Parotid Malignancy with Facial Weakness: Should the Facial Nerve Be Sacrificed?

  • Luiz Paulo Kowalski
  • Alvaro Sanabria
  • Joel Arevalo
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Carcinoma of the parotid gland accounts for 14–25% of all parotid lesions. 14–30% patients present with no clinical indications of an advanced tumor until discovery of FN weakness/paresis during the preoperative exam or a nerve invasion during surgery.

It is commonly accepted that patients with preoperative total paralysis of the FN are not candidates for preservation. Additionally, in cases of weakness or selectively compromised FN branches, attempts should be made to preserve the trunk and the non-compromised branches. In at least a third of patients without preoperative FN paralysis, an intraoperative finding obligated the sacrifice of the FN. The belief that postoperative radiotherapy can control positive microscopic margins in cases of FN preservation is not supported by evidence.

Approximately 25–33% patients have moderately functional sequelae even after FN sacrifice. An immediate reconstruction with nerve free graft improves functional recovery and should be attempted.


Parotid gland Facial nerve Paralysis Survival Recurrence Reconstruction Quality of life 


  1. 1.
    Preis M, Soudry E, Bachar G, Shufel H, Feinmesser R, Shpitzer T. Predicting facial nerve invasion by parotid gland carcinoma and outcome of facial reanimation. Eur Arch Otorhinolaryngol. 2010;267(1):107–11.CrossRefGoogle Scholar
  2. 2.
    Terakedis BE, Hunt JP, Buchmann LO, Avizonis VN, Anker CJ, Hitchcock YJ. The prognostic significance of facial nerve involvement in carcinomas of the parotid gland. Am J Clin Oncol. 2017;40(3):323–8.CrossRefGoogle Scholar
  3. 3.
    Swendseid B, Li S, Thuener J, et al. Incidence of facial nerve sacrifice in parotidectomy for primary and metastatic malignancies. Oral Oncol. 2017;73:43–7.CrossRefGoogle Scholar
  4. 4.
    Iseli TA, Karnell LH, Preston TW, et al. Facial nerve sacrifice and radiotherapy in parotid adenoid cystic carcinoma. Laryngoscope. 2008;118(10):1781–6.CrossRefGoogle Scholar
  5. 5.
    Bendet E, Talmi YP, Kronenberg J. Preoperative electroneurography (ENoG) in parotid surgery: assessment of facial nerve outcome and involvement by tumor—a preliminary study. Head Neck. 1998;20(2):124–31.CrossRefGoogle Scholar
  6. 6.
    Chung EJ, Lee SH, Baek SH, Kwon KH, Chang YJ, Rho YS. Oncological and functional results after the surgical treatment of parotid cancer. Int J Oral Maxillofac Surg. 2015;44(1):16–22.CrossRefGoogle Scholar
  7. 7.
    Hong TS, Kriesel KJ, Hartig GK, Harari PM. Parotid area lymph node metastases from cutaneous squamous cell carcinoma: implications for diagnosis, treatment, and prognosis. Head Neck. 2005;27(10):851–6.CrossRefGoogle Scholar
  8. 8.
    Lai SY, Weinstein GS, Chalian AA, Rosenthal DI, Weber RS. Parotidectomy in the treatment of aggressive cutaneous malignancies. Arch Otolaryngol. 2002;128(5):521–6.CrossRefGoogle Scholar
  9. 9.
    Shao A, Wong DK, McIvor NP, et al. Parotid metastatic disease from cutaneous squamous cell carcinoma: prognostic role of facial nerve sacrifice, lateral temporal bone resection, immune status and P-stage. Head Neck. 2014;36(4):545–50.CrossRefGoogle Scholar
  10. 10.
    Sweeny L, Zimmerman T, Carroll WR, Schmalbach CE, Day KE, Rosenthal EL. Head and neck cutaneous squamous cell carcinoma requiring parotidectomy: prognostic indicators and treatment selection. Otolaryngol Head Neck Surg. 2014;150(4):610–7.CrossRefGoogle Scholar
  11. 11.
    Huang CC, Tseng FY, Chen ZC, et al. Malignant parotid tumor and facial palsy. Otolaryngol Head Neck Surg. 2007;136(5):778–82.CrossRefGoogle Scholar
