BILATERAL PAROTID ENLARGEMENT

What causes both parotid glands to get larger? The parotid glands are the largest salivary glands located on either side of the face, just in front & under the ears. When they get larger, they change the whole structure and outline of the face.

There are a variety of possible causes of bilateral parotid enlargement (Table 1). Some cause the glands to only enlarge and others also cause pain and discomfort. The most common reasons for bilateral parotid swelling are sialosis and eating disorders such as Bulimia & Anorexia.

BILATERAL MICRO-PAROTIDECTOMIES FOR SIALOSIS
CROSS SECTION OF THE HEAD
SHOWING NORMAL PAROTID GLANDS
BILATERAL PAROTID ENLARGEMENT

TREATMENT

Viral infections – There is no treatment for Mumps. We can only help our patients that have mumps by treating their symptoms. We encourage our patients to hydrate well to prevent the salivary glands from getting into further problems. Generally, the swelling of the glands resolves after the infection is over and the person has recovered.

HIV-related cystic disease only requires treatment if the cysts are much larger & are disfiguring or if they keep getting infected. In which case, a parotidectomy would be done.

Sjögren’s syndrome – In the majority of cases, the only treatment is to manage the symptoms of dry mouth and dry eyes. In rare cases, the parotid gets very large and sometimes painful; the parotid swelling does not respond to treatment anymore, in which case surgery would be considered.

Sarcoidosis – is a systemic inflammatory disease and is usually treated with medical therapy.

Medication induced parotid enlargement – is usually responsive to stopping the medication.

Eating Disorders – This can be a very complex problem, and all aspects of the person’s health need to be considered. First and foremost, the underlying eating disorder needs to be treated by specialists that address the root causes. The salivary issues fall into 2 categories:
1. Those caused by acid causing damage to the ducts inside the gland: Generally speaking, patients suffering from this type of issue have glands that swell up with eating and then subside. As the disease progresses, the time it takes for the swollen gland to calm down becomes longer and longer until the swelling becomes permanent.

  • If caught early, the ducts may be treated by performing sialoendoscopy with dilation of the ducts and steroid treatment of the scarred main ducts.
  • In later stages, when the gland is permanently enlarged, the only option may be bilateral parotid surgery with reconstruction, which can be done through the micro-parotidectomy approach.

Normal saliva ow (Blue) through the duct into the mouth

Acid back owing (Orange) into the duct causing multiple
narrow spots (Red arrows)

2.Those caused by repeated vomiting inducing increased saliva production and thus enlargement of the salivary glands to be able to produce the increased saliva.

  • In early stages of this process, if the underlying eating disorder is treated and the vomiting stops, then the glands have a chance to get smaller on their own.
  • In later stages, the gland permanently changes architecture and always stays large. So it is imperative to address the eating disorder earlier on. If the gland stays permanently large, then the only solution is to perform bilateral parotid surgery with reconstruction.

BILATERAL PAROTID ENLARGEMENT

Surgical pictures of the incision and the removed parotid glands on both sides in a 38-year-old woman who had suffered from an eating disorder. She had fully recovered from Bulimia and had been well for years, but her parotid glands remained large despite conservative measures. The outline of the enlarged parotid glands is marked by the dotted lines.

She had a successful bilateral micro-parotidectomy done on the same day. The advantage of a bilateral procedure is that we can perform bilateral reconstruction and achieve symmetry & facial harmony very easily. It is still an outpatient procedure through the micro-parotidectomy incisions (green lines). The bottom left picture shows the amount of parotid tissue removed from each side (picture transformed into animation).

The images below show bilateral parotid swelling in a 27-year-old woman who had suffered from an eating disorder, but has fully recovered. The bilateral parotid enlargement happened gradually, but for years it has remained the same size without further growth or regression. As she was embarking on the next chapters of her life, she wanted to treat the visible reminder of the disorder; a reminder she could see in the mirror, daily.

She had a successful bilateral micro-parotidectomy with reconstruction. We were able to create great symmetry on the two sides of her face, and show her jawline again. At one week after surgery, she showed remarkable healing and recovery. The one-week pictures were taken by her on her mobile phone from home and sent to us.

Sialosis – Also known as sialadenosis, is a non-inflammatory enlargement of the salivary glands. It is a chronic condition that is usually painless and bilateral. The most common salivary glands affected by sialosis are the parotid glands, however, the submandibular & sublingual glands can also be affected.

The exact cause of sialosis is unknown, but it is thought to be due to a combination of factors, including:

Abnormal nerve function: The salivary glands are innervated by the autonomic nervous system. It is thought that sialosis may be caused by abnormal nerve function that stimulates the salivary glands to become overactive and grow.
Hormonal imbalances: Sialosis has been associated with hormonal imbalances, such as hypothyroidism and diabetes.

Medications: Some medications, such as lithium and diuretics, have been linked to sialosis.

Alcoholism: Alcoholism is a common cause of sialosis.
Nutritional deficiencies: Malnutrition, particularly vitamin A deficiency, has been linked to sialosis.

