Author: Osborne, Ryan F; Hamilton, Jason S; Zandifar, Hootan
Date published: February 1, 2012
Journal code: ENTJ
A 29-year-old woman who worked in the medical field presented to us with a history of bulimia nervosa with bilateral parotid enlargement (figure 1). After undergoing extensive psychological therapy, diet modification, and behavior modification, she had been free of her bulimia for the preceding 6 years. She had also undergone minor corrective dentistry to improve the appearance of her teeth. However, because of her occupation, she was in constant contact with physicians, and her parotid swelling was scrutinized almost daily. This led to social anxiety that was beginning to affect her daily routine. She had previously seen multiple specialists for this problem, and she was being managed with a wait-and-see approach.
The patient was well aware of the risks of parotid surgery, but she wanted to proceed with this treatment option. Prior to surgery, she received both psychological and medical clearance. She underwent bilateral superficial parotidectomies with facial nerve dissection without complication. Postoperatively, she did very well. One and one-half years after her surgery, she was extremely happy with the results, and she had not reverted back to her eating disorder (figure 2).
Bilateral parotid enlargement as a consequence of bulimia nervosa has been well documented in the literature.1'4 Although the exact mechanism is not well understood, several hypotheses exist.4
One psychological issue that must be considered is the nature of bulimia to recur. For patients who have overcome bulimia, the risk of relapse is heightened by the fact that they are constantly reminded of their previous disease by their parotid enlargement.2·4 It is no wonder then that these patients may seek treatment for parotid enlargement.
Several authors have investigated the role of parotidectomy in bulimic patients with bilateral parotid enlargement.1,3,4 Most of them have commented on the controversial aspects of this treatment in view of the recurring nature of the disease, the risks of surgery, and the lack of any medical benefit.1'4 Although we do agree that these points should be considered, there is a subgroup of bulimic patients who can benefit from parotidectomy. In our opinion, these are patients who have been free of their disease for several years and who have received full psychological clearance for surgery.
Another positive consideration is an attempt to distance oneself from the disease, such as by undergoing dental restoration or other cosmetic procedures intended to reverse the long-term physical manifestations of bulimia. We believe that performing bilateral parotidectomies for these patients can help them reintegrate into society without the constant reminder of their previous disease.
1. Berke GS, Calcaterra TC. Parotid hypertrophy with bulimia: A report of surgical management. Laryngoscope 1985;95(5):597-8.
2. Levin PA, Falko IM, Dixon K, et al. Benign parotid enlargement in bulimia. Ann Intern Med 1980;93(6):827-9.
3. Rauch SD, Herzog DB. Parotidectomy for bulimia: A dissenting view. Am J Otolaryngol 1987;8(6):376-80.
4. Wilson T1 Price T. Revisiting a controversial surgical technique in the treatment of bulimic parotid hypertrophy. Am J Otolaryngol 2003;24(2):85-8.
Ryan F. Osborne, MD, FACS; Jason S. Hamilton, MD, FACS; Hootan Zandifar, MD, FACS
From the Osborne Head and Neck Institute, Los Angeles.