Anaesthesia for Salivary Gland Surgery

Quick Answer

Salivary gland surgery requires meticulous attention to the facial nerve (parotid surgery) and airway management. Key considerations: (1) Facial nerve preservation: Electromyography (EMG) monitoring mandatory for parotidectomy; avoid long-acting NMBAs; maintain TOF count ≥2 or use TIVA without neuromuscular blockade [1,2]. (2) Surgical positioning: Supine with head-up 15-30° and head turned to contralateral side (parotid) or neck extended (submandibular); careful padding to prevent brachial plexus injury [3,4]. (3) Airway considerations: Shared airway with surgeon; nasal intubation or reinforced LMA; throat pack to prevent blood aspiration; potential for difficult airway if large parapharyngeal/retropharyngeal mass [5,6]. (4) Haemorrhage risk: Rich vascular supply to parotid (external carotid branches) and submandibular region; controlled hypotension (MAP 60-65 mmHg) improves surgical field; tranexamic acid 1 g IV may reduce bleeding [7,8]. (5) Nerve injury risks: Facial nerve (parotid), marginal mandibular branch (submandibular), lingual nerve, hypoglossal nerve; postoperative nerve assessment critical [9,10]. (6) Sialolithiasis: Stone removal may require transoral or combined approach; shorter procedures; local or general anaesthesia depending on stone location [11,12]. [1-12]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Oral and salivary gland disease affects Aboriginal and Torres Strait Islander populations with distinct patterns reflecting broader health disparities:

• Sialolithiasis: Higher prevalence in some remote Indigenous communities potentially related to chronic dehydration, dietary factors, and limited access to primary dental and medical care [13,14]
• Chronic sialadenitis: Recurrent infections and inflammatory conditions more common due to delayed presentation and suboptimal chronic disease management [15,16]
• Salivary gland tumours: Limited epidemiological data specific to Indigenous populations; general cancer screening and access disparities apply [17,18]

Perioperative considerations for Indigenous patients:

1. Delayed presentation: Indigenous patients often present with more advanced disease due to geographic barriers, competing health priorities, and cultural factors affecting healthcare-seeking behaviour [19,20]
2. Comorbidity burden: Higher rates of diabetes mellitus (2-3 times national average), cardiovascular disease, chronic kidney disease, and smoking increase surgical risk and affect wound healing [21,22]
3. Nutritional status: Malnutrition and iron deficiency anaemia more common in remote communities; may affect healing and require preoperative optimisation [23,24]
4. Communication and consent: Use of Aboriginal Health Workers (AHWs) or liaison officers (ALOs) for culturally safe communication; extended family involvement in decision-making; plain language explanations avoiding medical jargon [25,26]
5. Remote service delivery: Many Indigenous patients access specialist services through fly-in fly-out (FIFO) programs:
   • Limited preoperative assessment and optimisation opportunities
   • Postoperative follow-up challenges (wound review, nerve function assessment, suture removal)
   • Need for clear written and verbal postoperative instructions
   • Telephone or telehealth follow-up arrangements [27,28]

Cultural safety considerations:

• Recognition that head and neck surgery may have cultural significance regarding appearance and identity
• Family-centred care with appropriate involvement of kin in consent and recovery processes
• "Sorry Business" may impact appointment attendance, surgical timing, and family availability for support
• Coordination with Aboriginal Community Controlled Health Services (ACCHSs) for ongoing care [29,30]
• Consideration that facial nerve function outcomes have particular significance for communication and cultural expression [31,32]

Māori Populations (Aotearoa New Zealand)

Māori populations experience significant health inequities that extend to surgical and perioperative care:

• Cancer disparities: Māori have higher incidence and mortality rates for many head and neck cancers; delayed diagnosis contributes to poorer outcomes [33,34]
• Chronic disease burden: Higher rates of diabetes, cardiovascular disease, and obesity increase perioperative risk [35,36]
• Access barriers: Geographic (rural iwi), financial, and cultural barriers to accessing specialist head and neck services [37,38]

Te Tiriti o Waitangi obligations in salivary gland surgery:

1. Whānau-centred care: Involvement of extended family in perioperative processes, consistent with Māori collectivist values; facial appearance outcomes particularly important for cultural identity [39,40]
2. Māori Health Workers: Navigation support through hospital systems, particularly for those unfamiliar with institutional processes; assistance with communication about surgical risks including facial nerve injury [41,42]
3. Cultural context of appearance: Recognition that facial symmetry and expression have particular importance for Māori cultural practices including kapa haka, whaikōrero (oration), and facial expressions in communication [43,44]
4. Data sovereignty: Ensuring surgical outcomes data contributes to Māori-led health improvement initiatives [45,46]

Structural determinants affecting Māori surgical outcomes:

• Higher smoking rates affecting wound healing and cancer outcomes
• Higher rates of diabetes mellitus affecting recovery and infection risk
• Lower socioeconomic status limiting preventive care access
• Geographic barriers to specialist follow-up care [47,48]

Rural and regional considerations:

• Northland, Tairāwhiti, and Midland regions have limited ENT and maxillofacial specialist services
• RFDS and regional hospitals may provide limited postoperative support
• Coordination with local Māori health providers for ongoing wound care and nerve function monitoring [49,50]

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Clinical Overview and Surgical Indications

Anatomy of Salivary Glands

Parotid Gland:

• Location: Preauricular region; extends from zygomatic arch superiorly to angle of mandible inferiorly; from masseter anteriorly to mastoid process posteriorly [51,52]
• Size: Largest salivary gland (15-30 g); serous secretion [53,54]
• Duct (Stensen's): Emerges from anterior border, crosses masseter, pierces buccinator, opens opposite upper second molar [55,56]
• Innervation: Auriculotemporal nerve (parasympathetic secretomotor from otic ganglion); great auricular nerve (sensory C2-C3) [57,58]
• Blood supply: External carotid artery (posterior auricular, superficial temporal, maxillary, transverse facial branches); retromandibular vein [59,60]
• Facial nerve: Exits stylomastoid foramen; enters parotid posteromedially; divides into five branches within gland (temporal, zygomatic, buccal, mandibular, cervical) [61,62]

Submandibular Gland:

• Location: Submandibular triangle; superficial lobe superficial to mylohyoid; deep lobe wraps around posterior mylohyoid border [63,64]
• Size: Second largest (7-15 g); mixed serous/mucous secretion [65,66]
• Duct (Wharton's): Emerges from deep lobe; runs between mylohyoid and hyoglossus; opens at sublingual caruncle lateral to lingual frenulum [67,68]
• Innervation: Lingual nerve carries parasympathetic fibres from submandibular ganglion [69,70]
• Blood supply: Facial artery and vein; submental vessels [71,72]
• Relations: Lingual nerve (superior), hypoglossal nerve (inferior), marginal mandibular branch of facial nerve (superficial in submandibular triangle) [73,74]

Sublingual Gland:

• Location: Sublingual space; between oral mucosa and mylohyoid [75,76]
• Ducts: Multiple (8-20) ducts of Rivinus open along sublingual fold; occasionally Bartholin's duct joins Wharton's duct [77,78]
• Relations: Lingual nerve, submandibular duct, hypoglossal nerve [79,80]

Surgical Indications

Parotid Surgery:

Neoplastic:

• Pleomorphic adenoma: Benign mixed tumour (70-80% of parotid tumours); superficial parotidectomy with facial nerve preservation [81,82]
• Warthin's tumour (papillary cystadenoma lymphomatosum): Second most common benign tumour; often bilateral; male smokers; superficial parotidectomy [83,84]
• Malignant tumours: Mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, squamous cell carcinoma; requires wide excision often with facial nerve sacrifice if invaded [85,86]
• Metastatic disease: Lymphoma, cutaneous SCC/melanoma metastases to parotid lymph nodes [87,88]

Inflammatory/Infectious:

• Chronic recurrent parotitis: Failed conservative management; parotidectomy for symptom control [89,90]
• Parotid abscess: Drainage; may require superficial parotidectomy [91,92]
• Sialolithiasis: Parotid duct stones; transoral or external removal [93,94]
• Sjögren's syndrome: Benign lymphoepithelial lesions; rarely requires surgery [95,96]

Other:

• Frey's syndrome: Post-parotidectomy gustatory sweating; prevention with fascial interposition during initial surgery [97,98]
• Sialadenosis: Non-inflammatory, non-neoplastic enlargement; rarely surgical [99,100]

Submandibular Gland Surgery:

Neoplastic:

• Pleomorphic adenoma (less common than parotid; 50% malignant vs 20% in parotid) [101,102]
• Malignant tumours requiring gland excision [103,104]

Sialolithiasis:

• Submandibular duct stones: 80-90% of salivary stones occur in submandibular gland due to thicker, more mucous saliva and uphill duct course [105,106]
• Transoral stone removal: For stones in anterior duct [107,108]
• Sialadenectomy: For recurrent stones, stone in gland, chronic sialadenitis [109,110]

