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return to: Sialosis or Sialadenosis of the Salivary Glands; Sialosis (Sialadenosis) Sialogram; Salivary Swelling; Parotidectomy with Facial Nerve Dissection

see also: Great auricular nerve pain (great auricular neuralgia)

Note that other management options for sialosis (sialadenosis) other than surgical treatment are generally preferred with options including botox injection to the painful/swollen glands, steroid infusion through the ducts of the glands and autonomic stimulation as per

Mahler (1993) and Park (2009) who identified that "Pilocarpine has proved to be beneficial in the treatment of sialadenosis in bulimic patients" and "This article presents a case of painful sialoadenomegaly associated with hyperamylasemia in a bulimic patient successfully managed with pilocarpine'

History: Onset of left parotid swelling with pain at age 52 in male without diabetes, liver disease, history of alcoholol use or other known risk factor for sialosis.

    09-2010 First episode of left parotid swelling - including left ear pain and swelling about the eye  treated with antibiotics - resolved

    10-2010 Second episode of left parotid swelling followed by more swelling - with subsequent swelling persisting despite dental work designed to address possible source  CT imaging done

    3,4-2012 First encounters at the U of Iowa with allergy/immunology and then rheumatology with infectious and autoimmune workup negative.

    6-12-2012 Consult to Otolaryngology resulting in review of outside CT's (c/w sialosis) and

    6-22-2012 Left parotid sialogram (c/w with sialosis)

    7-10-2012 Kenalog 10 infusion to left parotid (3 cc) with 2 weeks of relief of discomfort followed by return of painful swelling and request for paotidectomy

    9-5-2012 Left parotidectomy (along with normal sialendoscopy)

    1-17-2013 4 1/2 months followup without pain or swelling with the patient report "I am cured!"

Modified Operative Note

INDICATIONS: 54-year-old male with likely sialosis, brief improvement after steroid insufflation to the gland with recurrence of left parotid swelling and pain.

PROCEDURE DETAILS: Informed consent was confirmed. The patient was brought to the operating room where anesthesia was induced. The table was turned 180 degrees with the head away from anesthesia (extra long tubing). NIMS (nerve integrity monitoring system) was placed with needle electrodes modified in position to permit access to the oral cavity (monitoring upper orbicularis oris) and for standard monitoring of orbicularis oculi. The preparation included intraoral rinse of dilute (1:20 dilution of 10% povidine iodine) oral prep (see Betadine prep) after placement of an oral throat pack (vaginal pack). Injection as for a doubly modified Blair (parotid) incision was done with 1:100,000 epinephrine. The face and neck were prepped with 'solo prep' (betadine gel) with draping appropriate for parotidectomy with access intraorally.

A timeout was performed. The procedure began with left parotid sialendoscopy. The microscope was brought into place to assist in identifying Stensens duct orifice. Fordyce spots were identified. The duct was cannulated with a 0.018 inch guide wire (see: Sialogram Technique) over which a 22-gauge angiocatheter was advanced by the Seldinger technique and followed by 1 mL of 1% lidocaine instilled through the 22 guage angiocath. The 0.018 inch guidewire was replace through the 22 angiocath and, with removal of the angio cath, Marchal hollow-bore dilators were placed over the guide wire (progressing from smallest to the next two sizes) to dilate the duct. We then placed the diagnostic endoscope (0.8 mm) was then placed. He was noted to have a normal parotid duct; however, there was a significant turn, which required some negotiation. We then replaced the 0.018 guidewire and passed the 1.8 endoscope over the guidewire with the endoscope placed to the depth of 7 cm from Stensen's duct orfice (see transillumination photo taken externally). No abnormalities in the internal ductal system were identified. It should be noted that the sialendosocpy was done with continuous infusion pressure of distilled water through the endoscope, therefore likely dilating the ductal system to a greater degree than was seen on the sialogram.

We then turned our attention to the parotidectomy. An incision was planned in preauricular, down into the skin crease. This incision was made sharply through the platysma. The great auricular nerve was identified, dissected up and the posterior two branches to the auricle were preserved. The SCM was identified and the anterior aspect was dissected. We then, without lifting a separate skin paddle (permitting anterior traction on the still attached parotid gland with skin hooks in the dermis, the posterior aspect of the parotid gland was mobilized from the SCM, the tragal cartilage and the posterior belly of the digastric muscle. The facial nerve trunk was readily identified with assistance employing the McCabe Parsons facial nerve stimulator. The facial nerve was then traced with care using McCabe's and a Shaw blade to resection the parotid. All branches were identified and preserved posteriorly - with anterior dissection completed after elevation of the skin flap in a thick plan (immediately over the parotid fascia) to decrease the risk of subsequent Frey's syndrome. At the end of the case, the nerve successfully stimulated at the main trunk and all main branches. A 10 flat fully perforated drain was also placed and secured (see Closed Suction (Jackson Pratt) Drain Placement and Removal). The platysma was closed with interrupted 3-0 Vicryl sutures. The skin was approximated deeply with 3-0 Vicryl sutures. The skin was closed with 6-0 nylon in front of the ear and a running 5-0 nylon on the neck.

References

Pape SA, MacLeod RI, McLean RN and Soames JV: Sialadenosis of the salivary glands. Brit J. of Plastic Surgery (1995), 48, 419-22

Scully C, Bagan JV, Eveson JW, Barneard N, and Turner Fioan:  Sialosis: 35 cases of persistent parotid swelling from two countries. British Journal of Oral and Maxillofacial Surgery 46 (2008) 468-72

Chen S, Benjamin C and Myssiorek D: An Algorithm Approahc to Diagnosin Bilateral Parotid EnlargementOtolaryngology – Head and Neck Surgery 148(5) 732-739

Duggan J and Rothbell E: Asymptomatic enlargement of the parotid glands. NEJM 1957;257:1262-1267

Carda C et al Structural and functional salivary disorders in type 2 diabetic patietns. Med oarl patol Oral Cir Bucal. 2006; 11:E 309-E314

Merlo C et al Parotid sialosis: morphometrical analysis of the glandular parenchyme and stroma among diagbetic and alchoholic patients. J Oral Pathol Med. 2010;39:10-15

Mehler PS and Wallace JA: Sialadenosis in bulimia. A new treatment Arch Otolaryngol Head Neck Surg. 1993 Jul;119(7):787-8.

Park KK1, Tung RC, de Luzuriaga AR. Painful parotid hypertrophy with bulimia: a report of medical management. J Drugs Dermatol. 2009 Jun;8(6):577-9.