The document discusses the anatomy, development, disorders, and tumors of the parotid gland. It begins by describing the location and structures of the parotid gland. It then discusses various inflammatory and infectious disorders that can affect the gland such as mumps, bacterial infections, and HIV-associated sialadenitis. Obstructive disorders from stones, strictures, or papillary obstruction are also reviewed. The majority of the document focuses on tumors of the parotid gland, describing the classification and most common tumor types as well as their presentation, investigations, and surgical management.

1. MOSTAFA HEGAZY

2. THE PAROTID GLAND
Anatomy
 The parotid gland lies in a recess bounded by the
ramus of the mandible, the base of the skull and the
mastoid process.
 It lies on the carotid sheath and CNs XI and XII and
extends forward over the masseter muscle.
 The gland is enclosed in a sheath of dense deep
cervical fascia.
 Its upper pole extends just below the zygoma and its
lower pole (tail) into the neck.

3. THE PAROTID GLAND
Anatomy
Several important structures run through the parotid
gland. These include:
● Facial nerve trunk that divides into its major five
branches;
● Terminal branch of the external carotid artery that
divides into the maxillary artery and the superficial
temporal artery;
● Retromandibular vein;
● Intraparotid lymph nodes.

4. THE PAROTID GLAND
Anatomy
 The gland is arbitrarily divided into deep and
superficial lobes, separated by the facial nerve.
 Eighty per cent of the parotid gland lies superficial and
20% deep to the nerve.
 An accessory lobe is occasionally present lying anterior
to the superficial lobe on the masseter muscle.

5. Developmental disorders
 Developmental disorders such as agenesis, duct atresia
and congenital fistula are extremely rare

6. Inflammatory disorders
Viral infections
 Mumps is the most common cause of acute painful
parotid swelling and predominantly affects children.
 It is spread via airborne droplets of infected saliva.
 The disease starts with a prodromal period of 1–2 days,
during which the patient experiences fever, nausea and
headache.
 This is followed by pain and swelling in one or both
parotid glands.

7. Inflammatory disorders
Viral infections
 Parotid pain can be very severe and exacerbated by
eating and drinking.
 Symptoms resolve within 5–10 days.
 The diagnosis is based on history and clinical
examination; recent contact with an infected patient
with a painful parotid swelling is often sufficient to
lead to a diagnosis.

8. Inflammatory disorders
Viral infections
 Atypical viral parotitis does occur and may present
with predominantly unilateral swelling or even
submandibular involvement.
 A single episode of infection confers lifelong
immunity.

9. Inflammatory disorders
Viral infections
 Treatment of mumps is symptomatic with regular
paracetamol and adequate oral fluid intake.
 Complications of orchitis, oophoritis, pancreatitis,
sensorineural deafness and meningoencephalitis are
rare, but are more likely to occur in adults.
 Other viral agents that produce parotitis include
Coxsackie A and B, parainfluenza 1 and 3, Echo and
lymphocytic choriomeningitis.

10. Inflammatory disorders
Bacterial infections
 Acute ascending bacterial sialadenitis is historically
described in dehydrated elderly patients following
major surgery.
 Reduced salivary flow secondary to dehydration results
in ascending infection via the parotid duct into the
parotid parenchyma.
 The more common picture today is an acute bacterial
parotitis associated with a salivary calculus.

11. Inflammatory disorders
Bacterial infections
 The patient presents with a tender, painful parotid
swelling that arises over several hours .
 There is generalized malaise, pyrexia and occasional
cervical lymphadenopathy.
 The pain is exacerbated by eating or drinking.
 The parotid swelling may be diffuse, but often
localizes to the lower pole of the gland.
 Intraoral examination may reveal pus exuding from
the parotid gland papilla

13. Inflammatory disorders
Bacterial infections
 The infecting organism is usually Staphylococcus
aureus or Streptococcus viridans, and treatment is
with appropriate intravenous antibiotics.
 If the gland becomes fluctuant, ultrasound may
identify abscess formation within the gland that may
require aspiration with a large-bore needle or formal
drainage under general anesthesia.

14. Inflammatory disorders
Bacterial infections
 In the latter procedure, the skin incision should be
made low to avoid damage to the lower branch of the
facial nerve.
 Blunt dissection using sinus forceps is preferred, and
the cavity is opened to facilitate drainage.

