CLINICAL REVIEW
Eisele, MD, Section Editor
Complications after surgery for benign parotid gland neoplasms:
A prospective cohort study
Johanna Ruohoalho, MD,1* Antti A. M€akitie, MD, PhD,1,2 Katri Aro, MD, PhD,1 Timo Atula, MD, PhD,1 Aaro Haapaniemi, MD,1 Harri Keski–S€antti, MD, PhD,1
Annika Takala, MD, PhD,3 Leif J. B€ack, MD, PhD1
1
Department of Otorhinolaryngology – Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, 2Division of Ear, Nose, and Throat
Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Karolinska sjukhuset, Stockholm, Sweden, 3Division of Anaesthesiology, Department
of Anaesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Accepted 22 March 2016
Published online 00 Month 2016 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24496
ABSTRACT: Background. Prospective studies on procedure-specific
incidences of complications after benign parotid surgery are lacking.
Predictive factors for postoperative facial dysfunction remain
controversial.
Methods. We conducted a prospective study on 132 patients undergoing
parotid surgery for benign parotid neoplasms. We analyzed complication
rates and assessed risk factors of postoperative transient facial palsy.
Results. Facial palsy rate was 40.2% on the first postoperative day,
28.3% at 2 weeks, 3.9% at 6 months, and 1.6% at 12 months. Immedi-
ate postoperative palsy rates in subgroups of partial superficial paroti-
dectomy, superficial parotidectomy, extended parotidectomy, and ECD
INTRODUCTION
Parotid gland neoplasms account for approximately 2% of
head and neck tumors and three fourths of them are
benign.1 Despite the recent developments in operative
techniques, surgery for benign parotid tumors is associ-
ated with a relatively high rate of sequelae, most fre-
quently temporary facial nerve palsy.2–4 The morbidity
after parotid surgery for benign tumors is addressed in a
number of publications,2–13 but only a few of these stud-
ies are prospective and they are limited with a small num-
ber of patients.11–13
In retrospective studies on benign parotid surgery,
reported rates for postoperative temporary facial palsy
varies between 18% and 65%2–10,14 and for permanent
weakness between 0 and 19.6%.2,4,6–10,14,15 This variation
can be partly explained by different operation techniques
and the timing of evaluation in relation to surgery. How-
ever, the most significant limitation of retrospective materi-
als is the lack of standardized methods for the assessment
of facial palsy. In addition, the contributory factors associ-
ated with post-parotidectomy facial palsy vary considerably
from study to study and remain unclear.
*Corresponding author: J. Ruohoalho, Department of Otorhinolaryngology –
Head and Neck Surgery, Helsinki University Hospital, P.O. Box 220, FI – 00029
HUCH, Helsinki, Finland. E-mail: johanna.ruohoalho@hus.fi
David W.
were 41.5%, 43.8%, 53.8%, and 6.3%, respectively. Age, duration of
surgery, and use of ultrasound knife were identified as risk factors for
transient facial palsy.
Conclusion. Depending on the operation type, up to half of the patients
experience facial palsy after benign parotid surgery. Higher age and lon-
ger duration of operation increase the risk. The role of operative instru-
mentation requires further studies. VC 2016 Wiley Periodicals, Inc. Head
Neck 00: 000–000, 2016
KEY WORDS: parotidectomy, postoperative complication, benign
tumor, facial palsy, risk factors
Other commonly reported complications of benign
parotid surgery are Frey’s syndrome, salivary fistula,
postoperative infection, hematoma/hemorrhagia, and sialo-
cele.2–4,7,14 The definitions for these complications are
rarely described, and incidences have wide variance.
Especially reporting Frey’s syndrome is highly susceptible
to biases, because it occurs with a delay and has variable
severity.
The purpose of this study was to analyze the incidence
of and factors associated with postoperative facial nerve
dysfunction in parotid surgery for benign neoplasms in a
prospective study setting with strictly standardized evalu-
ation methods. In addition, we report the incidences of
other defined complications related to parotid surgery.
MATERIALS AND METHODS
Patients who underwent parotid surgery at the Depart-
ment of Otorhinolaryngology – Head and Neck Surgery,
Helsinki University Hospital, Helsinki, Finland, between
September 2011 and November 2012 were prospectively
enrolled. Exclusion criteria were age <18 years, suspicion
of malignancy or facial schwannoma, a tumor extending
into the parapharyngeal space, and previous parotid sur-
gery exposing the facial nerve. The study was approved
by the Ethics Committee at the Helsinki University Hos-
pital (DNRO 89/13/03/02C/2011) and is registered at
ClinicalTrials.gov with the identifier NCT02049372. Each
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RUOHOALHO ET AL.

