Head & Neck Disorders
Parotidectomy (Salivary Gland Surgery)
The parotid gland is the largest of the salivary glands, all of which produce saliva to help lubricate the oral cavity during meals. It is located just anterior to the ear, with extensions behind the ear and inferiorly into the upper neck. The most common indication for parotidectomy is tumors in the gland; the operation is rarely performed for severe, recurrent infections within the gland. Fortunately, most parotid tumors (85-90%) are benign. The malignancies vary widely in their aggressiveness and prognosis; many low grade parotid cancers are highly curable with surgery. The most common parotid tumor is a pleomorphic adenoma, also called a benign mixed tumor. Pleomorphic adenomas have been known to degenerate into cancers if they are neglected for many years, hence the standard treatment for most parotid tumors is surgery. Fine needle aspiration biopsy (FNA) can be done preoperatively but rarely changes the decision as to whether to operate or not, hence FNA is not always required.
Parotidectomy is performed under general anesthesia. The operation usually takes about 1-2 hours to perform, and the recovery is usually rapid. Most patients are ambulatory the day of surgery, and most are discharged from the hospital the following morning. Most are able to return to work without restriction within 2 weeks. A drain is routinely inserted at the conclusion of surgery to evacuate any fluid that might accumulate. This drain is removed in the office about 72 hours after surgery.
Unfortunately, every operation entails some risk, and parotidectomy is no exception. Every operation carries a risk of anesthesia, infection, bleeding, and poor cosmetic result. The risk of general anesthesia is small in otherwise healthy patients; those with significant medical problems are urged to speak with their primary care physicians preoperatively. Infections are rare after parotid surgery, as is the risk of significant bleeding. However, all patients are counseled to avoid blood-thinning agents before surgery. These include aspirin, Advil, Motrin, Naprosyn, ibuprofen, and other non-steroidal anti-inflammatory drugs. Vitamin E and Gingko biloba are also blood-thinners to be avoided. The parotidectomy incision is very similar to that used for a facelift. Although this scar will be noticeable immediately after the surgery, it will usually become much less visible with time. Permanent unsightly scars are quite unusual.
The cheek area will be numb after the surgery, as will the lower half of the earlobe. This numbness improves with time but never resolves completely. In addition, when the cheek skin is lifted up to gain access to the parotid gland, tiny nerves that supply the salivary gland and the sweat glands in the skin are unavoidably divided. When these nerves grow back, sometimes a nerve that supplied the salivary gland grows into a sweat gland by mistake. Therefore when the patient smells or tastes food, the nerve fires but stimulates the wrong gland. This facial sweating during meals (Frey’s syndrome) occurs in most patients after parotidectomy to a variable degree. It is rarely a significant problem.
The major risk of parotid surgery is the risk of facial paralysis. The facial nerve is a motor nerve; each nerve supplies all the muscles on that side of the face. This nerve exits the skull underneath the earlobe, the nerve then directly enters the substance of the parotid gland where it divides into small branches that supply all the muscles of the face. If the facial nerve is cut or severely damaged, the results are devastating. The patient will lose the ability to move all the muscles on that side of the face, leading to a twisted facial appearance. In addition, facial paralysis has significant functional consequences, since the patient cannot close the eye or blink. Eye drops and ointment are then required to prevent infections of the cornea of the eye.
Fortunately, facial paralysis is an extremely rare occurrence after parotid surgery. Facial nerve injury is prevented by identifying and dissecting out the facial nerve before attempting to remove the tumor. Although the risk of permanent facial nerve weakness is extremely small, many patients do experience some temporary weakness in one or more branches of the nerve as a result of the facial nerve dissection. This weakness, which in rare instances may be a complete facial paralysis, usually resolves completely within several weeks to months of the operation.
Despite the afore-mentioned risks, the vast majority of patients undergoing parotidectomy do not experience any significant complications from the operation. Although this is obviously not an operation to be undertaken without clear indications, in experienced hands it is a very safe procedure.