15. Inflammatory disorders
Bacterial infections
 A drain is inserted and left in situ for 24–72 hours.
 Sialography is contraindicated during acute infection.
 Chronic bacterial sialadenitis is rare in the parotid
gland.

16. Recurrent parotitis of childhood
 Recurrent parotitis of childhood is a distinct clinical
entity of unknown etiology and variable prognosis.
 It is characterized by rapid swelling of one or both
parotid glands, in which the symptoms are made worse
by chewing and eating.
 Systemic upset with fever and malaise is variable.

17. Recurrent parotitis of childhood
 The symptoms usually last from 3 to 7 days, and are
then followed by a quiescent period of weeks to several
months.
 Children usually present between the ages of 3 and 6
years, although symptoms have been reported in
infants as young as 4 months.

18. Recurrent parotitis of childhood
 The diagnosis is based on the characteristic history
and can be confirmed by Sialography.
 This shows a characteristic punctate sialectasis likened
to a ‘snowstorm’ .
 The condition is difficult to manage if it becomes
established and so the initial treatment is important.

19. Characteristic ‘snowstorm’ appearance of recurrent
parotitis of childhood (circled)

20. Recurrent parotitis of childhood
 The condition responds to regular endoscopic
washouts and long courses of antibiotics.
 The suspicion is that in some cases the condition is
caused by an incompetent punctum that leads to
soiling of the parotid ducts with contaminated oral
fluids.

21. Human immunodeficiency virus-associated
sialadenitis
 Chronic parotitis in children may signify human
immunodeficiency virus (HIV) infection.
 The presentation of HIV-associated sialadenitis is very
similar to classical Sjögren’s syndrome in adulthood
 Although HIV-associated sialadenitis and Sjögren’s
syndrome are histologically similar, the former
condition is usually associated with a negative
autoantibody screen.

22. Human immunodeficiency virus-associated
sialadenitis
 Other presentations of salivary gland disease in HIV-
positive patients include multiple parotid cysts, which
 cause gross parotid swelling and facial disfigurement.
 CT and MRI demonstrate the characteristic ‘Swiss
cheese’ appearance of multiple large cystic lesions.
 The swollen glands are usually painless and may
regress on the institution of antiviral therapy.
 Cysts can be aspirated

23. Obstructive parotitis
 There are several causes of obstructive parotitis, which
produces intermittent painful swelling of the parotid
gland, particularly at mealtimes;
 Stone formation and strictures
 Papillary obstruction

24. Obstructive parotitis
Stone formation and strictures
 Sialolithiasis is less common in the parotid gland
(20%) than in the submandibular gland (80%).
 Parotid duct stones are usually radiolucent and rarely
visible on plain radiography.
 They are frequently located at the confluence of the
collecting ducts, at the point the duct courses over the
masseter muscle or in the distal aspect of the parotid
duct adjacent to the parotid papilla.

25. Obstructive parotitis
Stone formation and strictures
 The stones are easily demonstrated on ultrasound.
 The same rules for treatment apply to parotid stones as
to submandibular duct stones. Small stones (~4 mm)
can be retrieved by baskets, slightly larger stones up to
8 mm can be broken with lithotripsy and stones over 8
mm diameter should be removed by endoscopic
assisted surgery while preserving the gland.

26. Obstructive parotitis
Stone formation and strictures
 The stones are easily demonstrated on ultrasound.
 The same rules for treatment apply to parotid stones as
to submandibular duct stones. Small stones (~4 mm)
can be retrieved by baskets, slightly larger stones up to
8 mm can be broken with lithotripsy and stones over 8
mm diameter should be removed by endoscopic
assisted surgery while preserving the gland.

27. Obstructive parotitis
Stone formation and strictures
 Strictures are common in the parotid gland and are
 responsible for about 20% of obstructive cases.
 The symptom complex is a little different as the
obstruction is due to mucus plugs.
 These form after periods of stagnation.
 Classically, the patient complains of a meal-time
syndrome starting at breakfast and the saliva cannot
seep past the mucus plug so the swelling persists.

28. Obstructive parotitis
Stone formation and strictures
 Massage eventually releases the plug with a gush of
salty saliva.
 Infection is uncommon unless there is stone
formation.
 Strictures respond to dilatation and endoscopic
washouts with steroid solutions.