Chronic Sialadenitis:

• Recurrent bacterial infections; sialolithiasis-associated; post-radiation; autoimmune [111,112]
• Submandibular gland excision for failed conservative management [113,114]

Ranula:

• Definition: Mucous extravasation cyst from sublingual gland; "plunging ranula" extends into neck [115,116]
• Treatment: Marsupialisation or sublingual gland excision; plunging ranula requires transcervical approach [117,118]

Surgical Procedures

Superficial Parotidectomy:

• Indication: Benign tumours in superficial lobe; low-grade malignancies not involving facial nerve [119,120]
• Technique: Skin flap elevation; facial nerve trunk identification at stylomastoid foramen; anterior dissection along nerve branches; superficial lobe excision with tumour [121,122]
• Duration: 2-4 hours depending on tumour size and nerve dissection complexity [123,124]
• Complications: Facial nerve palsy (temporary 10-20%, permanent 1-3%), Frey's syndrome, salivary fistula, haematoma [125,126]

Total Parotidectomy:

• Indication: Deep lobe tumours, malignant tumours, recurrent tumours [127,128]
• Technique: Complete gland excision; facial nerve dissection and preservation or sacrifice if invaded [129,130]
• Nerve sacrifice: If preoperative palsy or intraoperative invasion confirmed; immediate cable grafting or delayed reconstruction [131,132]

Submandibular Gland Excision:

• Indication: Stones, chronic sialadenitis, tumours [133,134]
• Technique: Submandibular incision 2-3 cm below mandible (marginal mandibular nerve protection); gland dissection preserving lingual and hypoglossal nerves; duct ligation [135,136]
• Duration: 45-90 minutes [137,138]
• Complications: Marginal mandibular nerve palsy (temporary 5-15%, permanent <2%), lingual nerve injury, hypoglossal nerve injury, haematoma [139,140]

Sialolithotomy:

• Transoral: For accessible stones in anterior duct; longitudinal duct incision, stone removal, duct marsupialisation [141,142]
• Combined approach: External incision for gland stone or failed transoral; gland may be excised [143,144]
• Sialendoscopy: Minimally invasive; diagnostic and therapeutic; requires specialised equipment [145,146]

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Preoperative Assessment

Medical History and Optimisation

General Assessment:

• Cardiovascular: Optimise hypertension (reduces bleeding); assess for ischaemic heart disease; delay elective surgery if recent MI or unstable angina [147,148]
• Respiratory: Smoking cessation 4-6 weeks preoperatively (reduces wound infection and improves healing) [149,150]
• Diabetes mellitus: Optimise glycaemic control (HbA1c <8%); morning list preferred; monitor perioperative glucose [151,152]
• Anticoagulation: Warfarin (usually continued if INR therapeutic; higher bleeding risk acceptable); DOACs may need cessation depending on bleeding risk [153,154]
• Renal/hepatic dysfunction: Drug metabolism considerations; avoid nephrotoxic drugs [155,156]

Specific Risk Factors:

• Previous parotid/submandibular surgery: Scar tissue increases difficulty and nerve injury risk [157,158]
• Previous radiotherapy: Difficult dissection, poor wound healing, increased infection risk [159,160]
• Facial nerve palsy: Document preoperative function; affects surgical approach and patient counselling [161,162]
• Recurrent laryngeal nerve palsy: If prior thyroid/neck surgery; consider vocal cord assessment [163,164]

Medication Considerations:

• Anticholinergics: May worsen dry mouth symptoms in Sjögren's patients [165,166]
• Antihypertensives: Continue perioperatively; beta-blockers prevent reflex tachycardia from surgical stimulation [167,168]
• Steroids: If chronic use, stress-dose supplementation required [169,170]

Airway Assessment

Key Considerations:

• Mouth opening: Adequate for intubation; trismus may indicate parapharyngeal extension [171,172]
• Neck mobility: Required for positioning; cervical spine pathology may limit extension/rotation [173,174]
• Mallampati score: Predictor of intubation difficulty; shared airway considerations [175,176]
• Tumour extension: Large parapharyngeal or retropharyngeal tumours may cause:
  • Airway compression
  • Difficult mask ventilation
  • Difficult intubation [177,178]
• Sleep apnoea: Common in head and neck cancer patients; increases postoperative airway obstruction risk [179,180]

Investigations for Airway Assessment:

• CT neck/chest: Assess tumour extent, airway compression, tracheal deviation [181,182]
• MRI: Soft tissue extent; parapharyngeal space involvement [183,184]
• Nasendoscopy: ENT assessment of airway and vocal cord function preoperatively if indicated [185,186]

Investigations

Standard Investigations:

• FBC: Anaemia assessment; baseline for blood loss monitoring [187,188]
• Coagulation studies: If bleeding disorder history or anticoagulation [189,190]
• Renal function: Drug dosing; contrast considerations if imaging required [191,192]
• ECG: If >65 years or cardiovascular disease [193,194]

Specific Investigations:

• Fine needle aspiration cytology (FNAC): Preoperative diagnosis of tumour nature; guides extent of surgery [195,196]
• CT/MRI: Tumour extent, relation to facial nerve, deep lobe involvement [197,198]
• Sialography: For sialolithiasis; delineates stone location and duct anatomy [199,200]
• Ultrasound: Initial imaging; guides FNAC; useful for follow-up [201,202]
• Chest X-ray: Pulmonary metastases workup for malignancy [203,204]

Preoperative Fasting and Preparation

Fasting Guidelines (ANZCA PS15):

• 6 hours for solid food
• 2 hours for clear fluids [205,206]

Specific Preparation:

• Oral hygiene: Chlorhexidine mouthwash reduces oral flora and surgical site infection risk [207,208]
• Antibiotics: Prophylaxis for contaminated cases (through oral cavity); typically amoxicillin-clavulanate or clindamycin [209,210]
• Thromboprophylaxis: LMWH or compression stockings for prolonged procedures (>60 minutes) and malignancy [211,212]
• Skin preparation: Standard surgical prep; hair clipping if necessary (avoid shaving which increases infection risk) [213,214]

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Facial Nerve Anatomy and Monitoring

Facial Nerve (CN VII) Anatomy Relevant to Parotid Surgery

Course:

• Exits skull base at internal auditory meatus; traverses facial canal in petrous temporal bone; exits stylomastoid foramen [215,216]
• Extracranial course: Immediately divides into main trunk and small branches; enters posteromedial aspect of parotid gland [217,218]
• Pes anserinus: Terminal bifurcation within parotid into temporofacial and cervicofacial divisions; further branches (typically five) emerge from anterior border of gland [219,220]

Five Terminal Branches:

1. Temporal (frontal): Frontalis, orbicularis oculi; forehead wrinkling, eye closure [221,222]
2. Zygomatic: Orbicularis oculi, zygomaticus; eye closure, upper lip elevation [223,224]
3. Buccal: Buccinator, orbicularis oris, upper lip muscles; cheek and upper lip movement [225,226]
4. Mandibular (marginal mandibular): Depressor anguli oris, mentalis; lower lip depression, chin movement [227,228]
5. Cervical: Platysma; lower neck and lip depression [229,230]

Surgical Landmarks:

• Stylomastoid foramen: Trunk identified at this point; landmarks: tympanomastoid suture (posterior), posterior belly of digastric (anterior), tragal pointer (lateral) [231,232]
• Retromandibular vein: Parallel to facial nerve trunk; deep to nerve branches [233,234]
• Tympanomastoid suture: Reliable landmark; facial nerve 6-8 mm deep at this point [235,236]

Facial Nerve Monitoring

Rationale:

• Visual identification of nerve challenging in scarred or previously irradiated tissue
• Early detection of traction or thermal injury before permanent damage [237,238]
• Standard of care for parotid surgery; medicolegally important [239,240]

Technique:

• EMG electrodes: Needle or surface electrodes in muscles supplied by facial nerve branches (frontalis, orbicularis oculi, orbicularis oris, mentalis) [241,242]
• Stimulation: Probe delivers stimulus to identify nerve; if stimulated, muscle depolarisation detected as EMG signal and/or audible sound [243,244]
• Threshold: Determine stimulus threshold; increased threshold suggests nerve compromise [245,246]

Anaesthetic Considerations:

• Avoid long-acting NMBAs: Rocuronium, vecuronium, pancuronium interfere with EMG monitoring [247,248]
• Acceptable: Short-acting NMBA if necessary (suxamethonium for intubation) - wears off by surgical nerve identification [249,250]
• Preferred: No NMBAs; TIVA technique with remifentanil provides adequate relaxation without neuromuscular blockade [251,252]
• TOF monitoring: If NMBAs used, maintain TOF count ≥2 (preferably ≥4); stop NMBA infusion before nerve dissection anticipated [253,254]
• Volatile agents: Acceptable but may slightly affect monitoring; TIVA preferred for optimal conditions [255,256]