Laryngopharyngeal Reflux
Laryngopharyngeal reflux (LPR) is an extremely common condition caused by weakness of the lower esophageal sphincter muscle. This muscle separates the esophagus from the stomach and opens and closes involuntarily during swallowing. Incomplete closure of the muscle can allow gastric contents to reflux into the esophagus. This can cause gastroesophageal reflux disease (GERD), which typically presents as heartburn, abdominal pain, or indigestion. In LPR the gastric contents reflux all the way up the esophagus and spill over into the larynx, which is located just anterior to the opening of the esophagus. LPR symptoms vary, but often include throat clearing, chronic cough, hoarseness, throat pain, and swallowing difficulties. 85% of patients with LPR do not have GERD, therefore the absence of GI symptoms does not preclude a diagnosis of reflux.
The diagnosis of LPR is usually made on the basis of the history and the laryngeal examination. A diagnosis of suspected LPR is usually sufficient to justify treatment; the diagnosis is confirmed by response to anti-reflux therapy. LPR can also be diagnosed with accuracy by double pH probe studies, wherein a thin, flexible catheter is introduced through the nose and advanced through the esophagus into the stomach. The catheter contains 2 pH probes to measure acidity- one probe is placed just above the stomach, the second is placed higher in the pharynx. This test is not currently available in the Hudson Valley, but patients can be referred to Albany, Westchester, or NYC if necessary.
Treatment of LPR consists of a diet designed to minimize reflux, plus the use of anti-reflux medication. The diet is essentially avoidance of foods that cause more acid secretion, such as caffeine, chocolate, citrus juices, tomatoes, nuts, mints, and fried and spicy foods. The best medication for LPR are the proton-pump inhibitors (Aciphex, Nexium, Prevacid, and Prilosec). In contrast to GERD, LPR can take months of treatment before an adequate response is obtained. The American Academy of Otolaryngology-Head and Neck Surgery currently recommends taking one of these drugs twice a day for a minimum of 6 months. Even with high doses for prolonged time periods, some patients do not respond. If symptoms warrant, these patients should have double pH probe studies to confirm the diagnosis, and then consideration can be given to surgery. The fundoplication procedure tightens the lower esophageal sphincter muscle and is currently performed laparoscopically (band-aid incisions). Nevertheless, it is reserved for patients with severe LPR whose symptoms cannot be controlled with diet and medication. Although LPR is extremely common, surgery is rarely required.
Post-Operative Instructions Tonsillectomy and Adenoidectomy
Diet
eat and Drink as much as you are able to. Whatever is wet, cool and sweet is more desirable for the first few days. Plan to eat soft foods and liquids that are easiest to swallow. Avoid hard, sharp or spicy foods for 2 weeks. Remember to encourage children to drink lots of liquids in order to minimize pain and prevent dehydration.
Physical Activities
Stay at home for one week. Quiet indoor play and activity is permitted. Avoid people with colds.
Work or School
As a general rule, do not plan to go to school or work for one week. Adults may require 10 days to 2 weeks.
Medications
If a prescription for pain medication is provided, take as directed. Small children should be given Tylenol by mouth or suppository. Do not take any aspirin or ibuprofen containing products (Advil, Motrin etc.). Pain medicine may cause stomach ache or constipation, requiring you to reduce the amount being used. Mild laxatives are permitted for constipation. Antibiotics are sometimes prescribed to decrease the amount of bacteria in the throat and promote healing. Take as directed. If you experience side effects such as nausea or diarrhea you may stop them.
Additional Instructions
Pain in the throat and ears is present from the time of surgery and may increase around the 5th or 6th days. It is common to have white/yellow patches in the throat for 10 to 14 days after surgery. Temperature normally is elevated on the day of surgery and may be low grade for several days. If you feel warm or have chills after the first day, you should call your doctor for a temperature over 102.5 F. Blood streaked saliva is not unusual the day of surgery. If there is evidence of bright red bleeding or vomiting of blood at any time, call the doctor.
Follow - Up Care
You should be seen in the office about two weeks after surgery. If you have any questions or concerns, please do not hesitate to call Hudson Valley Otolaryngology.
Reference Source
www.entnet.org/kidsent
Common Questions About Disorders of the Head, Neck and Throat
Throat, Voice, Swallowing
Tobacco and Cancer
Head and Neck Surgery
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