29. Papillary obstruction
 Obstructive parotitis, can be caused by trauma to the
parotid papilla.
 The subsequent inflammation and edema obstructs
salivary flow, particularly at mealtimes.
 This is a rare but real entity.

30. Papillary obstruction
 The partial obstruction over a protracted period leads
to dilation of the duct and an entity called ‘mega-duct’.
 A large dilated duct is visible coursing over the
patient’s cheek.
 Drainage has to be re-established.

31. Papillary obstruction
 This can be done by progressive dilatation of the
punctum and the insertion of a stent that is kept in
position for many weeks.
 Surgical attempts to refashion the punctum are
unlikely to be successful.

32. Papillary obstruction
 Papillotomy should not be performed as this often
leads to stricture formation and a life time of
problems.
 This is not the case with the submandibular gland.

33. Tumors of the parotid gland
The parotid gland is the most common
site for salivary tumors.
Most tumors arise in the superficial lobe
and present as slow-growing, painless
swellings
below the ear
in front of the ear or
in the upper aspect of the neck.

34. Tumors of the parotid gland
Less commonly, tumors may arise
from the accessory lobe and
present as persistent swellings
within the cheek.
Rarely , tumors may arise from
the deep lobe of the gland and
present as a parapharyngeal mass.

35. Benign tumour of the left parotid gland producing
characteristic deflection of the ear lobe.

36. Pleomorphic adenoma arising from the upper pole of the left parotid gland
producing a preauricular swelling

37. Deep lobe tumour of the right parotid presenting with a swelling of the right soft
palate.

38. Magnetic resonance imaging scan revealing a large deep lobe tumour (arrow) of
the right parotid gland, occupying the parapharyngeal space.

39. Tumors of the parotid gland
 Symptoms include difficulty in swallowing and
snoring.
 Clinical examination reveals a diffuse firm swelling in
the soft palate and tonsil.
 Some 80–90% of tumours of the parotid gland are
benign, the most common being pleomorphic
adenoma.

40. Tumors of the parotid gland
Malignant salivary
gland tumors are
divided into two
distinct sub-groups:

41. Tumors of the parotid gland
1 Low-grade malignant
tumors (e.g. acinic cell
carcinoma) are
indistinguishable on
clinical examination
from benign neoplasms.

42. Tumors of the parotid gland
2 High-grade malignant
tumors usually present
as rapidly growing, often
painless swellings in and
around the parotid
gland.

43. Tumors of the parotid gland
The tumour presents as either
a discrete mass with
infiltration into the overlying
skin or
 a diffuse but hard swelling of
the gland with no discrete
mass.

44. Tumors of the parotid gland
Presentation with
advanced disease is
common, and cervical
lymph node metastases
may be present.

45. Tumors of the parotid gland
Among primary parotid malignant
tumors, mucoepidermoid carcinoma
is the most common, followed by
adenocystic carcinoma.
The latter is notorious for its proclivity
for perineural invasion and metastatic
potential so surgery is normally
supported by adjuvant radiotherapy to
gain local control of the disease.

46. Classification of salivary gland tumours
(simplified).
I Adenoma
 Pleomorphic : Pleomorphic adenoma
 Monomorphic : Adenolymphoma (Warthin’s
tumour)

47. Classification of salivary gland tumours
(simplified).
II Carcinoma
Low grade
 Acinic cell carcinoma
 Adenoid cystic carcinoma
 Low-grade mucoepidermoid carcinoma
High grade
 Adenocarcinoma
 Squamous cell carcinoma
 High-grade mucoepidermoid carcinoma

48. Classification of salivary gland tumours
(simplified).
III Non-epithelial tumors
 Haemangioma, lymphangioma
IV Lymphomas Primary lymphomas
 Secondary lymphomas
 Non-Hodgkin’s lymphomas
 Lymphomas in Sjögren’s syndrome
V Secondary tumors
 Local : Tumors of the head and neck especially
 Distant: Skin and bronchus

49. Classification of salivary gland tumours
(simplified).
VI Unclassified tumors
VII Tumour-like lesions
Solid lesions
 Benign lymphoepithelial lesion
 Adenomatoid hyperplasia
Cystic lesions
 Salivary gland cysts

50. Malignant tumour of the left parotid gland with
invasion of the overlying skin.

51. Investigations
 The initial imaging modality of choice is ultrasound as
it demonstrates if the lump is intrinsic to the parotid
or not.
 It also facilitates accurate sampling of the lesion by
FNAC or True-Cut biopsy.
 Subsequently, CT and MRI are the most useful
imaging techniques .