TABLE 1. Definitions of complications.

Complications Definitions

Facial palsy
Temporary Any postoperative facial nerve dysfunction with full recovery within 12 mo of the operation.
Permanent Any facial nerve dysfunction persisting at 12 mo after the operation.
Sialocele/seroma Persistent fluid collection at surgical site lasting over 2 wk from surgery and needing treatment.
Salivary fistula Salivary flow from surgical site lasting >7 d.
Infection Purulent drainage from the wound and/or microbe isolated in an aseptically obtained culture of fluid or tissue
from the surgical site and/or surgeon’s diagnosis of infection based on signs or symptoms of infection (fever,
pain or tenderness, localized swelling, redness, or heat) within 30 d of surgery.
Hemorrhage/hematoma
Primary Bleeding/collection of blood at surgical site within 24 h of operation.
Secondary Bleeding/collection of blood at surgical site after 24 h of operation.
Frey’s syndrome Gustatory sweating occurring within 12 mo of operation and leading to outpatient contact.

patient gave written informed consent to participate in the
study.
A wide range of demographic and clinical data were
collected at the time of surgery, including age, sex,
comorbidities (Charlson comorbidity index [CCI]), body
mass index (BMI), American Society of Anesthesiologists
(ASA) Physical Status Classification, patients’ functional
status (Karnofsky score), cytological and histological
reports, extent of operation, surgical technique, surgeon’s
experience, and duration of surgery. Extracapsular dissec-
tion (ECD) was defined as a resection of the tumor
through parotid tissue without identifying the facial nerve
trunk. Partial superficial parotidectomy (PSP) included
any procedure in which the facial nerve trunk was
exposed but only a part of the superficial lobe was
removed. Superficial parotidectomy (SP) was defined as a
total removal of the lateral lobe of the parotid gland. As
previously proposed by Upton et al,16 operation was con-
sidered as extended parotidectomy (EP), if the patient
underwent total or subtotal parotidectomy, or if any por-
tion of the deep lobe was removed. Accordingly, the
tumors involving the deep lobe are the ones in the EP
group, and the tumor locations are not separately
reported.
Altogether, 11 surgeons performed 1 to 25 operations
each. Five of them were experienced head and neck sur-
geons with at least 10 years of experience on parotid sur-
gery (each performing 12–25 of the procedures included
in the study), 4 were specialized ear, nose, and throat
(ENT) doctors with a few years of experience on parotid
surgery (1–16 operations each), and 2 were residents (1–2
operations each) operating under supervision of experi-
enced surgeons. Electromyographic monitoring (NIM-
Response; Medtronic, Minneapolis, MN) was used in all
operations. Surgical techniques used were cold steel with
bipolar dissection, cold steel combined with monopolar
and bipolar dissection, and cold steel with ultrasound
knife.
We prospectively recorded the incidents of postopera-
tive complications (facial palsy, Frey’s syndrome, infec-
tions, hemorrhage [primary <24 hours postoperatively
and secondary >24 hours], salivary fistula, and sialocele)
occurring within 12 months of the operation. On the first
postoperative day, 2 physicians, at least one of them
being an experienced head and neck surgeon, separately
performed clinical examination of all facial nerve
branches. Even a minimal impairment in facial function
was considered as palsy. If the facial nerve was postoper-
atively affected, we evaluated the patient again after 2
weeks, and, if necessary, after 6 months and 12 months.
Any facial weakness from which the patient fully recov-
ered during the follow-up period was defined as tempo-
rary. Permanent facial palsy was defined as facial
weakness remaining after 12 months. Definitions of the
complications are presented in Table 1.
Before analyzing the data, all patient records were
reviewed and any missing data in the prospectively col-
lected background information were completed and the
accuracy of complication data was verified.
Statistical analyses were performed with SPSS software
version 19.0 (IBM, Armonk, NY). Normality distribution
of continuous variables was determined visually by using
histograms and by using Skewness and Kurtosis meas-
ures. Comparisons between the operation groups were
performed with the Kruskal–Wallis test and 1-way analy-
sis of variance. Risk factors of transient facial palsy were
evaluated with logistic regression analysis. As several fac-
tors were significant based on univariate analysis, these
were included in the multivariable logistic regression
model to evaluate the independent risk factors of transient
facial palsy. Odds ratios (ORs) with 95% confidence
intervals (CIs) of relevant risk factors were reported.
Two-sided p values < .05 were considered significant.
RESULTS
From September 2011 to November 2012, a total of
178 patients underwent parotid surgery at our department.
The following patients who had parotid surgery during
the study period were not included: age <18 years (n 5
4); malignancy (n 5 25); facial schwannoma (n 5 1);
biopsy only (n 5 4); facial nerve exposed in previous sur-
gery (n 5 3); preoperative facial palsy (n 5 1); and
patients with tumor extending into the parapharyngeal
space (n 5 4). Thus, altogether 136 patients were
enrolled. In 4 initially recruited cases, preoperative fine-
needle aspiration was suggestive of benign disease, but
histological diagnosis was malignant, so they were subse-
quently excluded. The final study group comprised 132
patients. In 5 patients, the assessment of possible facial
palsy on the first postoperative day was not performed in

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 COMPLICATIONS OF BENIGN PAROTID SURGERY

