Special Surgical Procedures II
LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery
Section IV: THROAT, TONGUE, AND NECK SURGERY
1-40
1-40. PAROTIDECTOMY
a. General. This operation involves the removal of a tumor and gland through a curved incision in the upper neck and behind the lobe of the ear, or through a Y-type incision in both sides of the ear and below the angle of the mandible. The majority of benign tumors of the salivary glands occur in the parotid gland. These benign tumors are of the same types as are those found in soft tissues in other parts of the body. The closeness of the parotid gland to the facial nerve makes it difficult to remove the entire tumor. Parotidectomy is indicated for removal of all benign and some malignant tumors, for inflammatory lesions, for vascular anomalies, and for metastic cancer involving lymph nodes overlying the gland. When malignant tumors are found to involve adjacent structures, the operation may have to be extended to become a more radical procedure.
b. Preparation of the Patient. The patient is placed on the operating table in a dorsal recumbent position with the entire affected side of the face uppermost. The entire side of the face, the mouth, the outer canthus of the eye, and the forehead are prepared and left exposed.
c. Operative Procedure.
(1) The incision may extend from the posterior angle of the zygoma downward in front of the tragus of the ear and behind the lobule of the ear backward over the mastoid process, then downward and forward on the neck parallel to and below the body of the mandible. (A chin incision may be used.) Bleeding vessels are controlled by hemostats and fine ligatures.
(2) Using fine-toothed tissue forceps and scissors, the skin flaps are elevated as described for thyroidectomy. The skin wound edges are retracted away by means of silk sutures fastened to the clamps.
(3) The upper portion of the sternocleidomastoid muscle is exposed and retracted, the auricular nerve is identified, and the lower part of the parotid gland is elevated, using curved hemostats.
(4) The superficial temporal artery and vein and external jugular vein are identified by means of blunt dissection.
(5) The parotid tissue is dissected from the cartilage of the ear and the tympanic plate of the temporal bone. The temporal, zygomatic, mandibular, and cervical branches of the facial nerve are identified and preserved.
(6) The superficial portion of the parotid gland containing the tumor is removed. In some cases, the entire superficial portion is removed, followed by ligation and division of the parotid duct.
(7) When the deep portion of the parotid gland must be removed, the facial nerve is retracted upward and outward by nerve hooks; then the parotid tissue is removed from beneath the nerve. Kocher retractors are used to retract the mandible. The external carotid artery is identified. In many cases, the internal maxillary and superficial temporal arteries are clamped, ligated, and divided.
(8) The wound is closed in layers with fine silk sutures. A small Penrose drain is inserted, and a pressure dressing is applied.
