Salivary Gland Removal — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Salivary gland removal (sialoadenectomy) is a surgical procedure to excise one of the major salivary glands: the parotid gland (the largest, located in front of and below the ear), the submandibular gland (beneath the lower jaw), or the sublingual gland (under the tongue). The parotid gland is the most frequently operated upon, and parotidectomy is one of the most complex head and neck procedures due to the facial nerve (cranial nerve VII) running through the substance of the gland, dividing it into superficial and deep lobes.

Three main types of parotidectomy are performed: superficial parotidectomy (removal of the superficial lobe only, containing 80% of the gland's tissue and the majority of tumours), total parotidectomy (superficial plus deep lobe, required for deep lobe tumours or malignancy), and partial/extracapsular dissection (minimal-access removal of small, superficially placed benign tumours). Submandibular gland excision is a simpler procedure performed through a neck incision and carries lower nerve-injury risk, though the marginal mandibular and lingual nerves require identification and protection.

The three pairs of major salivary glands collectively produce approximately 1–1.5 litres of saliva daily, essential for digestion, lubrication, and oral health. Removal of one gland is generally well tolerated as the remaining glands compensate adequately.

The most common indication for parotidectomy is benign parotid tumours, which comprise 80% of all salivary gland neoplasms. Pleomorphic adenoma (mixed tumour) — the most common benign parotid tumour — accounts for 60% of parotid neoplasms and requires complete surgical excision with a cuff of normal tissue to prevent recurrence. Enucleation alone (shelling out the tumour) carries recurrence rates of up to 20–45% from satellite nodules, whereas proper parotidectomy reduces recurrence to below 2%. Warthin tumour (cystadenolymphoma) is the second most common, affects older men bilaterally in 10% of cases, and has a very low malignant potential.

Malignant parotid tumours require total parotidectomy with clear margins and frequently neck dissection and post-operative radiotherapy. Types include mucoepidermoid carcinoma (most common), adenoid cystic carcinoma (known for perineural spread and late recurrence), and acinic cell carcinoma.

Submandibular gland excision is most often indicated for chronic obstructive sialadenitis due to sialolithiasis (salivary gland stones) — stones in Wharton's duct causing recurrent swelling, pain, and infection — when endoscopic removal (sialendoscopy) fails or is not feasible, and for submandibular gland tumours.

Parotidectomy is performed under general anaesthesia with neuromuscular monitoring of the facial nerve using needle electromyography (EMG) electrodes placed in the frontalis, orbicularis oculi, and orbicularis oris muscles. A facial nerve monitor provides continuous real-time feedback — critical for nerve preservation.

The classic Blair incision begins in the pre-auricular crease, curves around the inferior border of the earlobe, and extends into a skin crease in the neck. The skin flap is elevated in the sub-platysmal plane to expose the outer surface of the parotid gland.

Facial nerve identification: the main trunk of the facial nerve is identified at the stylomastoid foramen using one of three landmarks — the tragal pointer (1 cm medial and deep), the posterior belly of the digastric muscle, or the tympanomastoid suture. Once the main trunk is identified, it is traced forward as it divides into upper temporofacial and lower cervicofacial divisions, then into five terminal branches (temporal, zygomatic, buccal, marginal mandibular, cervical), each of which is carefully dissected and preserved as the superficial lobe is removed from the nerve surface.

For deep lobe tumours, the nerve is carefully reflected and the deep lobe removed from beneath it. Haemostasis is achieved, a drain inserted, and the wound closed in layers. Submandibular gland excision: a 4 cm transverse neck incision 2 finger-breadths below the mandible; the marginal mandibular nerve (above), lingual nerve, and hypoglossal nerve (below) are identified and protected; the gland and duct are removed. Operative time: 1–3 hours for parotidectomy, 45–90 minutes for submandibular excision.

Cure rates for benign parotid tumours exceed 95–98% with complete superficial or total parotidectomy with adequate surgical margins. Recurrence of pleomorphic adenoma following proper parotidectomy is below 2% at 10 years, compared to 20–45% following simple enucleation, making definitive surgical excision clearly advantageous.

For malignant salivary gland tumours, total parotidectomy combined with post-operative radiotherapy provides 5-year survival rates of 80–90% for low-grade tumours (mucoepidermoid grade 1–2, acinic cell carcinoma) and 40–60% for high-grade or advanced-stage disease. Chronic submandibular sialadenitis from calculi is definitively resolved by gland excision, eliminating recurrent painful swelling, infection, and the need for repeated hospital attendances.

Modern facial nerve monitoring and microsurgical technique have dramatically reduced permanent facial nerve palsy to below 2% in experienced hands, making the procedure considerably safer than in earlier decades. Cosmetically, the pre-auricular and cervical incision heals to a largely imperceptible scar in most patients, particularly when placed in natural skin creases.

Facial nerve injury is the most feared complication of parotidectomy. Temporary facial nerve weakness (neuropraxia) — resulting from nerve stretching or thermal injury during dissection — occurs in 10–20% of patients undergoing superficial parotidectomy but resolves completely within 3–6 months in the majority. Permanent facial nerve palsy affecting one or more branches occurs in less than 2% of cases when performed by experienced head and neck surgeons with nerve monitoring. Marginal mandibular branch injury (causing drooping of the lower lip) and buccal branch injury (causing cheek weakness) are the most functionally significant.

Frey syndrome (auriculotemporal nerve syndrome) — sweating and flushing of the cheek skin during eating — develops in 15–30% of patients months to years after parotidectomy due to aberrant reinnervation of skin sweat glands by parasympathetic fibres of the auriculotemporal nerve. It is often mild and tolerated without treatment, though botulinum toxin injection is effective when symptomatic.

Other complications include haematoma (2–3%), wound infection (1–2%), seroma, salivary fistula or sialocele (subcutaneous saliva pooling, managed with aspiration and pressure dressings), and numbness of the earlobe and pre-auricular skin from greater auricular nerve sacrifice.

Patients typically remain in hospital for 1–2 days post-operatively. The surgical drain is removed at 24–48 hours once drainage is minimal. A soft diet avoiding tough or chewy foods reduces salivary flow and surgical site stress; normal diet resumes within 2 weeks. Facial swelling and stiffness of the jaw are expected for 2–3 weeks.

Wound sutures are removed at 7–10 days, or absorbable sutures dissolve without removal. The scar matures and fades over 6–12 months; scar massage with silicone gel can be commenced from 6 weeks. Most patients return to office-based work within 2 weeks and resume full activity by 4–6 weeks.

Facial nerve recovery, when weakness occurs, is monitored closely. Incomplete eyelid closure (lagophthalmos) from upper facial branch injury requires lubricating eye drops, tape at night, and occasionally a moisture chamber to prevent corneal exposure injury. Physiotherapy (facial muscle exercises) is recommended if facial weakness persists beyond 6 weeks. Follow-up at 6 weeks, 3 months, and 12 months, with imaging surveillance for malignant cases per oncological protocol.