TABLE 2. Patient characteristics and surgery-related factors (no. of patients’ age and duration of surgery. The mean age was
patients 5 132). 54.3 years (SD 5 15.4; range, 20–86 years), patients
being younger in the ECD group (PSP 5 54.9; SD 5
Characteristics No. of patients (%) 14.5; range, 20–85; SP 5 54.5; SD 5 14.2; range, 25–77;
Age, y, mean, (SD, range) 54.3 (6 15.4; 20–86)
EP 5 58.6; SD 5 16.2; range, 20–86; and ECD 5 45.3;
60 81 (61.4) SD 5 14.8; range, 25–71; p < .05). The median duration
>60 51 (38.6) of surgery was 2 hours and 2 minutes (range, 0:32–7:17).
Sex In the subgroups of PSP, SP, EP, and ECD, median dura-
Male 59 (44.7) tions of surgery were 1:55 (range, 1:05–3:00), 2:17
Female 73 (55.3) (range, 1:25–7:17), 2:29 (range, 1:19–4:32), and 1:05
BMI, median (range) 26.8 (18.4–48.6) (range, 0:32–2:25), respectively (p < .001). The most
25 39 (29.5) common final pathological diagnosis was pleomorphic
>25 74 (56.1) adenoma (47.7%; n 5 63), followed by Warthin tumor
Side
Right 75 (56.8)
(36.4%; n 5 48), nonneoplastic cyst (7.6%; n 5 10), and
Left 57 (43.2) oxyphilic adenoma (3.8%; n 5 5). The other diagnoses
CCI included 2 fibromatous lesions, 1 lipoma, 1 oncocytic
0 96 (72.7) metaplasia, 1 intraparotid lymph node, and 1 basal cell
1 19 (14.4) adenoma.
2 10 (7.6) Table 3 shows the incidence of facial palsy by surgical
3 7 (5.3) groups in terms of timing in relation to surgery. The over-
ASA all rate of postoperative facial palsy on the day after sur-
1 48 (36.4) gery was 40.2% (n 5 51 of 127 patients). Only the
2 49 (37.1)
3–4 35 (26.5)
marginal branch was affected in 23 patients (45.1%) and
Karnofsky score* palsy of several branches was seen in 25 patients
Normal (100%) 98 (77.2) (49.0%). Only 3 patients (5.9%) had functional deficiency
Decreased (90%) 29 (22.8) restricted to a single branch other than the mandibular
Extent of operation branch. After 2 weeks, facial nerve function was fully
ECD 17 (12.9) recovered in 29.4% of the affected patients. At 6 months,
PSP 57 (43.2) the recovery rate was 90.2%. Permanent facial palsy
SP 32 (24.2) occurred in 2 patients (1.6%). In 1 of the patients, 2
EP 26 (19.7) minor buccal branches were attached to the tumor and
Surgical technique
sacrificed. No nerve adherence or visible damage of the
Cold steel 1 bipolar 69 (52.3)
Cold steel 1 monopolar 1 bipolar 38 (28.8) facial nerve was noted with the other patient. Both the
Cold steel 1 ultrasound knife 25 (18.9) patients were in the PSP group and the remaining symp-
Experience of the surgeon toms at 12 months were mild.
Highly experienced 91 (68.9) The second most common complication was postopera-
