Salivary Gland Surgery: Parotid & Submandibular Removal Guide

What Is Salivary Gland Surgery?

Salivary gland surgery is a procedure to remove part or all of a salivary gland, typically the parotid gland located in front of the ear or the submandibular gland located under the jaw. The surgery is performed under general anesthesia to investigate or treat tumors, chronic infections, salivary stones, and other conditions affecting these glands.

The salivary glands produce saliva, which is essential for digestion, oral health, and swallowing. The human body has three pairs of major salivary glands: the parotid glands (located in front of each ear), the submandibular glands (located under the jawbone), and the sublingual glands (located under the tongue). While surgery on the sublingual glands is extremely rare, operations on the parotid and submandibular glands are relatively common procedures performed by ear, nose, and throat (ENT) surgeons, also known as otolaryngologists or head and neck surgeons.

Salivary gland surgery is most commonly performed for tumors within the glands. Approximately 70-80% of salivary gland tumors occur in the parotid gland, and while most of these are benign (non-cancerous), surgical removal is often recommended because even benign tumors can grow larger over time and potentially transform into malignant (cancerous) growths. Other indications for surgery include chronic recurrent sialadenitis (inflammation of the salivary gland), sialolithiasis (salivary stones) that cannot be removed by less invasive methods, and certain autoimmune conditions affecting the glands.

The complexity of salivary gland surgery, particularly parotidectomy, lies in the intricate anatomy of the region. The facial nerve, which controls the muscles of facial expression, passes through the parotid gland and must be carefully preserved during surgery. Modern surgical techniques, including intraoperative nerve monitoring, have significantly reduced the risk of permanent facial nerve damage to less than 2-5% in experienced hands.

Why Is Salivary Gland Surgery Performed?

There are several medical conditions that may require salivary gland surgery. The most common reasons include:

• Salivary gland tumors: Both benign tumors (such as pleomorphic adenoma and Warthin's tumor) and malignant tumors require surgical removal for diagnosis and treatment
• Chronic sialadenitis: Repeated infections of the salivary gland that do not respond to antibiotic treatment or other conservative measures
• Sialolithiasis: Salivary stones (calculi) that cause blockage, pain, and recurrent infections when they cannot be removed by minimally invasive techniques
• Diagnostic purposes: When imaging studies cannot determine the nature of a mass within the gland, surgery may be needed to obtain tissue for pathological examination
• Sjogren's syndrome complications: In some cases, severe complications of this autoimmune condition may necessitate surgical intervention

The Anatomy of Salivary Glands

Understanding the anatomy of the salivary glands helps patients appreciate why surgery requires specialized expertise. The parotid gland is the largest salivary gland and wraps around the ramus (back part) of the mandible (jaw bone). Critically, the facial nerve enters the posterior part of the gland and branches within it, essentially dividing the gland into superficial and deep lobes. This intimate relationship between the gland and the facial nerve is what makes parotidectomy a technically demanding procedure.

The submandibular gland lies in the submandibular triangle of the neck, below the mandible. While the facial nerve does not pass through this gland, several important structures are nearby, including the marginal mandibular branch of the facial nerve, the lingual nerve, and the hypoglossal nerve. The surgeon must carefully identify and protect these structures during submandibular gland excision.

How Do I Prepare for Salivary Gland Surgery?

Preparation for salivary gland surgery includes stopping smoking and alcohol several weeks before the procedure, reviewing all medications with your doctor, fasting before surgery as directed, and arranging transportation home. You will receive specific pre-operative instructions from your surgical team.

Proper preparation for salivary gland surgery is essential for optimal outcomes and reduced risk of complications. Your surgical team will provide detailed instructions, but there are several general principles that apply to most patients undergoing this type of procedure. Taking the time to prepare properly can significantly improve your surgical experience and recovery.