52. Investigations
 Open surgical biopsy is contraindicated unless
evidence of gross malignancy is present, and
preoperative histological diagnosis is required as a
prelude to radical parotidectomy.

53. Parotidectomy

54. Parotidectomy
 The aim of superficial parotidectomy is to remove the
tumour with a cuff of normal surrounding tissue.
 The most important structure traversing the parotid
gland is the facial nerve.
 Parotid tumour excision techniques are classified
based on the approach onto the facial nerve.

55. Parotidectomy
 Essentially the traditional parotidectomy is in reality a
dissection of the facial nerve.
A parotidectomy is
 conservative when the nerve is spared ,
 radical when the nerve is excised en bloc with the
tumour.

56. Parotidectomy
 A superficial parotidectomy is when the part of the
gland superficial to the facial nerve is removed.
 A deep lobe parotidectomy is when the part of the
gland beneath the nerve is removed and
 Total parotidectomy is when both are dissected and
removed.

57. Parotidectomy
 Superficial parotidectomy can be partial in relatively
small tumors that are removed with a cuff of clinically
normal parenchyma without removal of the entire
superficial portion of the gland.
 An alternative surgical approach is to focus on the
tumour itself as the principal procedure and not facial
nerve dissection.

58. Parotidectomy
 Extracapsular dissection is now an established
alternative to parotidectomy.
 It does not require formal facial nerve dissection and is
a less invasive technique with reduced morbidity.
 Temporary facial nerve injury rates are 7% compared
with 25% for superficial parotidectomy.

59. Superficial parotidectomy
 Superficial parotidectomy is the most common
procedure for parotid gland pathology.
 Surgery is performed under endotracheal general
anesthesia, which may or may not be accompanied by
hypotensive anesthesia to facilitate dissection, improve
the visual surgical field and reduce blood loss.
 The operation has several distinct phases.

60. INCISION AND DEVELOPMENT OF A
SKIN FLAP
 The most commonly used incision is the ‘lazy S’ pre-
auricular–mastoid–cervical.
 The incision is marked out and three points identified
along its length to facilitate closure.
 Infiltration with local anesthetic and adrenaline is
optional, but does aid in the development of the skin
flap, improves visibility and reduces blood loss in the
initial phase.

61. (a) Landmarks and cervical–mastoid preauricular
incision for superficial parotidectomy.

62. INCISION AND DEVELOPMENT OF A
SKIN FLAP
 The skin flap is developed in an anterior direction by
either scalpel or scissors dissection.
 The plane of dissection is well below the hair follicles,
just above the parotid fascia.
 The skin flap is developed forwards to the anterior
border of the gland.
 Posterior undermining of the incision in the cervical
region facilitates access to the anterior border of the
sternomastoid muscle.

63. MOBILISATION OF THE GLAND
 This phase of the dissection aims to free the posterior
margin of the gland, allowing identification of the
facial nerve.
 Clips are applied along the fascia overlying the
sternomastoid muscle, with the assistant applying
traction anteriorly.
 By sharp dissection along the anterior border of the
sternomastoid, an avascular plane is developed, which
requires elective transection of the great auricular
nerve.

64. (b) Development of the avascular plane
along the anterior border of the sternomastoid
prior to sacrifice of the great auricular nerve.

65. MOBILISATION OF THE GLAND
 At the lower end of the dissection, the external jugular
vein is often encountered and ligated.
 The gland is gradually mobilized by sharp dissection
up to and on to the anterior aspect of the mastoid
process, identifying the posterior belly of the digastric
muscle.
 A second avascular plane is developed along the
anterior border of the cartilaginous and bony external
auditory meatus immediately anterior to the tragus.

66. MOBILISATION OF THE GLAND
 The two avascular planes are then connected by blunt
and sharp dissection.
 By developing two broad avascular planes,
identification of the facial nerve trunk is facilitated.
 It is best achieved by scissors dissection in the line of
the facial nerve trunk.
 Intraoperative use of a facial nerve stimulator is
recommended.

