Salivary gland neoplasms most commonly arise in the parotid gland, rendering parotidectomy a frequently performed surgical procedure. The primary objective is to complete tumor excision while preserving facial nerve function. However, facial palsy remains a notable complication, occurring temporarily in 25–60% of cases and permanently in 2–6%.1

Facial nerve dysfunction can profoundly impact the patient’s quality of life. Thus, accurate identification and meticulous dissection of the facial nerve trunk and its branches are critical for favourable outcomes. Both antegrade and retrograde dissection techniques are commonly used to enhance nerve preservation, though the utility of intraoperative facial nerve monitoring remains a topic of debate.2

Historically performed without magnification, there has been a progressive shift toward the use of microsurgical techniques, improving visualization and reducing nerve injury.3 this case series explores current advancements in parotid surgery with an emphasis on facial nerve preservation and highlights the role of microsurgery in enhancing outcomes. Additionally, the approach has educational value in surgical training.

This case series includes three patients (one male and two females) diagnosed with benign neoplasm of the parotid gland.

CASE 1

A 22-year-old male presented to the outpatient department with a chief complaint of swelling in front of the left ear persisting for the past two year

On physical examination, a unilateral, globular swelling measuring approximately 3 × 2 × 1 cm was observed in the left preauricular region. The overlying skin was intact with no evidence of redness, pigmentation, or sinus formation. The swelling was:

• Firm in consistency
• Non-tender
• Non-fluctuant
• Non-adherent to the skin or underlying structures
• No local rise in temperature

Ultrasound of the neck revealed a well-defined hypoechoic lesion located in the superficial lobe of the left parotid gland, suggestive of a benign etiology with pleomorphic adenoma being the most likely diagnosis. FNAC was advised for further evaluation.

Fine Needle Aspiration Cytology (FNAC) smears were cellular, showing:

• Clusters of cells with uniform round nuclei and moderate cytoplasm
• Presence of metachromatic stroma
• Few squamous cells with clear cytoplasm
• No significant nuclear atypia, mitosis, or necrosis noted

The cytological diagnosis was salivary gland neoplasm with uncertain malignant potential. The differential diagnosis included:

• Pleomorphic adenoma with squamous metaplasia
• Low-grade mucoepidermoid carcinoma

Following surgical excision and histopathological examination, the lesion was confirmed to be a pleomorphic adenoma of

the parotid gland.

CASE 2

A 26-year-old female presented to the outpatient department with a chief complaint of swelling in front of the left ear persisting for the past two years and pain since one month.

On physical examination, a unilateral, globular swelling measuring approximately 3 × 2.5 × 2 cm was observed in the left preauricular region. The overlying skin was intact with no evidence of redness, pigmentation, or sinus formation. The swelling was:

• Firm in consistency
• Mildly-tender
• Non-fluctuant
• Non-adherent to the skin or underlying structures
• No local rise in temperature

Ultrasound of the neck revealed well-defined hypoechoic lesion of 2.8x2.6x2 cm located in the superficial lobe of the left parotid gland, with no evidence of any calcification or no significant vascularity suggestive of a pleomorphic adenoma. FNAC was advised for further evaluation.

Fine Needle Aspiration Cytology (FNAC) smears were of moderate cellular, showing:

• Clusters of ductal cells mixed with chondromyxoid stroma against the haemorrhagic background
• Presence of plasmacytoid cells is also seen

The cytological diagnosis was s/o pleomorphic adenoma of the parotid gland.

Following surgical excision and histopathological examination, the lesion was confirmed to be a pleomorphic adenoma of the parotid gland.

CASE 3:

A 56-year-old female presented to the outpatient department with a chief complaint of swelling in front of the left ear persisting for the past 20 years & pain since three years.