The symptoms of sialosis can vary depending on the severity of the condition. Some people may experience only mild swelling of the salivary glands, while others may experience more severe swelling, pain, and difficulty opening the mouth.

The diagnosis of sialosis is usually made based on the patient’s medical history and physical examination. Imaging tests, such as ultrasound or MRI scan, may be used to confirm the diagnosis and rule out other conditions. In some cases, a biopsy may be performed to rule out other possible causes of glandular enlargement.

The treatment of sialosis aims to alleviate symptoms and manage any underlying conditions contributing to the disorder. This may involve addressing metabolic disorders, adjusting medications, or providing supportive care for dry mouth symptoms. Saliva substitutes and good oral hygiene practices can help manage the dry mouth symptoms and reduce the risk of dental complications. In severe cases, surgical intervention may be necessary to remove the affected salivary glands.

FREQUENTLY ASKED QUESTIONS

Does bilateral parotid enlargement cause pain?
Depends on the cause. When there is an inflammatory component to the cause, then there is usually pain associated with it. Even if no inflammation is involved, when the glands get very large, they often cause great discomfort.

Can the surgery be done one side at a time?
Yes, although it is not recommended, as creating symmetry is easier when both sides are done at the same time. And the person is exposed to the anesthetic only once. Either way, the surgery is outpatient.

Is this a painful surgery?
Fortunately not. The greater auricular nerve (GAN) that is in charge of sensation of the earlobe and the skin around the ear & parotid is identified, separated & preserved. The processes of separating the GAN causes it to temporarily not work, which means the area of surgery will be numb for the period of time, during which the surgical area heals relatively pain-free. Most patients mainly use Tylenol.

Why is bilateral parotid surgery not commonly done?
It requires a lot of patience and attention to detail. It also takes a long time. In the hands of less experienced surgeons, it seems daunting to tackle both sides at the same time, but with experience and expertise, it is clear that bilateral surgery should be done on the same day, not only for the greater chance to create symmetry and harmony, but also the recovery is not much more when both sides are treated at the same time.

Are the facial nerves monitored and preserved?
Absolutely. Nerve monitoring is done at all times during parotid surgery. Not only are the nerves monitored, but also after the gland is removed, the facial nerves are stimulated with a nerve stimulator to make sure all the branches are functioning appropriately. A lot of time and attention is paid to the identification and preservation of the facial nerves; it is of utmost importance that every branch is preserved.

Can a plastic surgeon perform parotid surgery?
If the plastic surgeon is trained in the field of head & neck surgery, then they will have the appropriate training to do a parotidectomy; however, this is a very intricate surgery that should only be done by surgeons that specialize in parotid surgery. The facial nerve is too important to be operated on by a surgeon that is not always doing this surgery.

STIMULATION OF THE FACIAL NERVES AFTER REMOVING THE TUMOR TO ASSURE ALL BRANCHES ARE WORKING

Does bilateral micro-parotidectomy need to be performed at a hospital, and does it require overnight stay at the hospital?
The answer to both questions is no. This is an outpatient procedure for the majority of patients. The only exceptions are patients who have other medical problems such as heart, lung, or kidney disease that requires more medical attention and monitoring for these particular organs rather than the parotid surgery itself.

Can bilateral micro-parotidectomy be done for out-of-town patients?
Yes. In fact, more than 90% of parotid surgeries done at the CENTER are for patients traveling from out of town or other countries, including bilateral parotidectomies. The complication rates during and after surgery are exceedingly low, and so there is only a 5-day post-surgery observation period when you may need to remain in town and be seen by Dr. Larian (usually 2-3 visits after surgery during the 5 days). The plastic surgery sutures are very fine, absorbable, and under the surface; thus there are no sutures to be removed. In short, the surgery and recovery from micro-parotidectomy is planned for patients to only have a very short stay in Los Angeles.

The images shown here are from a patient that traveled from another state to have the surgery done; it was done at an outpatient surgery center. He did very well. The AFTER surgery pictures were taken by himself from his home and sent to us.

Is there more than one surgeon present during bilateral micro-parotidectomy?
The majority of bilateral parotidectomies and reconstructions are performed by Dr. Larian alone. The more complex cases with larger or more aggressive inflammatory reactions may require the assistance of Dr. Azizzadeh, especially if there is a concern for the health of the facial nerve, or if there is very complicated reconstruction to be done.

What proportion of patients get Frey’s syndrome after micro-parotidectomy?
A very low incidence of Frey’s syndrome, mainly because all patients have parotid reconstruction and the SMAS layer is always preserved, which separates the parotid from the skin.

Meet The Team

Led by board-certified parotid surgeon, Dr. Babak Larian, our team of specialists has decades of experience successfully diagnosing and treating diseases of the parotid glands with minimally invasive procedures. Distinguished by our compassionate care and cutting-edge techniques, the CENTER has developed a reputation for delivering the best parotid tumor surgery available.

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