ENT specialist 38 (28.8) tive infection (12.8%) followed by salivary fistula (9.8%).
Resident supervised by an 3 (2.3) Other complications are outlined in Table 4.
experienced surgeon For analyses of the risk factors of transient facial palsy,
Duration of surgery (median, range) 2:02 (0:32–7:17) the duration of operation was transformed into categorical
Histology
variable dividing the patients into 3 equal groups and the
Pleomorphic adenoma 63 (47.7)
Warthin tumor 48 (36.4) CCI and the surgeon’s experience level were evaluated as
Nonneoplastic cyst 10 (7.6) dichotomous variables. Results of univariate logistic
Oxyphilic adenoma 5 (3.8) regression analysis are presented in Table 5. Patient’s age
Other 6 (4.5) >60 years, impaired functional status (decreased Karnof-
Histological size of the tumor 18 (3–55) sky score), and higher comorbidity (elevated CCI) had
(mm; median, range)† statistically significant association on the development of
<20 mm 63 (53.8) transient facial palsy. Immediate postoperative palsy risk
20 mm 54 (46.2) was significantly lower after ECD than after more exten-
sive operations (PSP 5 41.5%; SP 5 43.8%; EP 5
Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; ASA, American Soci- 53.8%; and ECD 5 6.3%; p < .05). At 2 weeks, patients
ety of Anesthesiologists Physical Status Classification; PSP, partial superficial parotidectomy;
SP, superficial parotidectomy; EP, extended parotidectomy; ENT, ear, nose, and throat; ECD, in the EP group had significantly more palsies than
extracapsular dissection. patients in the other groups (PSP 5 26.4%; SP 5 28.1%;
* Value missing in 5 patients.
†
Value missing in 15 patients.
EP 5 50.0%, and ECD 5 0%; p < .05). The risk of
palsy increased significantly both on postoperative day 1
the designed manner, and they were excluded from the and postoperative day 14 as the operating time was pro-
analysis of facial palsy. longed. Operations performed with an ultrasound knife
Table 2 summarizes patient characteristics and surgery- had an increased risk of transient facial palsy compared
related factors according to operation type. PSP was per- with the other techniques (75.0% vs 32.0% [p < .001] on
formed in 57 cases (43.2%), SP in 32 cases (24.2%), and postoperative day 1, and 54.2% vs 22.3% [p < .01] on
EP in 26 cases (19.7%). Seventeen patients (12.9%) postoperative day 14). The palsy rate was lower with
underwent ECD. The groups were different regarding the highly experienced surgeons than with less experienced

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RUOHOALHO ET AL.

