PAROTIDECTOMY & SUBMANDIBULAR GLAND REMOVAL PATIENT INFORMATION

Specialist Salivary Gland Surgeon in Canberra

Dr Ardalan Ebrahimi is one of the few specialist Parotid & Submandibular Gland Surgeons based in Canberra. With extensive training and experience he offers minimally invasive parotid surgery to maximise function and cosmetic results. The patient information below will help you learn more about the parotid and submandibular glands, the reasons for needing salivary gland surgery, what to expect before, during and after parotidectomy and submandibular gland removal, as well as answers to frequently asked questions.

The key to successful parotidectomy and submandibular gland removal is experience and meticulous surgical technique. A/Professor Ardalan Ebrahimi minimises the risks of surgery to achieve the best possible outcomes with a combination of:

  • Extensive experience performing salivary gland surgery, including complex cancer cases, deep lobe tumours, recurrent tumours and cases requiring reconstruction
  • Routine use of intra-operative nerve monitoring to protect associated nerves.
  • Use of loupe magnification and a headlight to enhance visualisation
  • Regular use of minimally invasive approaches such as a modified facelift and parotid mini-incision to hide scarring
  • Use of fat grafts and other reconstructive procedures after parotidectomy to minimise contour change after surgery and reduce the risk of Frey’s syndrome
  • In cancer cases where nerves have to be sacrificed, we perform nerve grafts and other procedures to reduce the impact over time

The major salivary glands include the parotid, submandibular and sublingual glands. There are also hundreds of tiny minor salivary glands in the mouth. A lump or pain in any of them may indicate a salivary gland tumour. Any persistent lump in a salivary gland needs assessment by an experienced head and neck surgeon to exclude the possibility of malignancy.

The parotid glands are found on each side of the face in front of the ear. They produce saliva when you eat, as do the other salivary glands. The facial nerve runs through the middle of the parotid gland. This nerve controls the muscles in your face, which allow movements such as raising your eyebrows, closing your eyes, smiling, and preventing drooling when you eat. Parotidectomy always involves finding and operating near this nerve and its branches.

The submandibular glands lie beneath the jawbone, one on each side. They release saliva into the mouth through a duct (tube) that opens in the floor of mouth, behind the front teeth. Three important nerves are found next to these glands: lingual nerve, hypoglossal nerve and marginal branch of the facial nerve. These nerves give feeling, taste and movement to the tongue and move the lower lip.

TUMOURS
The most common reasons for removing part or all of the parotid gland (parotidectomy) or submandibular gland are tumours. These tumours are often benign but the risk of cancerous tumours is roughly 20% in the parotid and 50% in the submandibular gland. Even with a fine needle aspiration biopsy result suggesting a benign tumour, surgery is recommended for most patients. This is because the needle biopsies can sometimes miss cancer and also because the most common type of benign salivary gland tumour (pleomorphic adenoma) can transform into an aggressive cancer if left untreated for many years. In addition, the lumps tend to grow over time and become more difficult to remove. A/Professor Ebrahimi will discuss the reasons for recommending surgery in your specific case and whether there are non-surgical options for treatment.

SALIVARY GLAND STONES
The other common reason for operating on the salivary glands are stones which can block salivary flow causing swelling and pain after meals and sometimes serious infections. Depending on the location, size and number of stones you have, we strive to remove the stones through the duct opening in the mouth using transoral surgery rather than removing the salivary gland.

In general, patients undergoing parotidectomy or submandibular gland excision do not develop a dry mouth because the other salivary glands make enough saliva. There are occasional exceptions, however, such as patients who have a predisposition to dry mouth, patients having multiple salivary glands removed or patients having radiotherapy treatment.

Yes, all salivary gland surgery is performed under a general anaesthetic (you will be asleep). You should have nothing to eat or drink from midnight on the day before surgery (unless advised differently by your health care team) and should leave valuables and jewelry at home. The side effects of the anaesthetic may include nausea and sore throat, which settle down soon after surgery and will be treated with medications.

General anaesthetic is extremely safe but does carry a very small risk of serious complications. General anaesthetic can also affect your judgment, coordination and memory for 24 hours so during this time you must avoid driving, operating machinery, going to work or school, making important decisions or signing legal documents.

You will have a scar, which may be red for a few months, before fading to a thin line. In most people the scar ends up being relatively inconspicuous. Very occasionally, the scar can become thickened and red. This results mainly from some patients skin type and a predisposition to keloid scarring. You will be given instructions on managing the scar after surgery to maximize the chances that it heals nicely.

In the case of parotidectomy, most surgeons use an incision which runs in front of your ear and down into the neck. When it’s safe to do so, A/Prof Ebrahimi performs the surgery using other approaches such as a modified facelift incision or parotidectomy mini-incision to hide the scar and obtain excellent cosmetic results.

Most patients are surprised at how little pain they have after salivary gland surgery. Most patients take panadol to keep them comfortable at home but you will be given a prescription for something stronger in the first few days in case you need it.

The lump will be sent for analysis by a Pathology specialist. The results usually take 1-2 weeks to come back and will be discussed with you at your first post-operative review in the office.

Minimally invasive parotidectomy is an approach that uses a combination of strategies to minimize the long-term impact of parotidectomy. These include:

  • Using incisions such as the parotidectomy mini-incision or modified face-lift incision to hide the scar
  • Use of fat grafts and other reconstructive procedures after parotidectomy to prevent contour change after surgery and reduce risk of Frey’s syndrome
  • Minimizing the amount of salivary gland tissue that is removed to maximize function
  • Saving sensory nerves around the parotid gland when safe to do so

Parotidectomy is very delicate surgery and usually takes 3 hours while submandibular gland removal typically takes 1 hour. After surgery you will wake up in the recovery room. There will be a surgical drain in the incision (which is removed before you are sent home) and your throat may be sore because of the breathing tube placed during the operation. Once you are awake, you will be moved to a hospital bed where you will be able to eat and drink as you wish. Most patients stay in hospital 1-2 nights.