Pre-operative assessment typically includes a thorough medical history, physical examination, and various tests. You may need blood tests, imaging studies (such as ultrasound, CT scan, or MRI), and sometimes a fine-needle aspiration biopsy to help plan the surgery. If you have any chronic medical conditions, such as diabetes, heart disease, or breathing problems, these should be optimally controlled before surgery.

Stop Smoking and Alcohol Consumption

One of the most important steps you can take to prepare for surgery is to stop smoking and drinking alcohol. Smoking impairs wound healing, increases the risk of infection, and can lead to respiratory complications after anesthesia. Ideally, you should stop smoking at least 4-6 weeks before surgery and continue to abstain for several weeks afterward. If you need help quitting, speak with your healthcare provider about smoking cessation resources.

Alcohol consumption should also be reduced or eliminated in the weeks leading up to surgery. Alcohol can interfere with anesthesia, affect blood clotting, and impair immune function. Additionally, chronic alcohol use can lead to vitamin deficiencies that may affect wound healing. Most surgical teams recommend avoiding alcohol for at least two weeks before surgery.

Medication Review and Adjustments

It is crucial to discuss all medications you are taking with your surgeon and anesthesiologist before surgery. This includes prescription medications, over-the-counter drugs, herbal supplements, and vitamins. Some medications may need to be stopped or adjusted before surgery:

• Blood thinners: Medications such as warfarin, aspirin, clopidogrel, and newer anticoagulants may need to be stopped several days before surgery to reduce bleeding risk
• NSAIDs: Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen should be avoided for at least one week before surgery as they can increase bleeding
• Herbal supplements: Some supplements, including garlic, ginkgo biloba, ginseng, and vitamin E, can affect bleeding and should be stopped
• Diabetes medications: Your doctor will provide specific instructions about managing diabetes medications around the time of surgery

If you need pain relief in the week before surgery, paracetamol (acetaminophen) is generally safe to use. Always confirm with your surgical team before taking any medication.

Fasting Before Surgery

Because salivary gland surgery is performed under general anesthesia, you will need to fast before the procedure. This means not eating or drinking anything for a specified period before surgery, typically 6-8 hours for solid food and 2 hours for clear liquids. The exact fasting instructions will be provided by your anesthesia team. Following these instructions is extremely important for your safety, as having food or liquid in your stomach during anesthesia can lead to serious complications such as aspiration.

Preparing Children for Surgery

When a child needs salivary gland surgery, both the child and parents may have questions and concerns. It is important to prepare children in an age-appropriate manner, explaining what will happen in terms they can understand. Many hospitals offer pre-operative programs where children can visit the surgical area, meet staff, and become familiar with what to expect. Parents should discuss any concerns with the surgical team and ensure the child feels supported and reassured throughout the process.

How Is Salivary Gland Surgery Performed?

Salivary gland surgery is performed under general anesthesia. For parotidectomy, a 10 cm incision is made in front of the ear extending to the neck, taking 2-3 hours. For submandibular gland removal, a 5 cm incision is made on the side of the neck, taking about 1 hour. The facial nerve is carefully preserved during parotid surgery using nerve monitoring techniques.

The surgical approach depends on which salivary gland is being removed and the nature of the underlying condition. Both procedures are performed under general anesthesia, meaning you will be completely asleep during the operation. The surgical team will include the surgeon, an anesthesiologist, surgical nurses, and often a technician for intraoperative nerve monitoring.

Before the operation begins, you will be positioned appropriately on the operating table, and the surgical site will be cleaned and draped in a sterile manner. For parotid surgery, your head will be turned to expose the affected side, and special care is taken to position you in a way that allows for effective nerve monitoring throughout the procedure.

Parotidectomy: Surgery on the Parotid Gland

Parotidectomy is the surgical removal of part or all of the parotid gland. The incision for this procedure is made in front of the ear and extends downward along the natural skin crease, continuing into the upper neck. This incision pattern, sometimes called a modified Blair incision or facelift incision, is designed to minimize visible scarring while providing excellent surgical access. The total length of the incision is typically around 10 centimeters (about 4 inches).