Marginal Mandibular Nerve Considerations (Submandibular Surgery)

Anatomy:

• Branch of facial nerve; exits parotid inferiorly; courses through submandibular triangle 1-2 cm below mandible (variable) [257,258]
• Risk during submandibular surgery: Incision placed too high; dissection in wrong plane [259,260]
• Protection: Incision 3-4 cm below mandible; dissection deep to platysma; identify and preserve nerve [261,262]

Function:

• Supplies depressor anguli oris; loss causes drooping of corner of mouth (asymmetry) [263,264]
• Clinical significance: "Oral incompetence" and cosmetic deformity; difficult to rehabilitate [265,266]

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Anaesthetic Technique

Airway Management

Options:

1. Nasal Endotracheal Intubation (Preferred)

• Advantages: Secure airway, protected from aspiration, minimal interference with surgical field [267,268]
• Technique: Vasoconstrictor preparation (cocaine 5% or phenylephrine); softened NTT 6.0-7.0 mm; gentle insertion perpendicular then inferior; video laryngoscopy confirmation [269,270]
• Securing: Tape to nose and cheek; bite block essential [271,272]
• Throat pack: Protects against aspiration of blood and surgical debris [273,274]

2. Reinforced Laryngeal Mask Airway (rLMA)

• Advantages: Less stimulating, rapid emergence [275,276]
• Disadvantages: Aspiration risk (salivary gland surgery has bleeding and oral contamination risk) [277,278]
• Use: Selective for short, uncomplicated procedures with experienced surgeon and controlled bleeding [279,280]

3. Oral ETT

• Indication: Failed nasal intubation, contraindications to nasal route [281,282]
• Technique: Bite block essential; tube positioned to minimise surgical interference [283,284]

Difficult Airway Considerations:

• Large parapharyngeal/retropharyngeal masses may cause:
  • Airway obstruction when supine
  • "Can't intubate, can't ventilate" scenario [285,286]
• Awake fibreoptic intubation: Consider if significant airway compromise anticipated [287,288]
• Tracheostomy: Consider if airway severely compromised or prolonged intubation expected (radical parotidectomy with flap reconstruction) [289,290]

Anaesthetic Induction and Maintenance

Induction:

• Preoxygenation: 3-5 minutes (head and neck surgery increased aspiration risk) [291,292]
• Propofol 2-3 mg/kg (TIVA preparation) or thiopentone 3-5 mg/kg [293,294]
• Fentanyl 1-2 mcg/kg or remifentanil bolus 0.5-1 mcg/kg [295,296]
• Muscle relaxation: Suxamethonium 1-1.5 mg/kg for rapid intubation (short-acting, wears off before nerve monitoring); avoid rocuronium if EMG monitoring required early [297,298]
• Alternative: Rocuronium 0.6 mg/kg only if reversal with sugammadex planned well before nerve dissection [299,300]

Maintenance:

TIVA (Preferred for Parotid Surgery):

• Propofol 100-200 mcg/kg/min infusion [301,302]
• Remifentanil 0.05-0.2 mcg/kg/min infusion [303,304]
• Advantages: No NMBA required (preserves facial nerve monitoring), rapid recovery, reduced PONV [305,306]
• Depth monitoring: BIS or Entropy 40-60 [307,308]

Volatile Anaesthesia:

• Sevoflurane 1-2% or desflurane 3-6% in oxygen/air [309,310]
• Acceptable if no NMBAs used; slight EMG interference possible [311,312]
• Higher PONV risk than TIVA [313,314]

Balanced Technique:

• Volatile or TIVA with intermittent opioid boluses [315,316]
• Suitable for shorter submandibular procedures where facial nerve monitoring not required [317,318]

Controlled Hypotension (when indicated):

• Target MAP 60-65 mmHg or 20% below baseline [319,320]
• Reduces bleeding in vascular parotid tissue [321,322]
• Techniques: Propofol infusion, beta-blockade (labetalol, esmolol), remifentanil [323,324]
• Contraindications: Significant cerebrovascular disease, ischaemic heart disease, severe anaemia [325,326]
• Monitoring: Arterial line for prolonged procedures [327,328]

Positioning

Supine with Head Rotation:

• Parotidectomy: Supine; head-up 15-30° (reduces venous bleeding); head turned to contralateral side (extends neck, presents surgical field) [329,330]
• Submandibular: Supine; head-up 15-30°; neck extended (elevates submandibular triangle) [331,332]
• Shoulder roll: May improve neck extension for submandibular access [333,334]

Complications:

• Brachial plexus stretch: Head turned with arm abduction; ensure arms tucked at sides; padding under shoulders [335,336]
• Cervical spine strain: Excessive extension; ensure comfortable position; pad occiput [337,338]
• Pressure areas: Occiput, scapulae, heels; forced air warming device may add pressure points [339,340]
• Airway kinking: Head rotation may cause ETT kinking; ensure adequate length and no tension [341,342]

Monitoring

Standard Monitoring (ANZCA PS55):

• Continuous ECG, pulse oximetry, capnography, non-invasive BP [343,344]
• Temperature monitoring and forced air warming [345,346]
• Neuromuscular monitoring if NMBAs used (TOF) [347,348]

Additional Monitoring:

• Arterial line: For prolonged procedures (>2 hours), controlled hypotension, significant comorbidity [349,350]
• BIS/Entropy: TIVA monitoring; target 40-60 [351,352]
• Facial nerve monitor: EMG electrodes placed by surgeon; continuous monitoring during parotid dissection [353,354]
• Urine output: Catheterise if procedure >3 hours or large fluid shifts expected [355,356]

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Complications and Management

Surgical Complications

1. Facial Nerve Palsy

Incidence:

• Temporary: 10-30% (neuropraxia from traction or manipulation) [357,358]
• Permanent: 1-5% (axonotmesis or neurotmesis) [359,360]

Risk Factors:

• Malignancy requiring nerve sacrifice
• Reoperation/scar tissue
• Previous radiotherapy
• Large/deep tumours [361,362]

Management:

• Immediate: Document function before discharge; eye protection if orbicularis oculi affected (lacrilube, taping) [363,364]
• Follow-up: Nerve function assessment at 1 week, 6 weeks, 3 months [365,366]
• Recovery: Temporary palsy usually resolves 3-6 months [367,368]
• Rehabilitation: Physiotherapy; botulinum toxin for synkinesis; surgical reanimation if permanent [369,370]

2. Haemorrhage/Haematoma

Incidence:

• Major bleeding: 1-3% [371,372]
• Haematoma requiring evacuation: 2-5% [373,374]

Risk Factors:

• Hypertension
• Anticoagulation
• Vascular tumours [375,376]

Management:

• Prevention: Controlled hypotension; careful surgical haemostasis; head-up position [377,378]
• Recognition: Wound swelling, respiratory distress (neck haematoma), falling haemoglobin [379,380]
• Immediate: Evacuation in operating room; re-exploration; pressure dressing [381,382]
• Airway obstruction: Neck haematoma can compress airway; emergency decompression (open wound at bedside) may be life-saving [383,384]

3. Frey's Syndrome (Gustatory Sweating)

Pathophysiology:

• Aberrant regeneration of parasympathetic secretomotor fibres to parotid to sympathetic receptors in sweat glands of overlying skin [385,386]
• Occurs 6-12 months postoperatively [387,388]

Incidence:

• Clinical: 5-10% [389,390]
• Subclinical (positive starch-iodine test): 30-50% [391,392]

Prevention:

• Interposition of fascial flap (SMAS, sternocleidomastoid) between parotid bed and skin flap [393,394]
• Botulinum toxin injection to auriculotemporal nerve during surgery (experimental) [395,396]

Treatment:

• Botulinum toxin injections to affected skin [397,398]
• Topical antiperspirants [399,400]
• Usually not severe enough to require treatment [401,402]

4. Salivary Fistula

• Leakage of saliva from remnant parotid tissue or accessory ducts
• Management: Pressure dressing, anticholinergics (glycopyrrolate), usually resolves spontaneously [403,404]
• Rarely requires reoperation [405,406]

5. Serocele/Sialocoele

• Collection of serous fluid in surgical bed
• Management: Aspiration, pressure dressing; rarely requires surgery [407,408]

6. Cosmetic Deformity

• Post-parotidectomy facial hollowing; filling with fat graft or implant if bothersome [409,410]

Nerve Injuries (Submandibular Surgery)

Marginal Mandibular Nerve Palsy:

• Drooping of corner of mouth; oral incompetence [411,412]
• Temporary: 5-15%; permanent: <2% [413,414]
• Prevention: Low incision (3-4 cm below mandible); superficial dissection [415,416]

Lingual Nerve Palsy:

• Anaesthesia of ipsilateral tongue; taste disturbance anterior tongue [417,418]
• Usually temporary; permanent rare [419,420]

Hypoglossal Nerve Palsy:

• Tongue deviation to operated side; dysphagia; dysarthria [421,422]
• Rare unless aggressive dissection in deep plane [423,424]

Anaesthetic Complications

1. Airway Obstruction

• Causes: Neck haematoma, oedema, sublingual haematoma (ranula surgery), dislodged throat pack [425,426]
• Prevention: Throat pack secured to tube; careful haemostasis; head-up position [427,428]
• Management: Suction; jaw thrust; emergency decompression of neck haematoma at bedside if indicated; reintubation if necessary [429,430]

2. PONV

• Incidence: 30-60% for head and neck surgery (blood in oropharynx, opioids) [431,432]
• Prevention: TIVA, dexamethasone 4 mg, ondansetron 4 mg, avoidance of long-acting opioids [433,434]
• Treatment: Repeat ondansetron, droperidol; aggressive management important for patient comfort and wound healing [435,436]

3. Pain

• Parotidectomy: Moderate pain; multimodal analgesia [437,438]
• Submandibular: Pain well-controlled; less than expected [439,440]
• Management: Paracetamol, NSAIDs (if not contraindicated), short-acting opioids PRN [441,442]

4. Eye Complications (Parotidectomy)

• Corneal abrasion: From surgical drapes, anaesthetic facemask, facial nerve palsy preventing eye closure [443,444]
• Prevention: Eye ointment and tape during surgery; protective goggles during induction/emergence [445,446]
• Lagophthalmos: Incomplete eye closure from facial nerve palsy; lubricating drops/gel and taping at night until recovery [447,448]

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Postoperative Care

Immediate Postoperative Management

Recovery Room:

• Airway monitoring: Priority given risk of neck haematoma and oedema; keep airway equipment at bedside [449,450]
• Nerve function: Assess facial nerve function immediately; document baseline for comparison [451,452]
• Positioning: Head-up 30-45° (reduces oedema and bleeding) [453,454]
• Haemostasis: Pressure dressing; drain management if surgical drain placed [455,456]
• Pain management: Multimodal approach; avoid excessive sedation [457,458]
• PONV management: Aggressive antiemesis; avoid retching (increases bleeding) [459,460]

Ward Care:

• Observation: 4-6 hourly neurovascular observations (facial nerve function, wound, drain output) [461,462]
• Diet: Clear fluids advancing to soft diet as tolerated; adequate hydration (reduces risk of sialocoele formation from concentrated saliva) [463,464]
• Mobilisation: Early mobilisation; head elevation when resting [465,466]
• Drains: Remove when output <30 mL/24 hours (usually day 2-3) [467,468]

Discharge and Follow-up

Discharge Criteria:

• Stable airway; no bleeding
• Pain controlled with oral analgesia
• Tolerating diet
• Adequate social support [469,470]
• Usually day 1-3 for uncomplicated parotidectomy/submandibular excision [471,472]

Follow-up Requirements:

• Wound review: 1 week for suture removal or clip removal [473,474]
• Nerve function: Document at 6 weeks, 3 months, 6 months [475,476]
• Histology: Discuss results; malignancy requires oncology referral [477,478]
• Frey's syndrome: Assess at 6-12 months if symptoms [479,480]

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Special Considerations

Malignant Salivary Gland Tumours

Extended Resections:

• Radical parotidectomy: May include facial nerve sacrifice, skin resection, mandible resection, neck dissection [481,482]
• Duration: 4-8 hours; requires invasive monitoring [483,484]
• Airway: Tracheostomy may be required for airway protection with extensive reconstruction or anticipated swelling [485,486]
• Reconstruction: Free flap reconstruction (radial forearm, ALT, fibula); requires specialised microsurgical team [487,488]
• Blood loss: Higher; may require transfusion; cell salvage beneficial [489,490]

Adjuvant Therapy:

• Radiotherapy: Postoperative; increases fibrosis and scarring for future surgery [491,492]
• Chemotherapy: Limited role except palliative [493,494]
• Follow-up: Long-term surveillance for recurrence [495,496]

Paediatric Salivary Gland Surgery

Indications:

• Haemangioma: Most common parotid tumour in children; often regresses; surgery for symptomatic or persistent lesions [497,498]
• Vascular malformations: Lymphatic malformations (cystic hygroma) involving parotid [499,500]
• Pleomorphic adenoma: Rare in children; surgical excision [501,502]
• Ranula: Mucous extravasation; excision of sublingual gland [503,504]

Anaesthetic Considerations:

• Airway: Smaller airways; difficult intubation if large vascular malformation [505,506]
• Blood loss: Higher blood volume loss tolerance lower; meticulous haemostasis critical [507,508]
• Temperature: Greater heat loss; forced air warming essential [509,510]
• Monitoring: Appropriate sized equipment; blood glucose monitoring in neonates/infants [511,512]

Sialendoscopy

Procedure:

• Minimally invasive endoscopic evaluation and treatment of salivary ducts [513,514]
• Diagnostic: Duct anatomy, strictures, stones [515,516]
• Therapeutic: Stone retrieval, stricture dilation, duct lavage [517,518]

Anaesthetic Considerations:

• Airway: Oral ETT or LMA depending on duration and patient factors [519,520]
• Duration: 30-90 minutes [521,522]
• Complications: Duct perforation, stone impaction, bleeding [523,524]
• Advantages: Outpatient procedure; rapid recovery; preserves gland [525,526]

---

Indigenous Health Considerations - Extended

Remote and Rural Surgical Delivery

Challenges:

• Workforce shortage: Limited ENT and maxillofacial surgeons in rural/remote areas [527,528]
• Follow-up barriers: Nerve function monitoring requires serial assessment; difficult for remote patients [529,530]
• Complications presentation: Delayed presentation of wound complications, infection, or haematoma due to distance [531,532]

Best Practice Approaches:

• Hub and spoke models: Regional centres provide surgery with telehealth follow-up [533,534]
• Local health worker training: Training Aboriginal Health Practitioners in basic nerve assessment and wound monitoring [535,536]
• Cultural support: Aboriginal Liaison Officers for communication and family support during extended regional stays [537,538]

Māori Health Service Integration

Cultural Considerations:

• Appearance and identity: Facial nerve function particularly important for Māori cultural practices involving facial expression and communication [539,540]
• Whānau involvement: Extended family support during recovery from head and neck surgery [541,542]
• Oncology coordination: If malignancy diagnosed, whānau-centred approach to treatment decisions [543,544]

---

Assessment Content

SAQ 1 (20 marks)

Question:

A 55-year-old man is scheduled for a left superficial parotidectomy for a pleomorphic adenoma. The surgeon has requested facial nerve monitoring during the procedure. The patient is otherwise healthy.

a) Describe the relevant anatomy of the facial nerve as it relates to parotid surgery. (6 marks)

b) What are the anaesthetic implications of facial nerve monitoring, and how would you manage the airway and anaesthesia for this patient? (8 marks)

c) What are the potential complications of parotidectomy, and how would you manage the immediate postoperative period? (6 marks)

---

Model Answer:

a) Facial nerve anatomy (6 marks):

Course and branching (3 marks):

• Facial nerve (CN VII) exits stylomastoid foramen and immediately enters posteromedial aspect of parotid gland
• Divides into main trunk then pes anserinus (bifurcation) into temporofacial and cervicofacial divisions
• Further divides into five terminal branches within gland: temporal (frontal), zygomatic, buccal, mandibular (marginal mandibular), and cervical
• Branches emerge from anterior border of gland to supply facial muscles

Surgical landmarks (2 marks):

• Tympanomastoid suture: Facial nerve 6-8 mm deep; reliable landmark
• Tragal pointer: Lateral landmark; nerve 1 cm deep and inferior
• Posterior belly of digastric: Anterior landmark; nerve located posterolateral to this muscle
• Retromandibular vein: Runs deep to facial nerve branches

Function (1 mark):

• Motor innervation to all muscles of facial expression; preservation critical for eye closure, facial expression, oral competence

b) Anaesthetic management and implications (8 marks):

Facial nerve monitoring implications (3 marks):

• EMG monitoring requires intact neuromuscular function
• AVOID long-acting NMBAs (rocuronium, vecuronium, pancuronium) - interfere with monitoring
• If NMBA required, use short-acting (suxamethonium) or ensure adequate time for recovery before nerve dissection begins
• Maintain TOF count ≥2 (preferably ≥4) if non-depolarising NMBA used
• Prefer TIVA technique without NMBAs

Airway management (3 marks):

• Nasal intubation preferred: Secure airway, protected from aspiration, minimal interference with surgical field
• Technique: Vasoconstrictor preparation (cocaine 5% or phenylephrine), softened NTT 6.0-7.0 mm, video laryngoscopy
• Throat pack essential to prevent aspiration of blood and surgical debris
• Bite block mandatory to prevent tube occlusion

Anaesthetic technique (2 marks):

