Management of Parotidectomy Complications

Introduction

The most devastating complication of parotid surgery is facial paralysis (see Chapter 50 ) and therefore preoperative counseling is generally centered around it. Early postoperative complications include sialoceles/salivary fistula, skin anesthesia, and “wound complications” such as infection, bleeding, hematoma, seroma, and skin flap necrosis. Late complications include adverse scarring, Frey syndrome, local deformity with skin depression (see Chapter 40 ), as well as tumor recurrence (see Chapter 41 ).

Wound Complications

Although the incidence of surgical site infection after parotidectomy is poorly documented, it seems close to the average incidence of 2.6% found in surgical site infections from other sites. In one publication specifically interested in post-parotidectomy infections (a retrospective study over 17 years), an alarming rate of 20% was found and the variables associated with an infection were concomitant neck dissection and drain output >50 cc. Treatment should include wound opening and rinsing. Antibiotics are indicated in cases with erythema and induration extending >5 cm from the wound edge or with severe systemic manifestations (temperature >38.5°C, heart rate >110/min, or white blood cell count >12,000/µL).

Because vessels are close to facial nerve branches, hemostasis during parotidectomy is sometimes difficult to achieve and could result in postoperative hematoma. When specifically sought, the incidence could be as high as 18%, but the average incidence is probably below 5%. Possible factors contributing to postoperative hematoma have not been formally investigated but could include anticoagulant medications, rebound hypertension and coughing during extubation, as well as extensive procedures. Treatment depends on the amount of parotid swelling, with large hematoma requiring return to the operating theater for wound opening, clot evacuation, and bleeding control. Hematoma could lead to further wound complications, being the nidus of infection and probably favoring the development of skin flap necrosis and seroma/sialocele.

Skin flap necrosis after parotidectomy is rare (<1% ) and not well studied. Contributing factors include smoking, prior radiation, diabetes, lengthy procedures, and not keeping the flap moist. Skin necrosis usually occurs at the distal end of the flap, i.e., its retroauricular portion. Treatment consists of debridement of the necrotic skin and wound care.