The most critical aspect of parotid surgery is identifying and preserving the facial nerve. The surgeon carefully dissects through the tissues to locate the main trunk of the facial nerve, which typically exits from the base of the skull through a small opening called the stylomastoid foramen. Once the main trunk is identified, the surgeon traces its branches forward through the gland, carefully separating the gland tissue from the nerve. Intraoperative facial nerve monitoring uses small electrodes placed in the facial muscles to detect any nerve stimulation during surgery, providing real-time feedback to the surgeon.

Depending on the location and extent of the disease, the surgeon may perform a superficial parotidectomy (removing only the portion of the gland superficial to the facial nerve), a total parotidectomy (removing the entire gland while preserving the nerve), or in cases of malignancy, a radical parotidectomy (which may include removing portions of the nerve if involved by tumor). The entire procedure typically takes 2-3 hours, though this can vary depending on the complexity of the case.

Submandibular Gland Excision

Surgical removal of the submandibular gland is generally a less complex procedure than parotidectomy, primarily because the facial nerve does not pass through this gland. The surgeon makes an incision approximately 5 centimeters (about 2 inches) long in a natural skin crease on the side of the neck, below the jawbone.

After making the skin incision, the surgeon carefully dissects through the superficial tissues, identifying and protecting the marginal mandibular branch of the facial nerve, which runs along the lower border of the mandible. The submandibular gland is then mobilized and removed, with careful attention to preserving the lingual nerve and hypoglossal nerve, which are important for tongue sensation and movement respectively. The operation typically takes approximately one hour.

What Is the Recovery Like After Salivary Gland Surgery?

Most patients go home the day after surgery. Recovery involves 1-2 weeks off work, avoiding physical activity and heavy lifting for two weeks, and managing pain with over-the-counter medications. A drain may be placed temporarily to remove fluid. Stitches usually dissolve on their own, and a follow-up appointment is scheduled for a few months after surgery.

Recovery from salivary gland surgery is generally straightforward, though patients should expect some discomfort, swelling, and bruising in the first few days. Understanding what to expect during recovery can help you plan appropriately and recognize any signs that might require medical attention.

In the immediate post-operative period, you will be monitored in a recovery area until the effects of anesthesia wear off. You may feel groggy, nauseous, or have a sore throat from the breathing tube used during surgery. These effects are temporary and typically resolve within a few hours. Most patients spend one night in the hospital for observation before being discharged the following day.

Managing Pain and Discomfort

Pain after salivary gland surgery is usually mild to moderate and can be effectively managed with over-the-counter pain medications. Paracetamol (acetaminophen) is often recommended as the first-line treatment. After discharge, you can also use NSAIDs such as ibuprofen if needed, as the concern about bleeding is less once the initial healing has begun. Your surgeon may prescribe stronger pain medications for the first few days if needed.

Swelling around the surgical site is normal and typically peaks 2-3 days after surgery before gradually subsiding. Some bruising may also occur, particularly with parotid surgery, and this will fade over the following weeks. Applying cool compresses gently to the area during the first 24-48 hours can help reduce swelling.

Drain Care

A surgical drain is often placed at the end of the procedure to prevent fluid accumulation at the surgical site. The drain is a small, flexible silicone tube connected to a collection bulb that is typically pinned to your clothing. The drain removes excess blood and lymphatic fluid, reducing the risk of hematoma (blood collection) and seroma (fluid collection) formation.

The drain is usually removed before you leave the hospital. However, in some cases, you may need to go home with the drain in place for a few additional days. Your healthcare team will teach you how to care for the drain, including how to empty the collection bulb and measure the output. Once the drainage decreases to an acceptable level, you will return to have the drain removed, which is a quick and minimally uncomfortable procedure.