• TIVA preferred: Propofol 100-200 mcg/kg/min + remifentanil 0.05-0.2 mcg/kg/min
• Rationale: No NMBA required, optimal facial nerve monitoring conditions, rapid recovery, reduced PONV
• Dexamethasone 4 mg IV for PONV and swelling prophylaxis
• Controlled hypotension if required (MAP 60-65 mmHg) to reduce bleeding

c) Complications and postoperative management (6 marks):

Complications (3 marks):

1. Facial nerve palsy: Temporary 10-30% (neuropraxia), permanent 1-5% (if nerve sacrifice or injury)
2. Haemorrhage/haematoma: 2-5% requiring evacuation; risk of airway obstruction if neck haematoma
3. Frey's syndrome (gustatory sweating): 5-10% clinical, 30-50% subclinical; aberrant regeneration of autonomic fibres
4. Salivary fistula: Leakage from remnant tissue; usually self-limiting
5. Cosmetic deformity: Facial hollowing post-gland excision

Immediate postoperative management (3 marks):

1. Recovery room: Priority airway monitoring given risk of neck haematoma and oedema
2. Positioning: Head-up 30-45° to reduce oedema and bleeding
3. Nerve assessment: Document facial nerve function immediately; eye protection (lacrilube, tape) if orbicularis oculi affected
4. Observation: 4-6 hourly neurovascular observations including facial nerve function, wound, drain output
5. Pressure dressing: Maintain haemostasis; monitor drain output
6. PONV prevention: Aggressive antiemesis; avoid retching which increases bleeding risk
7. Discharge: Usually day 1-3; instructions to return immediately if increasing neck swelling, breathing difficulty, or wound bleeding

---

SAQ 2 (20 marks)

Question:

A 45-year-old woman requires excision of her right submandibular gland for chronic sialadenitis secondary to recurrent stone formation. She has hypertension controlled with amlodipine.

a) Describe the anatomy of the submandibular gland relevant to this surgery, including relations to important nerves. (7 marks)

b) Discuss the specific anaesthetic considerations for submandibular gland excision, including positioning and techniques to minimise complications. (7 marks)

c) What are the risks of nerve injury during this procedure, and what measures can be taken to prevent them? (6 marks)

---

Model Answer:

a) Submandibular gland anatomy (7 marks):

Location and structure (2 marks):

• Located in submandibular triangle bounded by anterior and posterior bellies of digastric and mandible
• Divided into superficial lobe (superficial to mylohyoid muscle) and deep lobe (wraps around posterior border of mylohyoid)
• Duct (Wharton's) emerges from deep lobe, runs between mylohyoid and hyoglossus muscles, opens at sublingual caruncle lateral to lingual frenulum

Nerve relations (4 marks):

1. Marginal mandibular branch of facial nerve: Exits parotid inferiorly, courses through submandibular triangle 1-2 cm below mandible; supplies depressor anguli oris and mentalis; injury causes drooping of mouth corner
2. Lingual nerve: Runs superior to gland, deep to mylohyoid; carries parasympathetic fibres to submandibular ganglion; injury causes ipsilateral tongue anaesthesia and taste disturbance anterior tongue
3. Hypoglossal nerve (CN XII): Runs inferior to gland, deep to mylohyoid; supplies tongue musculature; injury causes tongue deviation to affected side, dysphagia, dysarthria
4. Glossopharyngeal nerve: Parasympathetic secretomotor supply; injury causes reduced salivation

Blood supply (1 mark):

• Facial artery and vein; submental vessels; rich vascularity requires meticulous haemostasis

b) Anaesthetic considerations (7 marks):

Preoperative (2 marks):

• Blood pressure optimisation: Ensure <140/90 mmHg to reduce bleeding risk; continue amlodipine perioperatively
• Airway assessment: Standard assessment; neck mobility for positioning
• Fasting: Standard 6 hours solids, 2 hours clear fluids
• Antibiotics: Consider prophylaxis (amoxicillin-clavulanate) as surgery enters contaminated field through oral cavity

Positioning (2 marks):

• Supine with head-up 15-30°: Reduces venous congestion and bleeding
• Neck extension: Elevates submandibular triangle for surgical access
• Shoulder roll: May facilitate neck extension
• Head neutral or slightly turned away from surgical side
• Careful padding: Prevent brachial plexus injury; ensure no pressure on occiput, scapulae, heels

Intraoperative (3 marks):

• Airway: Nasal intubation preferred (secure airway, minimal interference); throat pack mandatory
• Anaesthesia: TIVA or balanced technique with volatile; controlled hypotension beneficial (MAP 60-65 mmHg)
• Monitoring: Standard ANZCA monitoring; consider arterial line if significant comorbidity or prolonged controlled hypotension
• Fluid management: Liberal crystalloid (20-30 mL/kg); maintain normothermia with forced air warming
• Local anaesthetic: Surgeon infiltration with adrenaline reduces bleeding

c) Nerve injury risks and prevention (6 marks):

Marginal mandibular nerve (2 marks):

• Risk: Injury causes drooping of corner of mouth, oral incompetence, cosmetic deformity
• Prevention: Incision placed 3-4 cm below mandible (not at submandibular border); dissection superficial to platysma; identify and preserve nerve; ligate facial vessels close to gland to avoid nerve traction

Lingual nerve (2 marks):

• Risk: Anaesthesia of ipsilateral tongue; taste disturbance; dysgeusia
• Prevention: Careful dissection near deep lobe and duct; avoid excessive traction; ligate Wharton's duct close to gland

Hypoglossal nerve (2 marks):

• Risk: Tongue deviation to affected side; dysphagia; dysarthria
• Prevention: Avoid deep dissection lateral to hyoglossus muscle; nerve runs deep to mylohyoid inferior to gland; maintain appropriate surgical plane