TABLE 3. Incidence of facial palsy according to operation type and timing in relation to surgery.

No. of patients with palsy (%)

All ECD PSP SP EP
Time of evaluation (n 5 127) (n 5 16) (n 5 53) (n 5 32) (n 5 26)

Postoperative day 1 51 (40.2) 1 (6.3) 22 (41.5) 14 (43.8) 14 (53.8)

Postoperative day 14 36 (28.3) 0 14 (26.4) 9 (28.1) 13 (50.0)
6 mo 5 (3.9) 0 3 (5.7) 2 (6.3) 0
12 mo 2 (1.6) 0 2 (3.8) 0 0

Abbreviations: PSP, partial superficial parotidectomy; SP, superficial parotidectomy; EP, extended parotidectomy; ECD, extracapsular dissection.

ones (34.9% vs 51.2% [p 5 .08] on postoperative day 1,
and 23.3% vs 39.0% [p 5 .07] on postoperative day 14),
but the difference did not reach significance.
In multivariable logistic regression analysis, assessing
the risk factors of transient facial palsy, advanced age,
longer duration of surgery, and use of an ultrasound knife
remained as independent risk factors both in the immedi-
ate postoperative period and on postoperative day 14
(Table 6). Extent of operation did not reach significance
on postoperative day 1 multivariable analysis, and it was
excluded from postoperative day 14 analysis because
none of the patients in the ECD group had facial palsy at
that point. CCI and Karnofsky score were left out from
multivariable logistic regression models because of strong
multicollinearity with age. As only 5 patients suffered
from facial palsy at 6 months after operation, we were
unable to perform logistic regression analyses of risk fac-
tors at that point.
DISCUSSION
We conducted a prospective study of 132 patients
undergoing benign parotid surgery at our department. Our
primary objective was to analyze the incidence of and
contributing factors for temporary and permanent postop-
erative facial palsy with strictly standardized methods in
facial nerve function evaluation. In addition, other com-
plications occurring within 12 months of operation were
recorded. In the present series, any type of facial nerve
dysfunction was observed in 40.2% of patients on the first
postoperative day and permanent facial palsy persisting
after 12 months in 1.6% of patients.
In prospective studies, the incidence of reported tempo-
rary facial nerve dysfunction after benign parotid surgery
varies between 15% and 66%.11,13,17,18 A meta-analysis
performed by Witt19 showed that the incidence of tempo-
rary facial palsy in benign parotid surgery was, on aver-
age, 60% for total parotidectomy, 26% for SP, 18% for
PSP, and 11% for ECD. Considering the large proportion
of patients with PSP and ECD in our material, our overall
rate of temporal facial palsy (40.2%) was slightly higher
than expected. This can be partly explained by the pro-
spective setting, a standardized assessment method, and
the strict criteria concerning the evaluation of facial dys-
function. In many studies, the time of first postoperative
evaluation of facial nerve function has not been standar-
dized, or the first follow-up has been at 1 week, so the
present observed high rate is likely to derive also from
the early evaluation of facial dynamics (postoperative day
1). Our palsy rate at 2 weeks was 28%, which is rather
congruent with previous literature. Our permanent facial
palsy rate of 1.6% was low and comparable to the range
of 0% to 17% reported in a recent review on benign
parotid surgery.20
The methodology of facial nerve function assessment
varies considerably in different studies. Especially in retro-
spective materials, the evaluation methods are rarely
described, and the timing of the evaluation is not standar-
dized. Furthermore, the site of nerve injury is seldom
specified. In some studies, the time span of conducted pro-
cedures is decades. As the parotidectomy techniques have
advanced from total and superficial parotidectomies to
more conservative approaches, and the electromyographic
monitoring during surgery has become a standard, the pop-
ulations and complication rates may not be comparable.