Returning to Normal Activities

Most patients are able to return to work within one to two weeks after surgery, depending on the nature of their employment. Those with sedentary office jobs may be able to return sooner, while those with physically demanding jobs may need more time. Your surgeon will provide specific guidance based on your individual situation.

During the first two weeks after surgery, you should avoid:

• Strenuous physical activity and exercise
• Heavy lifting (generally nothing heavier than 10 pounds)
• Bending over repeatedly or straining
• Swimming or soaking in bathtubs

You can eat and drink normally after surgery, though you may find that soft, cool foods are more comfortable in the first few days. Protect the surgical area from water when showering during the first three days, and avoid submerging the wound until it has fully healed.

Follow-Up Appointments

After surgery, stitches are typically either dissolvable (and will disappear on their own over 2-3 weeks) or need to be removed at a follow-up appointment, usually 7-10 days after surgery. Your surgeon will inform you which type of sutures were used.

A follow-up appointment is typically scheduled for several months after surgery to assess your healing and review the final pathology results if tissue was sent for analysis. If the surgery was performed for a tumor, the pathology results will determine whether any additional treatment, such as radiation therapy, is needed.

When Will I Receive the Results?

If the removed tissue requires laboratory analysis, results typically take 1-2 weeks. Your surgeon will contact you with the results and discuss any further treatment if needed. Some tissue samples may be stored in a biobank for future testing or research purposes.

In many cases, salivary gland surgery is performed to remove a tumor or suspicious mass that requires pathological examination. The removed tissue is sent to a laboratory where a pathologist examines it under a microscope to determine the exact diagnosis. This process, known as histopathological analysis, provides crucial information about whether the tumor is benign or malignant, and if malignant, what type of cancer it is and how aggressive it appears.

The time required to receive pathology results varies but is typically 1-2 weeks. Some complex cases may require additional specialized testing, which can extend this timeframe. Your surgeon will inform you when you can expect to receive the results and how they will be communicated to you, whether by phone, at a follow-up appointment, or through a patient portal.

If the pathology reveals a benign tumor, no further treatment is usually necessary beyond routine follow-up to monitor for recurrence. If a malignant tumor is identified, your case may be discussed at a multidisciplinary tumor board meeting, where specialists in surgery, oncology, radiation therapy, and pathology collaborate to determine the optimal treatment plan. Additional treatments such as radiation therapy may be recommended depending on the type, stage, and characteristics of the cancer.

Tissue Storage and Biobanks

When tissue samples are obtained during surgery, a portion may be stored in a biobank after the diagnostic analysis is complete. Biobanks are facilities that store biological samples for future medical use, including potential additional testing if new diagnostic methods become available, or for medical research purposes. Your consent for biobank storage is typically obtained before surgery, and you have the right to decline this storage without affecting your medical care.

What Are the Risks and Complications of Salivary Gland Surgery?

Complications after salivary gland surgery are uncommon but can include temporary facial nerve weakness (10-30% for parotid surgery, usually resolves), wound infection, bleeding, seroma, and Frey's syndrome (sweating while eating). Permanent facial nerve damage is rare (less than 2-5%) when surgery is performed by experienced surgeons.

Like all surgical procedures, salivary gland surgery carries some risks. However, serious complications are uncommon, and most patients recover without significant problems. Understanding the potential risks allows you to recognize symptoms that might require medical attention and to have informed discussions with your surgical team.

Your surgical team takes numerous precautions to minimize risks, including careful patient selection, appropriate pre-operative preparation, meticulous surgical technique, and close post-operative monitoring. The experience and expertise of the surgeon is one of the most important factors in determining outcomes, which is why salivary gland surgery is typically performed by specialists with specific training in this area.

Facial Nerve Injury

The most significant risk of parotid surgery is injury to the facial nerve, which can result in weakness or paralysis of the facial muscles on the affected side. Because the facial nerve courses through the parotid gland, it is vulnerable to injury during surgery. However, the use of careful surgical technique and intraoperative nerve monitoring has significantly reduced this risk.

