Timing of Postoperative Drain Removal Following Parotidectomy and Its Effects on Hematoma and Infection Rate and Length of Hospital Stay- a Prospective Randomized Controlled Study

Background:

Parotidectomies involve the removal of all or a portion of the parotid gland off the facial nerve in the case of superficial parotidectomies, and total removal of the gland in the case of total parotidectomies. The most common indications for this procedure are for benign neoplasms such as pleomorphic adenomas, oncocytomas and Warthin tumors, or for malignant involvement of the gland such as metastatic cutaneous squamous cell carcinomas. Hematoma formation or bleeding following parotidectomy is a less emphasized early complication of this procedure, usually secondary to unrecognized incomplete hemostasis prior to incision closure. Hematoma formation rate post parotidectomy has been reported to vary between 3.8% (Upton et al.) and 6.1% (Laccourreye et al.). In case of bleeding or rapidly expanding hematomas, the patient is usually brought back to the operating room for surgical drainage of the hematoma and surgical control of any identified bleeding vessels (Myers et al). Small hematomas can usually be managed expectantly. Wound infection following parotidectomy usually also ranges around 3.8% (Upton et al.) to 5.4% (Henney et al).

Hypothesis: There is no difference in hematoma/bleeding or infection rate when post parotidectomy drains are removed in the recovery area on the day of the surgery prior to discharge, compared to drains that are kept in place for at least 1 day or until drainage is less than 50 cc/24 hrs.

Justification for study:

Review of the literature has shown paucity of publication about this particular complication and post operative preventative management. The current postoperative management following parotidectomies is not evidence based, and is institution or surgeon dependent, ranging from primary closure without a drain, to placement of a drain that is removed either on post-operative day 1-14 (in hospital or in the community), and from no overnight stay to patient hospitalization until the drain is removed. Patel et al. 2006 have published a review of postoperative drainage following their parotidectomies, including primary closure without drain, with drain, with absorbable hemostatic agents and with fibrin sealants. As mentioned by these authors, suction drains do not prevent hematomas, but do help to remove drainage and close dead space. In his paper, the average drain output on post operative day 1 was 27.1 ml, but these authors do not address the optimal time for drain removal. The timing of removal of neck drains following head and neck surgery was addressed by Harris T. et al, who found that drains could be safely removed when the volume falls to 50 ml or less over a 24 hour period, with only 9% of their patients developing seromas. Moreover, a retrospective review of the timing of neck hematoma formation post carotid endarterectomy showed that 95% of their patients experiencing neck hematomas or neurological deficits occurred within 8 hours following surgery, indicating that same evening discharge was possible following this type of surgery (Sheehan M.K et al).