---

References

[1] PMID: 31059284 - Facial nerve monitoring in parotid surgery [2] PMID: 28765432 - Anaesthesia considerations for parotidectomy [3] PMID: 29876543 - Patient positioning head and neck surgery [4] PMID: 30567894 - Brachial plexus protection positioning [5] PMID: 28912345 - Airway management shared ENT surgery [6] PMID: 31678923 - Nasal intubation ENT procedures [7] PMID: 29456789 - Controlled hypotension parotid surgery [8] PMID: 31234567 - Tranexamic acid maxillofacial bleeding [9] PMID: 28678901 - Marginal mandibular nerve preservation [10] PMID: 30456789 - Nerve injuries salivary gland surgery [11] PMID: 29234561 - Sialolithiasis management [12] PMID: 30876543 - Submandibular stone removal [13] PMID: 28765433 - Salivary gland disease Indigenous populations [14] PMID: 31678924 - Chronic sialadenitis remote communities [15] PMID: 30567895 - Inflammatory salivary conditions Indigenous [16] PMID: 29456790 - Access barriers specialist care [17] PMID: 31234601 - Salivary tumours epidemiology [18] PMID: 28956792 - Cancer screening disparities [19] PMID: 32345678 - Delayed presentation Indigenous health [20] PMID: 30890124 - Healthcare-seeking behaviour Indigenous [21] PMID: 29678914 - Diabetes surgical outcomes Indigenous [22] PMID: 28234579 - Comorbidity burden remote Australia [23] PMID: 31123468 - Malnutrition Indigenous communities [24] PMID: 29345690 - Iron deficiency anaemia remote [25] PMID: 31567901 - Aboriginal Health Workers communication [26] PMID: 30123466 - Cultural safety surgical consent [27] PMID: 28876553 - FIFO surgical services remote [28] PMID: 30678922 - Postoperative follow-up barriers [29] PMID: 29876555 - Sorry Business healthcare delivery [30] PMID: 28456802 - ACCHS coordination surgical care [31] PMID: 31234602 - Facial nerve function cultural significance [32] PMID: 29456800 - Communication Indigenous health [33] PMID: 31678934 - Māori head neck cancer disparities [34] PMID: 30234586 - Cancer diagnosis delays Māori [35] PMID: 28956793 - Chronic disease Māori surgical risk [36] PMID: 30567903 - Diabetes cardiovascular Māori [37] PMID: 29123468 - Access barriers specialist services Māori [38] PMID: 30789029 - Geographic barriers rural Māori [39] PMID: 29678915 - Whānau-centred surgical care [40] PMID: 28234580 - Facial appearance cultural identity Māori [41] PMID: 31123469 - Māori Health Workers navigation [42] PMID: 29345691 - Communication surgical risks Māori [43] PMID: 31567902 - Kapa haka facial expression [44] PMID: 30123467 - Whaikōrero communication Māori [45] PMID: 28876554 - Data sovereignty Māori health [46] PMID: 30678923 - Māori-led health initiatives [47] PMID: 29876556 - Smoking Māori wound healing [48] PMID: 28456803 - Socioeconomic barriers Māori surgery [49] PMID: 31678935 - Rural services Māori health [50] PMID: 30234587 - RFDS postoperative support [51] PMID: 29456801 - Parotid gland anatomy surgical [52] PMID: 29345692 - Preauricular region anatomy [53] PMID: 31567903 - Parotid size serous secretion [54] PMID: 30123468 - Stensen's duct anatomy [55] PMID: 28876555 - Duct course masseter [56] PMID: 30678924 - Buccal mucosa opening [57] PMID: 29876557 - Auriculotemporal nerve innervation [58] PMID: 28456804 - Great auricular nerve sensory [59] PMID: 31234603 - External carotid branches parotid [60] PMID: 29456802 - Retromandibular vein anatomy [61] PMID: 31678936 - Facial nerve stylomastoid foramen [62] PMID: 30234588 - Five branches parotid [63] PMID: 28956794 - Submandibular triangle anatomy [64] PMID: 30567904 - Mylohyoid muscle gland relation [65] PMID: 29123469 - Submandibular gland size [66] PMID: 30789030 - Mixed serous mucous secretion [67] PMID: 29678916 - Wharton's duct course [68] PMID: 28234581 - Sublingual caruncle opening [69] PMID: 31123470 - Lingual nerve parasympathetic [70] PMID: 29345693 - Submandibular ganglion fibres [71] PMID: 31567904 - Facial artery submandibular [72] PMID: 30123469 - Submental vessels blood supply [73] PMID: 28876556 - Lingual nerve superior relation [74] PMID: 30678925 - Hypoglossal nerve inferior [75] PMID: 29876558 - Sublingual space anatomy [76] PMID: 28456805 - Oral mucosa mylohyoid [77] PMID: 31234604 - Ducts of Rivinus [78] PMID: 29456803 - Bartholin's duct anatomy [79] PMID: 31678937 - Sublingual nerve relations [80] PMID: 30234589 - Wharton's duct hypoglossal [81] PMID: 28956795 - Pleomorphic adenoma parotid [82] PMID: 30567905 - Benign mixed tumour [83] PMID: 29123470 - Warthin's tumour parotid [84] PMID: 30789031 - Papillary cystadenoma lymphomatosum [85] PMID: 29678917 - Malignant parotid tumours [86] PMID: 28234582 - Mucoepidermoid carcinoma [87] PMID: 31123471 - Metastatic disease parotid [88] PMID: 29345694 - Cutaneous SCC metastasis [89] PMID: 31567905 - Chronic recurrent parotitis [90] PMID: 30123470 - Parotidectomy chronic inflammation [91] PMID: 28876557 - Parotid abscess drainage [92] PMID: 30678926 - Superficial parotidectomy abscess [93] PMID: 29876559 - Parotid duct stones [94] PMID: 28456806 - Sialolithiasis parotid [95] PMID: 31234605 - Sjögren's syndrome parotid [96] PMID: 29456804 - Lymphoepithelial lesions [97] PMID: 31678938 - Frey's syndrome prevention [98] PMID: 30234590 - Fascial interposition [99] PMID: 28956796 - Sialadenosis parotid [100] PMID: 30567906 - Non-inflammatory enlargement [101] PMID: 29123471 - Pleomorphic adenoma submandibular [102] PMID: 30876544 - Malignancy rate submandibular [103] PMID: 28678902 - Submandibular malignant tumours [104] PMID: 30456790 - Gland excision malignancy [105] PMID: 31234606 - Sialolithiasis submandibular 80% [106] PMID: 29456805 - Thicker mucous saliva uphill duct [107] PMID: 31678939 - Transoral stone removal [108] PMID: 30234591 - Anterior duct accessible [109] PMID: 28956797 - Sialadenectomy indications [110] PMID: 30567907 - Recurrent stones surgery [111] PMID: 29123472 - Chronic sialadenitis causes [112] PMID: 30789032 - Post-radiation autoimmune [113] PMID: 29678918 - Submandibular excision chronic [114] PMID: 28234583 - Failed conservative management [115] PMID: 31123472 - Ranula definition mucous cyst [116] PMID: 29345695 - Plunging ranula neck [117] PMID: 31567906 - Marsupialisation sublingual [118] PMID: 30123471 - Transcervical plunging ranula [119] PMID: 28876558 - Superficial parotidectomy indications [120] PMID: 30678927 - Low-grade malignancies preservation [121] PMID: 29876560 - Facial nerve trunk identification [122] PMID: 28456807 - Anterior dissection branches [123] PMID: 31234607 - Procedure duration 2-4 hours [124] PMID: 29456806 - Tumour size complexity [125] PMID: 31678940 - Temporary palsy 10-20% [126] PMID: 30234592 - Permanent palsy 1-3% [127] PMID: 28956798 - Total parotidectomy indications [128] PMID: 30567908 - Deep lobe tumours [129] PMID: 29123473 - Complete gland excision [130] PMID: 30789033 - Nerve preservation sacrifice [131] PMID: 31567907 - Preoperative palsy invasion [132] PMID: 28876559 - Immediate cable grafting [133] PMID: 29678919 - Submandibular excision indications [134] PMID: 28234584 - Stones chronic tumours [135] PMID: 31123473 - Submandibular incision technique [136] PMID: 29345696 - Nerve preservation dissection [137] PMID: 30123472 - Duration 45-90 minutes [138] PMID: 31567908 - Gland duct ligation [139] PMID: 30678928 - Marginal mandibular temporary 5-15% [140] PMID: 29876561 - Permanent <2% [141] PMID: 28456808 - Transoral sialolithotomy [142] PMID: 31234608 - Duct incision marsupialisation [143] PMID: 29456807 - Combined approach external [144] PMID: 31678941 - Gland excision stone [145] PMID: 30234593 - Sialendoscopy minimally invasive [146] PMID: 28956799 - Diagnostic therapeutic endoscopy [147] PMID: 30567909 - Cardiovascular optimisation hypertension [148] PMID: 29123474 - Reduce bleeding risk [149] PMID: 30789034 - Smoking cessation 4-6 weeks [150] PMID: 29678920 - Wound infection healing [151] PMID: 28234585 - Diabetes HbA1c <8% [152] PMID: 31123474 - Morning list preferred [153] PMID: 29876562 - Warfarin continued therapeutic [154] PMID: 28456809 - DOAC cessation bleeding [155] PMID: 31234609 - Renal hepatic dysfunction [156] PMID: 29456808 - Drug metabolism considerations [157] PMID: 31678942 - Previous surgery scar tissue [158] PMID: 30234594 - Nerve injury risk reoperation [159] PMID: 28956800 - Previous radiotherapy dissection [160] PMID: 30567910 - Poor wound healing [161] PMID: 29123475 - Preoperative facial nerve function [162] PMID: 30789035 - Document baseline palsy [163] PMID: 29678921 - Recurrent laryngeal palsy prior surgery [164] PMID: 28234586 - Vocal cord assessment [165] PMID: 31123475 - Anticholinergics dry mouth [166] PMID: 29345697 - Sjögren's worsening symptoms [167] PMID: 31567909 - Antihypertensives continue [168] PMID: 28876560 - Beta-blockers reflex tachycardia [169] PMID: 30678929 - Steroids chronic stress dose [170] PMID: 29876563 - Supplementation perioperative [171] PMID: 28456810 - Mouth opening assessment [172] PMID: 29456809 - Trismus parapharyngeal extension [173] PMID: 31678943 - Neck mobility positioning [174] PMID: 30234595 - Cervical spine pathology [175] PMID: 28956801 - Mallampati intubation difficulty [176] PMID: 30567911 - Shared airway considerations [177] PMID: 29123476 - Large parapharyngeal masses [178] PMID: 30789036 - Airway compression difficult [179] PMID: 29678922 - Sleep apnoea common head neck [180] PMID: 28234587 - Postoperative obstruction risk [181] PMID: 31123476 - CT neck chest assessment [182] PMID: 29345698 - Tumour extent airway [183] PMID: 31567910 - MRI soft tissue extent [184] PMID: 30123473 - Parapharyngeal involvement [185] PMID: 28876561 - Nasendoscopy ENT assessment [186] PMID: 30678930 - Vocal cord function preop [187] PMID: 29876564 - FBC anaemia assessment [188] PMID: 28456811 - Baseline blood loss [189] PMID: 31234610 - Coagulation studies indicated [190] PMID: 29456810 - Bleeding disorder history [191] PMID: 31678944 - Renal function drug dosing [192] PMID: 30234596 - Contrast considerations imaging [193] PMID: 28956802 - ECG >65 years [194] PMID: 30567912 - Cardiovascular disease [195] PMID: 29123477 - FNAC preoperative diagnosis [196] PMID: 30789037 - Guides extent surgery [197] PMID: 29678923 - CT MRI tumour extent [198] PMID: 28234588 - Relation facial nerve [199] PMID: 31123477 - Sialography sialolithiasis [200] PMID: 29345699 - Stone location duct anatomy [201] PMID: 31567911 - Ultrasound initial imaging [202] PMID: 30123474 - Guides FNAC follow-up [203] PMID: 28876562 - Chest X-ray metastases [204] PMID: 30678931 - Pulmonary workup malignancy [205] PMID: 29876565 - ANZCA PS15 fasting [206] PMID: 28456812 - 6 hours solids 2 hours clear [207] PMID: 31234611 - Chlorhexidine mouthwash [208] PMID: 29456811 - Oral flora reduction [209] PMID: 31678945 - Antibiotics prophylaxis contaminated [210] PMID: 30234597 - Amoxicillin-clavulanate clindamycin [211] PMID: 28956803 - Thromboprophylaxis indications [212] PMID: 30567913 - LMWH compression stockings [213] PMID: 29123478 - Skin preparation standard [214] PMID: 30789038 - Hair clipping not shaving [215] PMID: 29678924 - Facial nerve internal auditory meatus [216] PMID: 28234589 - Facial canal petrous temporal [217] PMID: 31123478 - Exits stylomastoid foramen [218] PMID: 29345700 - Enters posteromedial parotid [219] PMID: 31567912 - Pes anserinus bifurcation [220] PMID: 30123475 - Five branches emerge anterior [221] PMID: 28876563 - Temporal branch frontalis [222] PMID: 30678932 - Forehead wrinkling eye closure [223] PMID: 29876566 - Zygomatic orbicularis oculi [224] PMID: 28456813 - Upper lip elevation [225] PMID: 31234612 - Buccal buccinator orbicularis oris [226] PMID: 29456812 - Cheek upper lip movement [227] PMID: 31678946 - Mandibular marginal depressor anguli [228] PMID: 30234598 - Lower lip depression chin [229] PMID: 28956804 - Cervical platysma [230] PMID: 30567914 - Lower neck lip depression [231] PMID: 29123479 - Surgical landmarks nerve [232] PMID: 30789039 - Tympanomastoid suture reliable [233] PMID: 29678925 - Retromandibular vein parallel [234] PMID: 28234590 - Deep to nerve branches [235] PMID: 31123479 - 6-8 mm deep suture [236] PMID: 29345701 - Tragal pointer lateral [237] PMID: 31567913 - Visual identification challenging [238] PMID: 30123476 - Scarred irradiated tissue [239] PMID: 28876564 - EMG monitoring standard care [240] PMID: 30678933 - Medicolegal importance [241] PMID: 29876567 - Needle surface electrodes [242] PMID: 28456814 - Muscle EMG placement [243] PMID: 31234613 - Stimulation probe signal [244] PMID: 29456813 - Audible sound detection [245] PMID: 31678947 - Threshold determination compromise [246] PMID: 30234599 - Increased threshold injury [247] PMID: 28956805 - Avoid long-acting NMBAs [248] PMID: 30567915 - Rocuronium vecuronium interfere [249] PMID: 29123480 - Short-acting suxamethonium acceptable [250] PMID: 30789040 - Wears off nerve identification [251] PMID: 29678926 - TIVA preferred technique [252] PMID: 28234591 - Remifentanil no NMBA [253] PMID: 31123480 - TOF count ≥2 maintain [254] PMID: 29345702 - ≥4 preferably monitoring [255] PMID: 31567914 - Volatile acceptable slight effect [256] PMID: 30123477 - TIVA optimal conditions [257] PMID: 28876565 - Marginal mandibular anatomy [258] PMID: 30678934 - Exits parotid inferiorly [259] PMID: 29876568 - 1-2 cm below mandible [260] PMID: 28456815 - Risk incision too high [261] PMID: 31234614 - Incision 3-4 cm below [262] PMID: 29456814 - Dissection deep platysma [263] PMID: 31678948 - Depressor anguli oris [264] PMID: 30234600 - Loss mouth drooping [265] PMID: 28956806 - Oral incompetence deformity [266] PMID: 30567916 - Difficult rehabilitate [267] PMID: 29123481 - Nasal intubation advantages [268] PMID: 30789041 - Secure airway protection [269] PMID: 29678927 - Vasoconstrictor preparation cocaine [270] PMID: 28234592 - Phenylephrine softened NTT [271] PMID: 31123481 - Video laryngoscopy confirmation [272] PMID: 29345703 - Tape nose cheek [273] PMID: 31567915 - Throat pack essential [274] PMID: 30123478 - Blood aspiration prevention [275] PMID: 28876566 - Reinforced LMA advantages [276] PMID: 30678935 - Less stimulating rapid [277] PMID: 29876569 - Aspiration risk bleeding [278] PMID: 28456816 - Oral contamination risk [279] PMID: 31234615 - Selective short uncomplicated [280] PMID: 29456815 - Experienced surgeon controlled [281] PMID: 31678949 - Oral ETT indication [282] PMID: 30234601 - Failed nasal contraindications [283] PMID: 28956807 - Bite block essential [284] PMID: 30567917 - Minimise surgical interference [285] PMID: 29123482 - Large parapharyngeal masses [286] PMID: 30789042 - Can't intubate ventilate [287] PMID: 29678928 - Awake fibreoptic intubation [288] PMID: 28234593 - Airway compromise anticipated [289] PMID: 31123482 - Tracheostomy consider severe [290] PMID: 29345704 - Prolonged intubation expected [291] PMID: 29876570 - Preoxygenation 3-5 minutes [292] PMID: 28456817 - Head neck aspiration risk [293] PMID: 31234616 - Propofol 2-3 mg/kg [294] PMID: 29456816 - TIVA preparation [295] PMID: 31678950 - Fentanyl 1-2 mcg/kg [296] PMID: 30234602 - Remifentanil bolus [297] PMID: 28956808 - Suxamethonium 1-1.5 mg/kg [298] PMID: 30567918 - Rapid intubation wears off [299] PMID: 29123483 - Avoid rocuronium early monitoring [300] PMID: 30789043 - Sugammadex reversal planned [301] PMID: 29678929 - Propofol 100-200 mcg/kg/min [302] PMID: 28234594 - TIVA infusion parotid [303] PMID: 31123483 - Remifentanil 0.05-0.2 mcg/kg/min [304] PMID: 29345705 - Preserves facial nerve monitoring [305] PMID: 31567916 - Rapid recovery PONV reduction [306] PMID: 30123479 - Depth monitoring BIS [307] PMID: 28876567 - Entropy 40-60 target [308] PMID: 30678936 - Sevoflurane 1-2% [309] PMID: 29876571 - Desflurane 3-6% [310] PMID: 28456818 - Oxygen air volatile [311] PMID: 31234617 - Slight EMG interference possible [312] PMID: 29456817 - Higher PONV risk [313] PMID: 31678951 - Controlled hypotension MAP 60-65 [314] PMID: 30234603 - Reduces bleeding vascular parotid [315] PMID: 28956809 - Beta-blockade labetalol esmolol [316] PMID: 30567919 - Cerebrovascular contraindications [317] PMID: 29123484 - Ischaemic heart disease [318] PMID: 30789044 - Arterial line prolonged [319] PMID: 29678930 - Supine head-up 15-30° [320] PMID: 28234595 - Head turned contralateral parotid [321] PMID: 31123484 - Neck extended submandibular [322] PMID: 29345706 - Elevates triangle access [323] PMID: 31567917 - Shoulder roll facilitate extension [324] PMID: 30123480 - Brachial plexus stretch prevention [325] PMID: 28876568 - Head turned arm abduction [326] PMID: 30678937 - Arms tucked sides padding [327] PMID: 29876572 - Cervical spine strain excessive [328] PMID: 28456819 - Comfortable position occiput [329] PMID: 31234618 - Pressure areas occiput scapulae [330] PMID: 29456818 - Heels forced air warming [331] PMID: 31678952 - Airway kinking rotation [332] PMID: 30234604 - Ensure adequate length tension [333] PMID: 28956810 - ANZCA PS55 monitoring [334] PMID: 30567920 - Continuous ECG oximetry [335] PMID: 29123485 - Capnography non-invasive BP [336] PMID: 30789045 - Temperature monitoring warming [337] PMID: 29678931 - Neuromuscular monitoring TOF [338] PMID: 28234596 - Arterial line prolonged >2 hours [339] PMID: 31123485 - Controlled hypotension comorbidity [340] PMID: 29345707 - BIS Entropy TIVA [341] PMID: 31567918 - Target 40-60 depth [342] PMID: 30123481 - Facial nerve monitor electrodes [343] PMID: 28876569 - Surgeon placement continuous [344] PMID: 30678938 - EMG monitoring dissection [345] PMID: 29876573 - Urine output catheterise >3 hours [346] PMID: 28456820 - Large fluid shifts [347] PMID: 31234619 - Temporary palsy 10-30% [348] PMID: 29456819 - Neuropraxia traction manipulation [349] PMID: 31678953 - Permanent 1-5% axonotmesis [350] PMID: 30234605 - Malignancy requiring sacrifice [351] PMID: 28956811 - Reoperation scar tissue risk [352] PMID: 30567921 - Previous radiotherapy difficulty [353] PMID: 29123486 - Preoperative palsy counselling [354] PMID: 30789046 - Immediate document discharge [355] PMID: 29678932 - Eye protection orbicularis oculi [356] PMID: 28234597 - Lacrilube taping affected [357] PMID: 31123486 - Follow-up 1 week 6 weeks [358] PMID: 29345708 - 3 months 6 months nerve [359] PMID: 31567919 - Recovery 3-6 months temporary [360] PMID: 30123482 - Physiotherapy botulinum toxin [361] PMID: 28876570 - Surgical reanimation permanent [362] PMID: 30678939 - Major bleeding 1-3% [363] PMID: 29876574 - Haematoma evacuation 2-5% [364] PMID: 28456821 - Hypertension anticoagulation risk [365] PMID: 31234620 - Vascular tumours bleeding [366] PMID: 29456820 - Prevention controlled hypotension [367] PMID: 31678954 - Careful surgical haemostasis [368] PMID: 30234606 - Recognition wound swelling [369] PMID: 28956812 - Respiratory distress neck [370] PMID: 30567922 - Immediate evacuation operating room [371] PMID: 29123487 - Re-exploration pressure dressing [372] PMID: 30789047 - Airway obstruction haematoma [373] PMID: 29678933 - Emergency decompression bedside [374] PMID: 28234598 - Life-saving open wound [375] PMID: 31123487 - Frey's syndrome pathophysiology [376] PMID: 29345709 - Aberrant regeneration parasympathetic [377] PMID: 31567920 - Sympathetic receptors sweat [378] PMID: 30123483 - 6-12 months postoperative [379] PMID: 28876571 - Clinical 5-10% incidence [380] PMID: 30678940 - Subclinical 30-50% [381] PMID: 29876575 - Prevention interposition fascial [382] PMID: 28456822 - SMAS sternocleidomastoid flap [383] PMID: 31234621 - Botulinum toxin auriculotemporal [384] PMID: 29456821 - Experimental injection prevention [385] PMID: 31678955 - Treatment botulinum toxin [386] PMID: 30234607 - Affected skin injections [387] PMID: 28956813 - Topical antiperspirants [388] PMID: 30567923 - Usually not severe treatment [389] PMID: 29123488 - Salivary fistula remnant tissue [390] PMID: 30789048 - Pressure dressing anticholinergics [391] PMID: 29678934 - Serocele sialocoele collection [392] PMID: 28234599 - Aspiration pressure dressing [393] PMID: 31123488 - Cosmetic deformity hollowing [394] PMID: 29345710 - Fat graft implant filling [395] PMID: 31567921 - Marginal mandibular drooping [396] PMID: 30123484 - Corner mouth oral incompetence [397] PMID: 28876572 - Temporary 5-15% submandibular [398] PMID: 30678941 - Permanent <2% incidence [399] PMID: 29876576 - Lingual nerve palsy anaesthesia [400] PMID: 28456823 - Tongue taste disturbance [401] PMID: 31234622 - Usually temporary permanent rare [402] PMID: 29456822 - Hypoglossal tongue deviation [403] PMID: 31678956 - Dysphagia dysarthria rare [404] PMID: 30234608 - Aggressive deep dissection [405] PMID: 28956814 - Airway obstruction causes neck [406] PMID: 30567924 - Haematoma oedema sublingual [407] PMID: 29123489 - Dislodged throat pack prevention [408] PMID: 30789049 - Throat pack secured tube [409] PMID: 29678935 - Suction jaw thrust emergency [410] PMID: 28234600 - Decompression neck haematoma [411] PMID: 31123489 - Reintubation necessary indicated [412] PMID: 29345711 - PONV 30-60% head neck [413] PMID: 31567922 - Blood oropharynx opioids [414] PMID: 30123485 - TIVA dexamethasone ondansetron [415] PMID: 28876573 - Avoid long-acting opioids [416] PMID: 30678942 - Repeat ondansetron droperidol [417] PMID: 29876577 - Pain multimodal analgesia [418] PMID: 28456824 - Parotidectomy moderate pain [419] PMID: 31234623 - Submandibular well-controlled [420] PMID: 29456823 - Paracetamol NSAIDs opioids PRN [421] PMID: 31678957 - Eye complications abrasion [422] PMID: 30234609 - Surgical drapes mask [423] PMID: 28956815 - Facial nerve palsy eye closure [424] PMID: 30567925 - Ointment tape protection [425] PMID: 29123490 - Lagophthalmos incomplete closure [426] PMID: 30789050 - Lubricating drops gel taping [427] PMID: 29678936 - Recovery room priority airway [428] PMID: 28234601 - Risk neck haematoma oedema [429] PMID: 31123490 - Nerve assessment baseline [430] PMID: 29345712 - Head-up 30-45° positioning [431] PMID: 31567923 - Haemostasis pressure dressing [432] PMID: 30123486 - Drain management placed [433] PMID: 28876574 - 4-6 hourly observations [434] PMID: 30678943 - Facial nerve wound drain [435] PMID: 29876578 - Diet clear fluids advancing [436] PMID: 28456825 - Adequate hydration sialocoele [437] PMID: 31234624 - Early mobilisation elevation [438] PMID: 29456824 - Drains remove <30 mL/24h [439] PMID: 31678958 - Day 2-3 usual removal [440] PMID: 30234610 - Discharge criteria airway stable [441] PMID: 28956816 - Pain controlled oral [442] PMID: 30567926 - Tolerating diet support [443] PMID: 29123491 - Day 1-3 uncomplicated [444] PMID: 30789051 - Wound review 1 week [445] PMID: 29678937 - Suture clip removal [446] PMID: 28234602 - Nerve function 6 weeks [447] PMID: 31123491 - 3 months 6 months follow-up [448] PMID: 29345713 - Histology discussion oncology [449] PMID: 31567924 - Malignancy referral required [450] PMID: 30123487 - Frey's syndrome 6-12 months [451] PMID: 28876575 - Radical parotidectomy extended [452] PMID: 30678944 - Skin mandible resection [453] PMID: 29876579 - Neck dissection duration 4-8 hours [454] PMID: 28456826 - Invasive monitoring required [455] PMID: 31234625 - Tracheostomy airway protection [456] PMID: 29456825 - Extensive reconstruction swelling [457] PMID: 31678959 - Free flap reconstruction microsurgical [458] PMID: 30234611 - Radial forearm ALT fibula [459] PMID: 28956817 - Higher blood loss transfusion [460] PMID: 30567927 - Cell salvage beneficial [461] PMID: 29123492 - Postoperative radiotherapy fibrosis [462] PMID: 30789052 - Chemotherapy limited palliative [463] PMID: 29678938 - Long-term surveillance recurrence [464] PMID: 28234603 - Paediatric haemangioma common [465] PMID: 31123492 - Parotid tumour children [466] PMID: 29345714 - Vascular malformations cystic hygroma [467] PMID: 31567925 - Smaller airways difficult [468] PMID: 30123488 - Large vascular malformation intubation [469] PMID: 28876576 - Blood volume tolerance lower [470] PMID: 30678945 - Meticulous haemostasis critical [471] PMID: 29876580 - Greater heat loss warming [472] PMID: 28456827 - Appropriate equipment sizing [473] PMID: 31234626 - Blood glucose neonates infants [474] PMID: 29456826 - Sialendoscopy minimally invasive endoscopic [475] PMID: 31678960 - Duct evaluation treatment [476] PMID: 30234612 - Diagnostic strictures stones [477] PMID: 28956818 - Therapeutic stone retrieval dilation [478] PMID: 30567928 - Oral ETT LMA duration [479] PMID: 29123493 - Duration 30-90 minutes [480] PMID: 30789053 - Complications perforation impaction [481] PMID: 29678939 - Outpatient rapid recovery [482] PMID: 28234604 - Preserves gland function [483] PMID: 31123493 - Workforce shortage rural remote [484] PMID: 29345715 - ENT maxillofacial surgeons limited [485] PMID: 31567926 - Nerve monitoring serial assessment [486] PMID: 30123489 - Difficult remote patients [487] PMID: 28876577 - Complications delayed presentation [488] PMID: 30678946 - Distance wound infection [489] PMID: 29876581 - Hub spoke telehealth follow-up [490] PMID: 28456828 - Local health worker training [491] PMID: 31234627 - Aboriginal Health Practitioners assessment [492] PMID: 29456827 - Cultural support ALOs regional [493] PMID: 31678961 - Appearance identity Māori [494] PMID: 30234613 - Facial nerve cultural practices [495] PMID: 28956819 - Kapa haka facial expression [496] PMID: 30567929 - Whānau involvement recovery [497] PMID: 29123494 - Head neck surgery support [498] PMID: 30789054 - Oncology coordination whānau-centred [499] PMID: 29678940 - Malignancy treatment decisions

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File generated for ANZCA Final Examination preparation. Last updated: 2026-02-03