Parotidectomy involves removal of part (superficial parotidectomy), or sometimes all (total parotidectomy), of the gland and the surgery is tailored to each patient. In the hands of an experienced parotid surgeon, parotidectomy is very safe, however, all surgery carries some risk. Some risks are common to any surgery such as infection, pneumonia, or blood clots in the legs or lungs. However, these are very rare after parotid surgery. There are a few risks specific to parotidectomy you should be aware of including the following:

Facial Nerve Injury
This is the most serious possible risk of parotid surgery. However, the risk does depend on factors such as the size and location of the tumour, it’s relationship to the facial nerve, whether you are having surgery for a second time on a recurrence, whether the lump is cancerous, and the most importantly experience and skill of your surgeon.

Injury to the facial nerve can result in weakness of the face (facial palsy) which can vary in severity as well as which parts of the face are affected. The chances of temporary weakness which can last anywhere from several weeks to 6 months or more, is less than 5%. The most common situation is temporary weakness of the branch to the lower lip for several months. Severe nerve injury with complete facial paralysis occurs in <1% of patients. If the nerve has to be removed for cancer, it will not work again unless we perform reconstructive procedures such as nerve grafts. If this situation applies to you, we will discuss this in detail during the office consultation.

Bleeding
A blood clot can collect beneath the skin (a haematoma) in 1% of patients. Sometimes it is necessary to return to the operating theatre to remove the clot and replace the drain.

Salivary Collection
In 5-10% of patients, the cut surface of the remaining parotid gland leaks saliva which collects under the skin. The wound may appear infected with swelling, redness and discomfort. If this happens, the saliva will be removed with a needle in the office. This is quick and painless but may need to be repeated several times until the leak settles.

Frey’s Syndrome
Once everything has healed, you may notice moisture on the skin in front of the ear when you eat. This is because the nerve supply to the gland can re-grow to supply the sweat glands in the skin. This rarely bothers patients significantly. If it is troublesome it can be treated by the application of a roll-on antiperspirant or a botox injection if severe.

In most patients who want to achieve the best cosmetic results, A/Professor Ebrahimi recommends use a fat graft or other reconstructive procedure after parotidectomy. This not only gives normal facial contour but also acts as a barrier between the residual parotid tissue and skin and usually prevents Frey’s syndrome.

Recurrence of the parotid lump
Benign tumours of the parotid gland rarely recur if they are removed properly. Cancers of the parotid gland do carry a risk of recurrence, which depends on the specific cancer type.

Numb ear lobe
After parotidectomy you will lose normal sensation in the earlobe and in front of the ear. Over time the numbness gets better but the earlobe remains numb for life in most patients.

Wound Infection
This is uncommon and usually easily treated with oral antibiotics

Seroma
This is a painless swelling due to fluid collecting under the skin in the first week or two after surgery. It occurs in less than 5% of patients but is more common with large goiters. It is treated simply by draining the fluid in the office.

Keloid Scar
These are thick, raised red scars. It is rare in Caucasians but relatively common in patients of Asian or African descent, particularly when young.

In the hands of an experienced salivary gland surgeon, removal of the submandibular gland is very safe, however, all surgery carries some risk. Some risks are common to any surgery such as infection, pneumonia, or blood clots in the legs or lungs. However, these are very rare after submandibular surgery. There are a specific risks should be aware of including the following:

Nerve Injury
There are three nerves that lie close to the submandibular gland that can be damaged during its removal. Nerve damage is rare in experienced hands. When it occurs it usually results from bruising of the nerves since they are held out of the way and protected during surgery so the damage is usually temporary.

These nerves include:

  • The lingual nerve: this is very rarely injured. Since it is the nerve that supplies feeling to the side of the tongue bruising results in a tingly or numb feeling in the tongue, similar to the sensation after having an injection at the dentist.
  • The hypoglossal nerve: this is very rarely injured. It is the nerve that makes the tongue move so damage can result in decreased tongue movement.
  • The marginal mandibular branch of the facial nerve: this is the nerve at most risk during removal of the submandibular gland. If bruising occurs it affects the movement of the lower lip, leading to a slightly crooked smile.

Bleeding
A blood clot can collect beneath the skin (a haematoma) in 1% of patients. Sometimes it is necessary to return to the operating theatre to remove the clot and replace the drain.

Recurrence of the tumour
Benign tumours of the submandibular gland rarely recur if they are removed properly. Cancers do carry a risk of recurrence, which depends on the specific cancer type.

Wound Infection
This is uncommon and usually easily treated with oral antibiotics

Seroma
This is a painless swelling due to fluid collecting under the skin in the first week or two after surgery. It occurs in less than 5% of patients but is more common with large goiters. It is treated simply by draining the fluid in the office.

Keloid Scar
These are thick, raised red scars. It is rare in Caucasians but relatively common in patients of Asian or African descent, particularly when young.

Normal activity can begin on the first day after surgery. Vigorous sports and activities that include heavy lifting should be delayed for 2 weeks. In general, you should wait 1-2 weeks before driving again but this depends on your comfort levels. You should be able to return to a light job after 1-2 weeks and any heavy job by 4 weeks.

Depending on their job type, most people will need to take 1-2 weeks off work after parotidectomy or submandibular gland removal.