TABLE 4. Complications other than facial palsy according to the type of surgery.

No. of patients with complications (%)

All ECD PSP SP EP
Complication (n 5 132) (n 5 17) (n 5 57) (n 5 32) (n 5 26)

Infection 17 (12.9) 3 (17.6) 9 (15.8) 2 (6.3) 3 (11.5)

Hemorrhage
Primary 7 (5.3) 1 (5.9) 4 (7.0) 1 (3.1) 1 (3.8)
Secondary 2 (1.5) 1 (5.9) 0 1 (3.1) 0
Frey’s syndrome 4 (3.0) 0 1 (1.8) 1 (3.1) 2 (7.7)
Salivary fistula 13 (9.8) 0 7 (12.3) 4 (12.5) 2 (7.7)
Sialocele/seroma 8 (6.1) 1 (5.9) 5 (8.8) 0 2 (7.7)

Abbreviations: PSP, partial superficial parotidectomy; SP, superficial parotidectomy; EP, extended parotidectomy; ECD, extracapsular dissection.

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 COMPLICATIONS OF BENIGN PAROTID SURGERY

TABLE 5. Univariate logistic regression analysis of factors associated with the development of postoperative facial palsy on postoperative day 1 and
postoperative day 14 (no. of patients 5 127).

Postoperative day 1 Postoperative day 14

Parameter Palsy % p value OR (95% CI) Palsy % p value OR (95% CI)

Age, y
60 32.5 Ref. 1 22.1 Ref. 1
>60 52.0 .03 2.25 (1.08–4.68) 38.0 .05 2.16 (1.00–4.74)
Sex
Male 32.1 Ref. 1 21.4 Ref. 1
Female 46.5 .10 1.83 (0.88–3.80) 33.8 .13 1.87 (0.84–4.19)
BMI
25 40.5 Ref. 1 27.0 Ref. 1
>25 41.7 .91 1.05 (0.47–2.35) 27.8 .93 1.04 (0.43–2.53)
CCI
0 34.8 Ref. 1 26.1 Ref. 1
1 52.8 .03 2.38 (1.07–5.29) 35.3 .31 1.55 (0.67–3.59)
ASA
1 38.3 Ref. 1 25.5 Ref. 1
2 32.6 .57 0.78 (0.33–1.83) 26.1 .95 1.03 (0.41–2.61)
3–4 52.9 .19 1.81 (0.74–4.43) 35.3 .34 1.59 (0.61–4.16)
Karnofsky score
100% 34.7 Ref. 1 23.2 Ref. 1
90% 60.7 .02 2.90 (1.22–6.92) 46.4 .02 2.88 (1.19–6.95)
Surgical technique
Cold steel 1 monopolar 1 bipolar 21.6 Ref. 1 13.5 Ref. 1
Cold steel 1 bipolar 37.9 .09 2.21 (0.87–5.59) 27.3 .11 2.40 (0.81–7.12)
Cold steel 1 ultrasound knife 75.0 < .001 10.88 (3.24–36.50) 54.2 .001 7.56 (2.19–26.09)
Experience of the surgeon
Highly experienced 34.9 Ref. 1 23.3 Ref.
ENT specialist/supervised resident 51.2 0.08 1.96 (0.92–4.18) 39.0 .07 2.11 (0.95–4.71)
Extent of operation
PSP 41.5 Ref. 1 26.4 Ref. 1
SP 43.8 .84 1.10 (0.45–2.66) 28.1 .86 1.09 (0.41–2.91)
EP 53.8 .30 1.64 (0.64–4.23) 50.0 .04 2.79 (1.04–7.44)
ECD 6.3 .03 0.09 (0.01–0.77) 0 – –
Duration of surgery
1:49 19.0 Ref. 1 9.5 Ref. 1
1:50–2:23 42.9 .02 3.19 (1.19–8.52) 35.7 .007 5.28 (1.58–17.67)
2:24 58.1 < .001 5.90 (2.22–15.73) 39.5 .003 6.21 (1.88–20.58)
Operated side
Left 37.7 Ref. 1 30.2 Ref. 1
Right 41.9 .63 1.19 (0.58–2.45) 27.0 .70 0.86 (0.39–1.87)
Histology
Warthin tumor 35.6 Ref. 1 20.0 Ref. 1
Pleomorphic adenoma 47.5 .22 1.64 (0.75–3.62) 32.8 .15 1.95 (0.79–4.82)
Other 28.6 .58 0.73 (0.24–2.24) 33.3 .24 2.00 (0.62–6.41)
Histological size of the tumor
<20 mm 37.3 Ref 1 27.1 Ref 1
20 mm 41.5 .65 1.19 (0.56–2.55) 28.3 .89 1.06 (0.46–2.43)

