injury to the buccal branch, which lies immediately superior to Stensen’s duct.

13. Once the facial nerve has been tentatively identified, confirmation is done by using gentle mechanical stimulation or a Farradic stimulation to produce the appropriate muscle contraction.

14. If facial nerve is not identified by the above anatomic guides, a search for the posterior auricular artery is made that most usually lies just lateral to the main trunk of the facial nerve.

15. The gland is then separated from the nerve and its’ branches through blunt dissection using a fine-tipped hemostat and scissors in lieu of Bovie cautery.

16. Some surgeons use gentle retraction of the gland by grasping the parenchyma with forceps or a hemostat and pulling it upwards.

17. The dissection is usually down in a superior to inferior fashion to take advantage of normal tissue and tissue planes, as most tumors are located in the inferior part of the gland.

18. Some bleeding is unavoidable and is controlled with carefully applied low voltage electrocoagulation (i.e., fine-tipped Bovie cautery) and fine silk sutures.

19. The lateral branch of Stensen’s duct is then located and ligated with fine silk ties (e.g., 3-0) and divided with a scissors.

20. Care must be taken to not injure or ligate the medial branch or main trunk of Stensen’s duct as this will result in medial lobe atrophy.

21. Once the portion of the lateral lobe that contains the tumor and a margin of normal surrounding gland has been completely dissected free, the parenchyma is transected.

22. The isthmus and remaining medial lobe should be carefully inspected for bleeding and the wound is thoroughly irrigated.

23. A small closed-suction Silastic catheter (i.e., small Jackson Pratt drain) is then placed over the remaining 20% of the parotid gland with a small stab wound brought through the skin posterior to the face.

24. The subcutaneous tissues are approximated using interrupted dissolvable sutures.

25. The skin is closed using a running dissolvable subcuticular stitch such as 4-0 Monocryl.

25. Adhesive skin strips are placed on the wound edges.

Postoperative Course

Temporary paralysis of the facial muscles is not uncommon and should clear by seven days. Sensory disturbances may be more lasting and include permanent numbness, particularly if the greater auricular nerve has been transected.

Unfortunately, permanent paralysis can occur after parotidectomy. Division of the marginal mandibular branch off the cervical segment of the facial nerve results in permanent paralysis as this branch lacks cross-anastomoses. The temporal branch also lacks significant cross-anastomoses and has poor regenerative ability. Significant injury to this nerve results in loss of function to the frontalis muscle (inability to raise eyebrows.)

Zenker’s diverticulum is an outpouching of the pharyngoesophagus. It is considered a pulsion diverticulum. The resection can be performed through an open or endoscopic approach.

Indications

Dysphagia (difficulty swallowing)

Partial obstruction

Aspiration of fluid causing coughing spells

Choking sensation

Pain on swallowing

Diagnosis

Barium swallow – this test will show an outpouching from the posterior wall of the esophagus distal (below) to the inferior constrictors of the pharynx and proximal (just before) the cricopharyngeus muscle. The pouch usually lies to the left of the esophagus.

Click the image to view a fluroscopic barium swallow.
The Zenker’s diverticulum is the sac-like structure seen filling at 3 o’clock.

Preoperative Preparation

The patient is instructed to take a clear liquid diet for two days before surgery to allow the pouch to be empty of food particles. Some surgeons have their patients gargle vigorously with an antiseptic mouthwash before surgery. Broad-spectrum preoperative antibiotics are usually administered.

Incision – open approach

The patient is placed supine (face up) on the operating table with a roll placed under the shoulders to hyperextend the neck. The incision is made along the anterior (front) border of the sternocleidomastoid muscle.

Surgical Details of the Procedure

1. A No. 10 scalpel is used to make the incision through the skin along the anterior border of the sternocleidomastoid muscle.

2. Bovie cautery is used to incise the subcutaneous tissue.

3. The platysma is divided using the Bovie cautery.

4. Care must be taken to not transect or injure the cervical cutaneous nerve that runs 2-3 cm below the angle of the jaw.

5. The fascial attachments of the sternocleiodmastoid are released by using Bovie cautery.

6. The sternocleidomastoid is retracted laterally (away from the midline.)

7. Two clamps are placed on he omohydoid muscle running horizontally across the lower margin of the incision before it isdivided with the Bovie cautery.

8. The ends of the omohyoid are then ligated with 0 silk ties.

9. The proximal omohyoid remnant is retracted medially and the distal omohyoid remnant is retracted laterally.

10. The superior thyroid artery is visualized in the cephalad (toward the head) portion of the wound as the omohyoid is retracted.

11. This artery is clamped and divided with 2-0 silk ligatures placed.

12. The fascia containing the trachea, esophagus, and thyroid gland is visualized medial to the carotid sheath and is incised using the Metzenbaum scissors.

13. Blunt dissection is used to visualize the posterior surfaces of the esophagus and pharynx.

14. If adhesions are present secondary to inflammation and the fascial planes are obscured, a rubber catheter is placed down the esophagus with gentle insufflation of air to distend the diverticulum.

