Salivary gland problems

The commonest salivary gland operations and their expected postoperative progress are outlined below.

Excision of mucocele

The mucous extravasation cyst is one of the commonest salivary gland problems and its excision is a minor operation under local anaesthesia.

Short term: pain and discomfort are minimal as is swelling, although the stitches used may irritate and feel tight.

Medium term: the stitches often unravel within 7 to 10 days before they completely dissolve, mainly because of the location of the wound. This does not usually cause a problem.

Long term: slight lumpiness of the scar and minor altered sensation may be noticed over the next 6 months, but the main problem is recurrence of the cyst. This is more likely if surrounding minor salivary glands are involved without being removed in the original operation.

Excision of ranula

The most usual approach is intraoral although occasionally a neck skin crease has to be used which would involve skin sutures (see below).

Short term: simple marsupialisation with spatulation of duct leaves minor discomfort only.

Medium term: recurrence is quite common and excision of the sublingual gland is recommended.

Excision of sublingual gland

Short term: swallowing can be uncomfortable for 5 to 7 days and analgesia and altered diet may be needed.

Medium term: it may take 3 weeks for the dissolving sutures to completely disappear because there is little direct trauma to them to cause them to unravel. Altered sensation to the floor of the mouth or tongue tip may be noticeable.

Long term: this is usually the definitive solution to ranula (see above) and recurrence is much less likely; the trade off is the risk of altered sensation.

Removal of submandibular duct calculus

This is often a very straightforward procedure when the calculus is lying superficially. There may be no need for sutures.

Short term: minor discomfort in the area of surgery.

Medium term: if stitches are used, they can take several weeks to dissolve as there is little direct friction to erode or unravel them.

Long term: it is possible for the draining submandibular duct to become scarred and narrowed causing backflow problems with the submandibular gland. Although this is quite rare, it may require the removal of the affected gland.

Excision of submandibular gland

This is done by way of a skin crease in the upper neck.

Short term: a drain is often used and removed the next day. Skin stitches which are removed 7 days later are common, although a dissolving subcutaneous stitch can also be used. This is often a matter of personal preference, so ask your surgeon. A feeling of stiffness and tightness around the suture line more than pain is common. The most concerning short-term issue is sudden bleeding, which is why a drain and an overnight stay in hospital is still the most usual approach.

Medium term: The scar will be red and a little tender for 10 days to 2 weeks, altered sensation to the tongue and floor of mouth may be noticed. A weakness of the lower lip on the side of the surgery may be present although this rarely lasts more than a few weeks.

Long term: the scar often fades quickly and is helped aesthetically by being in a natural skin crease. Altered sensation to the tongue or weakness of the lip very rarely lasts months, or extremely rarely can be permanent.

Parotidectomy - highly selective

All parotidectomy incisions use a variation on the cervico-mastoid-facial incision; the extent of visible scarring is largely a matter of whether a neck skin crease or a post-auricular ‘facelift’ approach is used.

In highly selective parotidectomy where only the branch of the facial nerve above and below the tumour is identified or ‘extracapsular dissection’ where no formal identification of the nerve is made, a similar minimal amount of glandular surgery and nerve dissection takes place.

Short term: visible skin sutures (rarely subcutaneous resorbable sutures or even glue) are used and removed at 6 to 7 days. Altered sensation of the earlobe is sometimes noticed. A small drain may be used and removed the next day.

Medium term: once the sutures (if used) are removed, a feeling of tightness gradually resolves and the sensation to the earlobe largely returns, although it may itch. There is usually no change in function to the muscle of facial expression.

Long term: there is a very low risk of recurrence when these techniques are used appropriately and the minimal surgical approach means little in the way of long-term issues.

Superficial parotidectomy

The classical version of this operation identifies the main facial nerve trunk and all the five branches of the facial nerve and the posterior branch of the greater auricular nerve is divided. Basically, the more nerve dissection is done, the greater the chance of a longer postoperative recovery of that nerve. Most benign parotid tumours are removed using a less invasive version of the classical operation.

Short term: more extensive dissection of the facial nerve means a likelihood of some mild weakness of the muscles that make expression in the face, most obviously the closure of the eye, raising the forehead or lip. The earlobe is usually numb. Skin sutures are present as above and a drain and an overnight stay in hospital is normal.

Medium term: over a period of a few weeks the muscles that move the face gradually return to their previous function, although the earlobe often remains numb. Any sinking in of the area where the lump previously was quickly fills in.

Long term: the more dissection takes place, the more the risk of a condition known as gustatory sweating – where the skin over the area of surgery sweats when appetite is stimulated. The area of numbness around the earlobe may be noticed less but if tested for will still persist.

Total conservative parotidectomy

The main difference between this and superficial parotidectomy is that it is generally used for chronic unremitting sialadenitis. The risks of facial nerve damage are thought to be higher in chronically scarred parotid gland dissection, but because there is no risk of tumour seeding the technique of ‘morselisation’ is appropriate, which greatly changes the postoperative process.

Short term: the skin incision is the same as above, although a neck skin crease approach is much more common because of the need to fully trace out the course of the facial nerve. It is almost certain there will be weakness of the muscles of facial expression and this should be planned for with regard to postoperative physiotherapy and other treatments such as TENS (transcutaneous electrical nerve stimulation).

Medium term: this is quite demanding as it can take as short a time as 6 weeks or as long as 18 months to get pre-treatment levels of facial movement back. This varies between individuals dramatically and is also dependent on the amount of nerve dissection and handling. Patience, preparation and input from the allied health-professionals team with use of a nerve stimulation device has proven useful.

Long term: for the vast majority of people undergoing this procedure the long-term results are return of full facial nerve function, a numb earlobe but relief from the symptoms of the chronically infected parotid gland.

Radical parotidectomy

This operation implies the resection of the facial nerve for malignant disease. Most surgeons undertaking parotidectomy for malignant disease will attempt to preserve a functioning facial nerve, so it is likely that anyone undergoing this operation has already lost facial nerve function. The operation is almost certainly going to be combined with neck dissection and radiotherapy; it has little resemblance to the other parotidectomy operations or postoperative pathways described above.

Short, medium and long term: the timelines have more in common with those for the treatment of mouth cancer and generally those for salivary gland malignancies.