67. c) Identification of the trunk of the facial nerve
(arrow).

68. LOCATION OF THE FACIAL NERVE
TRUNK
 The main methods of facial nerve trunk localization
can be divided into antegrade and retrograde.
 The former utilizes anatomical landmarks to identify
the nerve trunk after its exit from the stylomastoid
foramen, which is then traced distally.

69. LOCATION OF THE FACIAL NERVE
TRUNK
Landmarks commonly used are:
 1 the inferior portion of the cartilaginous canal.
 This is termed Conley’s pointer (tragal pointer) and
indicates the position of the facial nerve, which lies 1
cm deep and inferior to its tip;
 2 the upper border of the posterior belly of the
digastric muscle.

70. LOCATION OF THE FACIAL NERVE
TRUNK
 Identification of this muscle not only helps to mobilize
the parotid gland, but also exposes an area
immediately superior, in which the facial nerve is
usually located;
 3 the squamotympanic fissure;
 4 the styloid process (the nerve is superficial to it);
 5 the mastoid process can be drilled and the nerve
identified more proximally.

71. LOCATION OF THE FACIAL NERVE
TRUNK
 Retrograde techniques rely on the identification of one
of the nerve main branches (buccal in relation to the
parotid duct, marginal mandibular in relation to the
facial vessels, temporal branch), which is then traced
proximally until the main trunk is identified.
 These techniques can be useful in revision cases where
the anatomy is altered or postradiotherapy when
significant fibrosis distorts the planes of dissection.
 Once the facial nerve trunk has been identified, gentle
traction anteriorly facilitates further mobilization.

72. LOCATION OF THE FACIAL NERVE
TRUNK
 Control of hemorrhage at this stage is vital as bleeding,
no matter how minor, significantly impedes visibility
for the surgeon.
 Hemostasis can be achieved with bipolar diathermy,
although caution is necessary, particularly as the facial
nerve is approached.

73. LOCATION OF THE FACIAL NERVE
TRUNK
 Damage to the stylomastoid artery, which lies
immediately lateral to the nerve, can result in
troublesome bleeding immediately prior to
identification.
 Pledget swabs soaked in adrenaline are sometimes
helpful in reducing the ooze associated with this phase
of the dissection.

74. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
 Once the facial nerve trunk is identified, further
exposure of the branch of the facial nerve can be
achieved by scissors dissection in the perineural plane
immediately above the nerve.
 The tunnel thus created is then laid open, and
divisions and branches of the facial nerve are followed
to the periphery in a sequential manner, usually
beginning with the upper division.

75. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
 The upper division divides into a temporal and a
zygomatic branch, and
 the lower division into mandibular and cervical
branches.
 In this way, the superficial lobe and its associated
tumour are mobilized in a superior to inferior
direction.

76. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
 The upper division of the nerve is frequently tortuous
in its course and it can be damaged unless great care is
taken during perineural dissection.
 It is often not necessary to dissect all branches of the
facial nerve completely, as adequate tumour clearance
can be achieved with a more conservative resection of
the superficial lobe.

77. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
 When a branch of the facial nerve is adherent to the
tumour or running through the tumour, it may require
elective division.
 With the exception of the buccal branch, the
transected nerve should be repaired immediately with
a cable graft, harvested from the great auricular nerve.

78. (e) Branches of the facial nerve and retromandibular
vein following delivery of the tumour.

79. CLOSURE
 The patient is placed into a Trendelenburg position to
identify any residual bleeding vessels.
 A suction drain is applied for a period of 24–48 hours
and the wound closed in layers.
(f) Wound closure with a vacuum drain.

80. Extracapsular dissection
 Extracapsular dissection is an oncologically sound
technique for benign parotid gland tumors.
 The recurrent rates of pleomorphic adenomas excision
with extracapsular dissection compare favorably with
traditional superficial parotidectomies (extracapsular
dissection 1.3–1.5% vs superficial parotidectomy 2–
2.4%) and complication rates are less (temporary facial
nerve palsy 7% vs 25%: Frey’s syndrome 0 vs 60%)

81. Extracapsular dissection
 A preauricular incision is made, the length and
position of which is adapted to the size and site of the
tumour.
 The dissection proceeds in the plane just immediately
above the ‘shining’ parotid fascia (the SMAS or
superficial muscular aponeurotic system layer) and
continues in continuity with the platysma muscle.