Temporary facial weakness occurs in approximately 10-30% of parotidectomy patients and is usually due to nerve irritation rather than permanent damage. In most cases, function returns gradually over weeks to months as the nerve recovers. Permanent facial nerve weakness is much less common, occurring in less than 2-5% of cases when surgery is performed by experienced surgeons. The risk is higher in cases where the tumor is close to or involves the nerve, or in revision surgeries.

For submandibular gland surgery, the marginal mandibular branch of the facial nerve, which controls movement of the lower lip, is the structure most at risk. Injury to this nerve can cause asymmetry of the smile but is typically temporary when it occurs.

Infection

Wound infection can occur after any surgery. Signs of infection include increasing pain, redness, swelling, warmth around the incision, fever, and drainage of pus. If you experience these symptoms, contact your surgical team promptly. Infections are usually treatable with antibiotics, but occasionally may require additional intervention.

Bleeding and Hematoma

Some bleeding is normal after surgery, but significant bleeding can lead to hematoma formation, a collection of blood under the skin that causes swelling, pain, and potentially skin discoloration. A drain placed during surgery helps prevent this complication. If a significant hematoma develops, it may need to be surgically evacuated.

Seroma

A seroma is a collection of clear lymphatic fluid that can accumulate at the surgical site after the drain is removed. Small seromas may resolve on their own, while larger ones may need to be drained with a needle. This is a relatively common occurrence and is usually easily managed.

Frey's Syndrome

Frey's syndrome, also known as gustatory sweating, is a specific complication of parotid surgery that occurs in up to 30-50% of patients to some degree. It happens because the parasympathetic nerve fibers that normally stimulate saliva production regenerate incorrectly and instead connect to sweat glands in the skin overlying the surgical site. As a result, patients experience sweating and flushing of the cheek during eating or when thinking about food.

While Frey's syndrome can be bothersome, it is rarely severe. Treatment options include topical antiperspirants, botulinum toxin injections (which can effectively block the sweating response), or surgical interventions in severe cases.

How Can I Participate in My Care?

You have the right to be fully informed about your condition and treatment options, ask questions, seek second opinions, and participate in decisions about your care. Ensure you understand all information provided, and don't hesitate to ask for clarification or interpreter services if needed.

Active participation in your healthcare leads to better outcomes and higher satisfaction with care. You are an important member of your healthcare team, and your input, questions, and concerns should always be welcomed and addressed.

Before surgery, make sure you understand why the procedure is being recommended, what alternatives exist, what the expected benefits are, and what risks are involved. Don't hesitate to ask questions or request additional information if anything is unclear. It can be helpful to bring a family member or friend to appointments to help you remember the information discussed.

Understanding Your Treatment Options

For many salivary gland conditions, surgery may not be the only option. Depending on your specific diagnosis, alternatives might include:

• Watchful waiting with regular monitoring for small, stable tumors
• Minimally invasive procedures such as sialendoscopy for salivary stones
• Radiation therapy as primary treatment for certain conditions
• Medical management with antibiotics or anti-inflammatory medications

Discuss all available options with your healthcare team to make an informed decision that aligns with your values and preferences.

Your Rights as a Patient

You have the right to:

• Receive clear, understandable information about your condition and treatment
• Ask questions and have them answered fully
• Seek a second opinion from another specialist
• Refuse treatment or withdraw consent at any time
• Have your privacy and confidentiality protected
• Access interpreter services if you do not speak the local language fluently
• Request information about assistive devices if you have hearing or other impairments

Informed Consent

Before any surgical procedure, you will be asked to provide informed consent. This process involves your surgeon explaining the proposed procedure, its benefits and risks, and alternative options. You should have the opportunity to ask questions and have them answered before signing the consent form. Signing the consent form indicates that you understand the information provided and agree to proceed with the treatment. Remember that you can change your mind and withdraw consent at any time before the procedure.