Abbreviations: OR, odds ratio; CI, confidence interval; Ref., reference; BMI, body mass index; CCI, Charlson Comorbidity Index; ASA, American Society of Anesthesiologists Physical Status Classifica-
tion; ENT, ear, nose, and throat; PSP, partial superficial parotidectomy; SP, superficial parotidectomy; EP, extended parotidectomy; ECD, extracapsular dissection.
Figures in boldface indicate statistical significance.

Our method of 2 physicians assessing the postoperative
facial dynamics has not been described in previous prospec-
tive studies on facial palsy after benign parotid surgery.
Furthermore, prospective studies on complications of
benign parotid surgery, including all types of operations,
could not be found. As the operations included in this study
were carried out over a time frame of 14 months, they are
comparable with each other in terms of technical details.
Malignancy16,21–23 and the extent of surgery4,5,7,16,24,25
have been recognized as evident risk factors for postoper-
ative facial palsy in parotid surgery, but controversy
remains regarding the other risk factors. Association with
advanced age,8,24,26 tumor size,8,21 inflammatory histol-
ogy,2 revision surgery,4,27 operating time,8 tumor location
in the deep lobe,27 and diabetes5 have been described.
Our findings reinforce the role of advanced age, the
extent of surgery, and longer operating time in the devel-
opment of postoperative facial dysfunction. However, as
the longer duration of surgery may reflect the difficulty
and extent of the operation, and surgeons’ experience

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RUOHOALHO ET AL.

TABLE 6. Multivariable logistic regression analysis of the risk factors for facial palsy on postoperative day 1 and postoperative day 14.

Postoperative day 1 Postoperative day 14

Parameter Palsy % p value OR (95% CI) Palsy % p value OR (95% CI)

Age, y
60 32.5 Ref. 1 22.1 Ref. 1
>60 52.0 .01 3.36 (1.33–8.45) 38.0 .01 3.31 (1.31–8.33)
Surgical technique
Cold steel 1 monopolar 1 bipolar 21.6 Ref. 1 13.5 Ref. 1
Cold steel 1 bipolar 37.9 .10 2.45 (0.83–7.22) 27.3 .18 2.26 (0.70–7.36)
Cold steel 1 ultrasound knife 75.0 < .001 13.38 (3.28–54.52) 54.2 < .01 8.82 (2.20–35.38)
Duration of surgery
1:49 19.0 Ref. 1 9.5 Ref. 1
1:50–2:23 42.9 .06 3.22 (0.95–10.85) 35.7 .01 6.55 (1.76–24.34)
2:24 58.1 .02 4.35 (1.28–14.83) 39.5 .01 5.70 (1.59–20.43)
Extent of operation *
PSP 41.5 Ref. 1
SP 43.8 .90 0.93 (0.31–2.79)
EP 53.8 .59 1.38 (0.43–4.43)
ECD 6.3 .18 0.21 (0.02–2.02)