15. The diverticulum is dissected free until the neck has been visualized and is freely mobile.

16. Care must be taken to visualize both recurrent laryngeal nerves to gently dissect from the tissue surrounding the diverticulum and to then retract them to avoid injury.

17. Many surgeons now place a GIA or TA endostapler across the neck of the diverticulum and staple off the lumen and then transect the pouch.

18. Alternately, the diverticulum can be resected with a knife and the defect hand-sewn. This is accomplished by placing stay sutures of vicryl or silk at the 3 o’clock and 9 o’clock positions.

19. An incision is made in the mucosa and the diverticulum is transected cirumferentially distal to the stay sutures.

20. A nasogastric tube is placed past the opening in the esophagus to insure that the closure does not narrow the lumen.

21. A two layer closure of the esophagus is performed with the inner mucosa layer closed with interrupted 4-0 suture with the knot on the inside.

22. The outer layer of closure in the muscle defect between the inferior constrictors and the cricopharyngeus muscles is done with 4-0 interrupted suture.

23. The wound is irrigated and some surgeons place a small silastic drain over the repair.

24. The omohyoid is then reapproximated with 2-0 interrrupted sutures.

25. The platysma is then reapproximated using 2-0 interrupted sutures.

26. The skin is closed using 4-0 Monocryl sutures in a subcuticular manner.

Postoperative course

The patient is kept NPO (nothing by mouth) for three days with fluids and tube feedings given through the nasogastric tube. The drain is removed on the second postoperative day usually. Some surgeons perform a gastrograffin swallow before resuming feedings. The patient is started on clear liquids and advanced as tolerated. Antibiotic coverage is usually for the first 24 hours postoperatively.

Indications

Bleeding into the cartilage of the ear from trauma.

Surgical Details of Procedure

1. The ear surface is swabbed with a non-chlorhexidine antiseptic.

2. A medium gauge needle (e.g., #18) on a 5-10 cc syringe is inserted into the hematoma while the surgeon aspirates.

3. An antibiotic impregnated dressing is placed over the area of aspiration and secured with tape of collodion soaked gauze.

4. Close observation is made to insure hematoma does not reaccumulate

5. A second aspiration may be attempted in the face of a recurring hematoma.

6. If the hematoma again reaccumulates, one or two mattress sutures with pledgits can be placed through the scapha to allow chronic drainage.

7. If the hematoma is not adequately drained or ignored, fibrous deposits will appear in the ear cartilage requiring a surgical procedure.

8. An curvilinear incision is made with a No. 15 scalpel along the medial and/or lateral border of the antihelix depending on where the fibrous deposits are located.

9. Skin flaps are raised using sharp dissection with care taken not to lacerate or tear the skin.

10. The No. 10 blade is used to shave the fibrous deposits until all excess tissue has been removed.

11. Meticulous attention to hemostasis (i.e., stopping the bleeding) is required to prevent another hematoma (clot) from forming.

12. If needed a small drain can be placed under the skin flaps.

13. The skin is then reapproximated with interrrupted 6-0 nylon sutures.

Reduction (replacing the bones in a normal anatomic position) of a fractured (broken) nose should be done within the first 24 hours even in the presence of edema, unless massive. The defect noted on clinical exam is more important than the severity noted on the radiographs (X-ray). Generally, the reduction can be done under local anesthesia, except in noncooperative children.

Steps In the Procedure (to repair depression of left nasal bone with lateral displacement of the right nasal bone).

1. A test dose of 10% cocaine should be given to the patient by placing a small amount on the oral mucosa using a cotton swab.

2. A period of 5-10 minutes is allowed to lapse with careful hemodynamic monitoring.

3. Two cotton tampons soaked in 4 mls of 10% cocaine or 4 percent lidocaine and Afrin (oxymetazoline) for vasoconstriction are inserted into each nares end-to-end for 10-15 minutes.

4. If there is significant edema, the superior or deep tampons are then advanced further into the nares for an additional five minutes.

5. 1% lidocaine (Xylocaine) is injected at the base of the infraorbital nerve where it traverses the foramen and at the base of the columella and glabella.

6. 1% lidocaine is injected to provide topical anesthesia to anterior ethmoid nerves using an intranasal (inside the nose) technique.

7. A long, thin periosteal elevator is inserted into the left naris (nostril) to the superior edge of the noticeable deformity and is positioned so that the flat, broad surface is next to the nasal septum and the narrow edge is facing toward the surgeon.

8. When placing the periosteal elevator, care must be taken to avoid injuring the cribiform plate of the ethmoid bone.

9. Pressure is placed with the surgeons fingers on the laterally displaced right nasal bone.

10. The perosteal elevator is then used to “lift” the depressed nasal bone back into anatomic position by moving the elevator upward and laterally.

11. Pressure on the elevator is stopped when a clicking noise has been appreciated.

12. The periosteal elevator is removed and the nasal septum is examined.

13. If the nasal septum is fractured, the nares is packed with antibiotic coated gauze or Teflon splints are sutured into place.

14. External splints maybe be used to reduce pain and the liklihood of impaction.