  12. 12.
    Wang AY, Palme CE, Wang JT, et al. Quality of life assessment in patients treated for metastatic cutaneous squamous cell carcinoma of the head and neck. J Laryngol Otol. 2013;127(Suppl 2):S39–47.CrossRefGoogle Scholar
  13. 13.
    Renkonen S, Sayed F, Keski-Santti H, et al. Reconstruction of facial nerve after radical parotidectomy. Acta Otolaryngol. 2015;135(10):1065–9.CrossRefGoogle Scholar
  14. 14.
    Yla-Kotola T, Goldstein DP, Hofer SO, et al. Facial nerve reconstruction and facial disfigurement after radical parotidectomy. J Reconstr Microsurg. 2015;31(4):313–8.CrossRefGoogle Scholar
  15. 15.
    Hontanilla B, Qiu SS, Marre D. Effect of postoperative brachytherapy and external beam radiotherapy on functional outcomes of immediate facial nerve repair after radical parotidectomy. Head Neck. 2014;36(1):113–9.CrossRefGoogle Scholar
  16. 16.
    Leong SC, Lesser TH. Long-term outcomes of facial nerve function in irradiated and nonirradiated nerve grafts. Ann Otol Rhinol Laryngol. 2013;122(11):695–700.CrossRefGoogle Scholar
  17. 17.
    Brown PD, Eshleman JS, Foote RL, Strome SE. An analysis of facial nerve function in irradiated and unirradiated facial nerve grafts. Int J Radiat Oncol Biol Phys. 2000;48(3):737–43.CrossRefGoogle Scholar
  18. 18.
    Otsuka K, Imanishi Y, Tada Y, et al. Clinical outcomes and prognostic factors for salivary duct carcinoma: a multi-institutional analysis of 141 patients. Ann Surg Oncol. 2016;23(6):2038–45.CrossRefGoogle Scholar
  19. 19.
    Magnano M, Gervasio CF, Cravero L, et al. Treatment of malignant neoplasms of the parotid gland. Otolaryngol Head Neck Surg. 1999;121(5):627–32.CrossRefGoogle Scholar
  20. 20.
    Koul R, Dubey A, Butler J, Cooke AL, Abdoh A, Nason R. Prognostic factors depicting disease-specific survival in parotid-gland tumors. Int J Radiat Oncol Biol Phys. 2007;68(3):714–8.CrossRefGoogle Scholar
  21. 21.
    Godballe C, Schultz JH, Krogdahl A, Moller-Grontved A, Johansen J. Parotid carcinoma: impact of clinical factors on prognosis in a histologically revised series. Laryngoscope. 2003;113(8):1411–7.CrossRefGoogle Scholar
  22. 22.
    Carrillo JF, Vazquez R, Ramirez-Ortega MC, Cano A, Ochoa-Carrillo FJ, Onate-Ocana LF. Multivariate prediction of the probability of recurrence in patients with carcinoma of the parotid gland. Cancer. 2007;109(10):2043–51.CrossRefGoogle Scholar
  23. 23.
    Carinci F, Farina A, Pelucchi S, Calearo C, Pastore A. Parotid gland carcinoma: surgical strategy based on local risk factors. J Craniofac Surg. 2001;12(5):434–7.CrossRefGoogle Scholar
  24. 24.
    Iyer NG, Clark JR, Murali R, Gao K, O’Brien CJ. Outcomes following parotidectomy for metastatic squamous cell carcinoma with microscopic residual disease: implications for facial nerve preservation. Head Neck. 2009;31(1):21–7.CrossRefGoogle Scholar
  25. 25.
    Abt NB, Derakhshan A, Naunheim MR, Osborn HA, Deschler DG. Facial nerve sacrifice during parotidectomy: a cautionary tale in pathologic diagnosis. Am J Otolaryngol. 2017;38(3):358–9.CrossRefGoogle Scholar
  26. 26.
    Breeze J, Morrison A, Dawson D, et al. Health-related quality of life after treatment for neoplasia of the major salivary glands: a pilot study. Br J Oral Maxillofac Surg. 2016;54(7):806–11.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Luiz Paulo Kowalski
    • 1
  • Alvaro Sanabria
    • 2
    • 3
  • Joel Arevalo
    • 2
  1. 1.Head and Neck Service Surgery and Otorhinolaryngology DepartmentAC Camargo Cancer CenterSao PauloBrazil
  2. 2.Head and Neck ServiceFundación Colombiana de Cancerología—Clínica VidaMedellinColombia
  3. 3.Department of SurgeryUniversidad de AntioquiaMedellinColombia

Personalised recommendations