Abbreviations: OR, odds ratio; CI, confidence interval; Ref., reference; PSP, partial superficial parotidectomy; SP, superficial parotidectomy; EP, extended parotidectomy; ECD, extracapsular
dissection.
* Extent of operation could not be analyzed in postoperative day 14 multivariable analysis because no palsies occurred in the extracapsular dissection group.
Figures in boldface indicate statistical significance.

level and personal operative speed may also impact on
operating time, its role as an independent risk factor
seems controversial.
In addition, the operation technique reached signifi-
cance in the risk factor analysis. The operations carried
out with an ultrasound knife seemed to lead to an
increased risk of transient facial palsy. As only 1 experi-
enced head and neck surgeon in our institution has
adopted the technique and the instrumentation is only one
of the elements in a complex operation, we cannot rule
out the presence of confounding factors in this finding.
Despite the possibility of bias, we consider the reporting
of this finding important, as the role of operative instru-
mentation is largely unknown and will require further
research.
The occurrence of Frey’s syndrome varies between 0%
and 66% and depends strongly on the methodological fac-
tors and diagnostic examinations. In this study, the diag-
nosis of Frey’s syndrome was made based on
spontaneous clinical complains of the patients, as our
scope was to register the complications with clinical rele-
vance. Our rate of 3.0% is similar to that reported in
other studies with the same methodology.8,16 Frey’s syn-
drome is thought to be a result of aberrant reinnervation
between the damaged auriculotemporal nerve branches
stimulating parotid secretion and the sympathetic nerve
branches of cutaneous eccrine sweat glands.1 In the light
of this reinnervation theory, our follow-up time of 12
months was rather short and may partly explain the low
incidence. The other postoperative complication rates
(sialocele, salivary fistula, infection, and hemorrhage) at
our institution are comparable to those previously
reported in the literature.2,13,14
Our study had some limitations. Although we had
standardized the methods of evaluation of facial palsy,
other complications were not assessed in such a strict
manner. We did not arrange regular follow-up visits for
patients with normal facial function on the first postop-
erative day. Thereby, complications other than facial
dysfunction were registered based on the patient con-
tacting our department if they were experiencing prob-
lems in recovery. In the assessment of facial nerve
function, the degree of nerve injury was not recorded,
because, in the present study, our primary purpose was
to report the rate of any postoperative facial nerve
palsy, the pattern of its temporary or permanent charac-
ter, and the affected branches. We consider that the use
of available grading scales to determine the degree of
facial dysfunction would not have provided added value
for this study. Even though more than 20 physicians
participated in the evaluation process, they were all
given detailed instructions regarding the methodology
to assure that the assessment followed high standards.
Moreover, to stress the importance of the objectivity of
facial function evaluation, we wanted it to be a consen-
sus of 2 doctors. Five patients had to be excluded from
the analysis of facial palsy because the standardized
assessment of nerve function was not implemented as
planned. All except one of them were operated on Fri-
day, which led to the challenge of getting 2 physicians’
evaluation outside standard working hours on the first
postoperative day, although, in most of the cases, it
was achieved. Long time interval between the second
and third evaluation (2 weeks to 6 months) may also be
considered a limitation. However, any persisting dys-
function would not have led to any actions at that
point.
In conclusion, preoperative patient information should
emphasize the observation that, depending on the extent
of the operation, up to half of the patients experience
some degree of facial palsy after benign parotid surgery.
However, this dysfunction is rarely permanent. Patients
age, duration of surgery, and surgical technique used may
influence the risk of postoperative facial dysfunction. The

6 HEAD & NECK—DOI 10.1002/HED MONTH 2016


role of operative instrumentation requires further clarifica-
tion with larger scale randomized prospective studies.
Acknowledgment
The authors thank Tero Vahlberg (University of Turku,
Turku, Finland) for support and assistance in statistical
analysis and reporting of the results.
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