On physical examination, a unilateral, globular swelling measuring approximately 1.5 × 3 × 3 cm was observed in the left preauricular region. The overlying skin was intact with no evidence of redness, pigmentation, or sinus formation. The swelling was:

• Firm in consistency
• Tender
• Non-fluctuant
• Non-adherent to the skin or underlying structures
• No local rise in temperature

Ultrasound of the neck revealed a well-defined hypoechoic lesion measuring 1.6 × 4.6 × 5.2 cm located in the superficial lobe of the left parotid gland, suggestive of a benign etiology with pleomorphic adenoma being the most likely diagnosis. FNAC was advised for further evaluation. MRI & CT neck also revealed a well-defined peripherally enhancing hypodense hypoechoic soft tissue lesion in right parotid gland with further histopathological correlation suggested.

Following surgical excision and histopathological examination, tumour was showing hypocellular and hypercellular areas composed of spindle cells with elongated wavy nuclei and scanty bipolar cytoplasm. At places verocay bodies are also seen. No increased mitosis or necrosis in sections studied. The lesion was confirmed to be a benign spindle cell shwanoma of the parotid gland.

Surgical Technique

• All procedures were performed under general anaesthesia using microsurgical techniques aimed at minimizing facial nerve-related complications.
• Incision & Flap Elevation: A modified Blair’s incision was used. A subplatysmal flap was elevated. The anterior branch of the greater auricular nerve was sacrificed, while the posterior branch was preserved.
• Anatomical Landmarks Identified:
  • Tragal pointer
  • Posterior belly of the digastric muscle
  • Tympanomastoid suture
• Microsurgical Dissection& Nerve Preservation:
  Dissection of the superficial lobe of the parotid gland was performed under microscopic magnification (ranging from 1.3x to 3.2x), facilitating careful identification and preservation of
• the facial nerve trunk and its branches. Both antegrade and retrograde techniques were employed using microsurgical scissors and micro forceps.

Key procedural steps recorded included:

• Skin incision
• Flap elevation
• Separation of the parotid from the anterior border of the sternocleidomastoid muscle and the cartilaginous external auditory canal
• Exposure of the posterior belly of the digastric muscle
• Identification of the main facial nerve trunk and its branches

• Intraoperative Monitoring: Real-time facial nerve monitoring was used to assess nerve function during surgery. Postoperatively, facial nerve function was evaluated both immediately after recovery and on the first postoperative day. Paresis was identified based on the House-Brackmann grading system.

Microsurgical approaches significantly enhance the preservation of facial nerve function in parotidectomy. High-resolution visualization allows precise dissection, improving safety when working in close proximity to critical nerve structures. Accurate identification of anatomical landmarks is indispensable in avoiding nerve damage, particularly when the nerve is not directly involved by the tumor. Advanced nerve monitoring further aids in real-time evaluation of nerve integrity and can guide intraoperative decision-making. When nerve resection is unavoidable, immediate reconstruction has shown superior long-term functional outcomes compared to delayed or no repair.

This case series demonstrates that the integration of microsurgical techniques and consistent use of anatomical landmarks significantly improves facial nerve preservation during parotid surgery. Such strategies not only minimize postoperative complications but also enhance patient outcomes. Furthermore, the method has educational value and can serve as a practical model for surgical training.

1. Jin, H., Kim, B.Y., Kim, H. et al. Incidence of postoperative facial weakness in parotid tumor surgery: a tumor subsite analysis of 794 parotidectomies. BMC Surg 19, 199 (2019).
2. Mutlu V, Kaya Z. Which surgical method is superior for the treatment of parotid tumor? is it classical? is it new? [Internet]. U.S. National Library of Medicine; 2019.
3. Bhardwaj A, Sood R, Malhotra M, Priya M, Tyagi AK, Kumar A, Varshney S, Singh A. Microscopic Parotidectomy: A Prospective Study. Indian J Otolaryngol Head Neck Surg. 2022 Oct;74(Suppl 2):2273-2280. doi: 10.1007/s12070-020-02106-2.