From Clinic to Recovery · First Edition
Chapter 12 — Salivary Gland Surgery
Dr. Tamer Rushdy Elalfy · 14 min read
In this chapter
Salivary gland surgery brings one fear to the front of every consultation: “Will my face be paralysed?” The facial nerve runs through the parotid gland, and nerves to the lower lip, tongue, and tongue movement lie close to the submandibular gland. Most salivary lumps are benign, and most nerve weakness after surgery recovers, but patients need honest figures, clear eye-care instructions if weakness occurs, and an explanation of the less familiar after-effects, such as a numb earlobe and sweating on eating. This chapter covers parotid and submandibular surgery and gland-preserving treatment of salivary stones.
Learning objectives After reading this chapter you should be able to:
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Table 12.1. Salivary gland surgery at a glance.
| At a glance | |
|---|---|
| Main operations | Parotidectomy (partial, superficial, or total); submandibular gland excision; stone removal by endoscopy or through the mouth |
| Hospital stay | Usually one night, often with a small drain |
| Back to office work | About 1 to 2 weeks |
| Risks every patient should hear | Facial nerve weakness, numbness of the earlobe, Frey syndrome, saliva collection, and recurrence |
| The key counseling message | “Most lumps like this are benign. Weakness of the face after surgery is not unusual, but in most people it recovers within months.” |
STEP 1 Explaining the condition and the operation
12.1 Assessing a salivary gland lump
A salivary lump is assessed with ultrasound and a needle sample, with MRI when the lump is deep, fixed, or suspicious, or when the nerve may be involved [1]. Most parotid lumps are benign. A pleomorphic adenoma is usually removed, because it continues to grow and carries a small risk of becoming malignant over many years. A Warthin tumor, which is benign and common in older smokers, can be observed or removed according to the patient’s symptoms and preference [1]. Signs that suggest cancer, such as pain, rapid growth, facial weakness, or fixation, need multidisciplinary review. Figure 12.1 summarizes the pathway.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 12.1. Assessment and treatment of a salivary gland lump.
12.2 The counseling script
Script: explaining parotid surgery What the gland is. “The parotid is a salivary gland in front of the ear. It makes some of your saliva. You have one on each side, plus other salivary glands, so you will not have a dry mouth after this operation.” The nerve. “The nerve that moves your face runs right through the gland and divides into branches like a tree. The lump sits next to it. We find the nerve first and remove the lump while protecting every branch.” After the operation. “Bruising of the nerve can make part of your face weak for a while, especially the smile or the lower lip. In most people this recovers over weeks to months. Permanent weakness is uncommon.” Why remove a benign lump. “Your lump is not cancer, but this type keeps growing slowly, and over many years a small number can change. Removing it now, while it is small, is simpler and safer.” |
12.3 Submandibular gland and salivary stones
Stones and repeated infection are the most common reasons for submandibular surgery. Where possible, stones are removed with gland-preserving techniques, either through the mouth or with sialendoscopy, a fine telescope passed into the duct. When symptoms persist, or for a tumor, the gland is removed through a neck incision. Three nerves need to be discussed: the branch of the facial nerve to the lower lip, the lingual nerve supplying sensation to the tongue, and the hypoglossal nerve that moves the tongue.
12.4 Salivary gland cancer
Malignant salivary tumors are uncommon and varied, and are managed by a multidisciplinary head and neck team [1]. Surgery may include neck dissection, and radiotherapy is often added. If the facial nerve is directly involved by cancer, part of it may need to be removed, with immediate or later reconstruction and procedures to protect the eye and restore movement. These conversations need extra time and the support of a specialist nurse (Section 1.7).
STEP 2 Preparation, medicines, and recovery
12.5 Before the operation
- Facial nerve function. Examine and record facial movement before surgery, using the five movements in Figure 12.2.
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Medicines and fasting. Use the standard plans in Chapters 2, 18, 22, and 23.
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Smoking. Encourage stopping, particularly for patients with Warthin tumors.
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Shaving. Men may need to shave the area in front of the ear on the day; advise against shaving over the scar for some weeks afterward.