82. Extracapsular dissection.
(a) Left parotid pleomorphic adenoma: skin marking above tumour.

83. Extracapsular dissection
 The skin flap should extend past the lump for at least 1
cm .
 The circumference of the tumour is marked with ink
and a cruciate incision marked over the surface.
 The legs of the cruciate incision should extend 1 cm
past the edge of the tumour.
 This is an essential part of the technique.

84. (b) Development of skin flap and exposure of parotid fascia.

85. Extracapsular dissection
 Four small artery clips are then placed where the two
lines bisect.
 The artery clips are used to tent up the parotid fascia,
which is then divided along the cruciate lines.
 Small rounded end scissors are then used to
commence a dissection through the parotid gland.
 The dissection advances in a blunt fashion and only
when the scissors blades are visible through the fascia
may the tissue bridge be divided.

86. (c) Cruciate incision through parotid fascia.
The leaves of parotid fascia (arrows) have been raised exposing the
underlying glandular parenchyma that contains the tumour.

87. Extracapsular dissection
 As the dissection proceeds around the tumour, the
presence of a facial nerve is easy to discern.
 It is prudent to use continuous facial monitoring
during the operation, which helps alert the surgeon to
the presence of a facial nerve.
 It is not difficult to recognise a branch of the nerve as
long as the basic principle is adhered to that no
parotid parenchyma is diathermised or cut unless one
can see through the tissues.


88. (d) Exposure of tumour. The arrow depicts a branch of the facial nerve.

89. (e) Gradual mobilization of the tumour.

90. Extracapsular dissection
 The key to the extracapsular dissection technique is to
place traction on the artery clips, which pulls the
parotid tissue away from the lump and normally
reveals a plane through which the surgeon can work 2–
3 mm away from the tumour.
 When a branch of the facial nerve is observed, it is not
necessarily dissected unless in close vicinity to the
tumour capsule.

91. Extracapsular dissection
 Retractors can be used on the normal parotid gland to
improve exposure of the tumour, but direct pressure
on the tumour should be avoided to minimise the risk
of rupture.
 The tumour is removed ,leaving a parted but
essentially intact parotid gland .
 Depending on the depth of the tumour, a suction drain
can be used at the surgeon’s discretion.

92. (f) The tumour is mobilized with preservation of the facial nerve branch
(arrows).

93. (g) Excision of the tumour.
The picture shows the remaining parotid bed with the facial nerve branch
intact (arrows).

94. Extracapsular dissection
 The cruciate incision is re-approximated and the skin
incision closed.
 It is advised that a mastoid-type pressure dressing is
always applied at the end of the procedure otherwise
sialoceles can occur.
 The pressure dressing is kept for about 48 hours.

95. (h) The parotid fascia leaves are replaced and sutured together in a watertight fashion.
This restores the parotid capsule integrity and prevents development of Frey’s
syndrome.

96. Radical parotidectomy
 Radical parotidectomy is performed for patients in
whom there is clear histological evidence of a high-
grade malignant tumour (e.g. squamous cell
carcinoma) with invasion of facial nerve.
 Low-grade and low stage malignant tumors can
usually be managed by standard superficial
parotidectomy.
 Radical parotidectomy involves removal of all parotid
gland tissue and elective division of the facial nerve,
usually through themain trunk .

97. (a) High-grade malignant tumour in the left parotid gland.

98. (b) Magnetic resonance imaging scan demonstrating a diffuse
infiltrative malignant tumour of the left parotid gland (arrow).

99. (c) Skin incision outlined for radical neck dissection and left radical parotidectomy
including the removal of overlying skin.

100. (d) Skin flap developed.

101. (e) Appearance after left radical neck dissection and left radical parotidectomy.
Posterior mandible (upper arrow) and great vessels of the neck (lower arrow) are
visible.

102. Radical parotidectomy
 The surgery inevitably removes the ipsilateral masseter
muscle and may also require simultaneous neck
dissection, particularly where there is clinical,
radiological and cytological evidence of lymph node
metastases in the ipsilateral neck.
 When indicated, facial nerve can be repaired using
cable grafts (interpositional greater auricular or sural
nerve grafts).

103. (f) Wound closure after left radical neck dissection.