12.6 After the operation
A small drain is often left overnight. Facial movement is checked on waking and before discharge. If the eye does not close fully, the cornea must be protected with lubricating drops by day, ointment and a shield or tape at night, and review if the eye becomes red or painful. Numbness of the earlobe is expected after parotidectomy and usually improves over months. A soft swelling of saliva under the skin (sialocele) can occur in the first weeks and is usually managed with aspiration and pressure.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 12.2. Five facial movements used to check the facial nerve before and after surgery.
12.7 Recovery
Table 12.2. Typical recovery after salivary gland surgery.
| Activity | Usually from | Notes |
|---|---|---|
| Eating | The same day | Soft food at first; the first bite of a meal may cause a brief ache in the cheek |
| Showering | After the drain is removed | Keep the dressing dry for 1 to 2 days |
| Driving | About 1 week | When you can turn your head fully |
| Office work | About 1 to 2 weeks | |
| Exercise and swimming | About 2 weeks | When the wound has healed |
| Prayer and ablution | From the first day | Keep the wound dry for 1 to 2 days; use a waterproof dressing |
| Shaving over the scar | After a few weeks | The skin may be numb; take care not to cut it |
STEP 3 Questions patients ask
“Will my face be paralysed?”
Weakness of part of the face after parotid surgery happens in about 1 or 2 in every 10 people, and in most it recovers over weeks to months. Permanent weakness is uncommon, about 3 to 4 in 100 after surgery for benign lumps in published series [2, 3].
“If my face is weak, will it come back?”
Usually, yes. In one large study, 9 in 10 people with temporary weakness had normal movement again within 6 months [2].
“Is it cancer?”
Most parotid lumps are not cancer. The needle sample and scan help us tell, and the laboratory gives the final answer after the operation.
“If it is benign, why remove it?”
This type of lump slowly grows and, over many years, a small number change. It is simpler and safer to remove while small [1].
“Can I just keep an eye on it?”
For some benign lumps, such as a Warthin tumor, yes. We can check it with ultrasound if you prefer not to have surgery [1].
“Why is my earlobe numb?”
A small skin nerve to the earlobe is often stretched or divided. The numbness usually becomes smaller over months.
“Why do I sweat on my cheek when I eat?”
This is called Frey syndrome. Nerves that used to make saliva regrow into the skin’s sweat glands. It is often mild; if it bothers you, injections can control it.
“Will my mouth be dry?”
No. You have several other salivary glands, which make more than enough saliva.
“Can the stone be removed without removing the gland?”
Often, yes. Many stones can be removed through the mouth or with a small telescope, keeping the gland.
“Can I pray and do ablution?”
Yes, from the first day. Keep the wound dry for 1 to 2 days, using a waterproof dressing.
STEP 4 Risks, warning signs, and consent
12.8 Material risks
Risks are higher with larger resections, inflammation, malignancy, and revision surgery; revision surgery is the main risk factor for permanent weakness [2, 3]. Replace figures marked “unit data” with your own audit figures.
Table 12.3. Material risks of salivary gland surgery. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Numbness of the earlobe and the skin around the scar | Most patients after parotidectomy | “Your earlobe will feel numb. This usually improves over months.” |
| Common | Temporary facial weakness after parotidectomy | About 18 to 24 in 100 for benign disease [2, 3] | “About 1 or 2 people in 10 have some weakness, which usually recovers within months.” |
| Less common | Permanent facial weakness after parotidectomy | About 3 to 4 in 100 for benign disease [2, 3]; higher for cancer and revision | “About 3 or 4 people in 100 have some weakness that does not fully recover.” |
| Less common | Troublesome gustatory sweating (Frey syndrome) | About 4 in 100 severe [3]; milder forms more common | “Some people sweat on the cheek when eating. It can be treated.” |
| Less common | Saliva collection or leak; a hollow in front of the ear | [unit data] | “Saliva can collect under the skin and usually settles with drainage.” |
| Less common | Recurrence of a pleomorphic adenoma | [unit data] | “Rarely, this type of lump comes back years later.” |
| Less common | Lower lip weakness after submandibular gland excision | [unit data] | “Your lower lip may be weak for a while.” |
| Rare but serious | Tongue numbness or weakness after submandibular surgery; bleeding needing return to theater | [unit data] | “Rarely, the nerves to the tongue are affected.” |
12.9 Consent checklist
Before the patient signs ☐ Diagnosis and the reason for surgery explained, including observation for selected benign tumors and gland-preserving options for stones. ☐ Facial nerve function examined and recorded before surgery. ☐ Facial nerve risk explained in natural frequencies, with the usual recovery. ☐ Earlobe numbness, Frey syndrome, saliva collection, and scar explained. ☐ For submandibular surgery, lower lip, tongue sensation, and tongue movement discussed. ☐ For cancer: the possibility of nerve resection, neck dissection, and radiotherapy discussed by the team. ☐ Who will perform the operation, including trainee involvement under supervision. ☐ Eye-care plan explained in case of weakness; teach-back done; patient guide given. |
12.10 Warning signs
Table 12.4. Green, amber, and red warning signs after salivary gland surgery.
| Level | Signs after salivary gland surgery | What to do |
|---|---|---|
| Green | Numbness of the earlobe or cheek Mild weakness of the smile or lower lip that is improving A brief cheek ache with the first bite of a meal | Expected. Follow the guide. |
| Amber | A soft swelling under the scar that keeps growing Redness, warmth, or discharge from the wound An eye that does not close fully Temperature of 38 °C or more | Call the clinic the same day. Protect the eye with drops and a night shield. |
| Red | Rapid, tense swelling of the neck or face Difficulty breathing or swallowing A red, painful eye with blurred vision | Go to the emergency department now. Bring this guide. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the operation the patient had, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Your Salivary Gland Operation For you and your family. Keep it during your recovery. |
The operation you had
☐ Removal of part or all of the parotid gland (in front of the ear)
☐ Removal of the submandibular gland (under the jaw)
☐ Removal of a salivary stone, keeping the gland
1. Pain and pain medicines
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The area will be sore for a few days. Take your pain medicines regularly at first, as we told you.
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The first bite of a meal may cause a brief ache in the cheek. This usually settles.
2. Your wound
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Keep the dressing dry for 1 to 2 days. Use a waterproof dressing for ablution.
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Your earlobe and the skin near the scar may feel numb. This usually gets better over months.
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Men: do not shave over the scar for a few weeks. The skin may be numb, so take care.
3. Your face and your eye
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Check your face in a mirror: raise your eyebrows, close your eyes tightly, smile, puff your cheeks, and pull down your lower lip.
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Some weakness is common and usually recovers over weeks to months.
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If your eye does not close fully: use eye drops during the day, ointment and a shield or tape at night, and call us.
4. Eating and drinking
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Start with soft food and eat normally when ready.
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Some people later notice sweating on the cheek when eating. Tell us if it bothers you; it can be treated.
5. Getting back to normal
| Activity | Usually from |
|---|---|
| Showering | After the drain is removed |
| Prayer | From the first day |
| Driving | About 1 week, when you can turn your head fully |
| Office work or school | About 1 to 2 weeks |
| Exercise and swimming | About 2 weeks, when the wound has healed |
6. Follow-up and results
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We will tell you the laboratory result at your follow-up visit: ______________________
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If your face is weak, we will check it at each visit until it recovers.
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Numb earlobe or cheek; mild face weakness that is improving; brief cheek ache when eating | This is normal. Keep following this guide. |
| AMBER | A soft swelling that keeps growing; redness or discharge; an eye that does not close fully; temperature of 38 °C or more | Call us today. Protect your eye. |
| RED | Fast, tight swelling of the neck or face; difficulty breathing or swallowing; a red, painful eye with blurred vision | Go to the emergency department now. Take this guide with you. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Sood S, McGurk M, Vaz F. Management of salivary gland tumours: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130(S2):S142-S149.
2. Albosaily A, Aldrees T, Doubi A, et al. Factors associated with facial weakness following surgery for benign parotid disease: a retrospective multicenter study. Ann Saudi Med. 2020;40(5):408. doi:10.5144/0256-4947.2020.408
3. Guntinas-Lichius O, Gabriel B, Klussmann JP. Risk of facial palsy and severe Frey’s syndrome after conservative parotidectomy for benign disease: analysis of 610 operations. Acta Otolaryngol. 2006;126(10):1104-1109.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.