Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Indications for Preservation, Resection and Reconstruction of the Facial Nerve in Parotid Cancer

Guntinas-Lichius ODepartment of OtorhinolaryngologyInstitute of Phoniatry and PedaudiologyFriedrich-Schiller-University JenaDirector: O. Guntinas-Lichius

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Background

• Paralysis of the face is caused in 5% of patients by a tumor invading the facial nerve.

• The most frequent extracranial cause is a malignant parotid tumor.

• The incidence of facial palsy by parotid cancer is 12-25%.

• Parotid cancer is a rare disease: 2% of head and neck cancer.

• Hence: Less than 0.5% of head neck cancer patients have parotid cancer with facial palsy.

• Hence: EBM studies are rare and difficult to perform.

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Preservation of the Facial Nerve in Parotid Canceris possible, if …

• the patient with primary parotid cancer presents with normal facial nerve function (as >75% of patients do).

• an operation microscope is used.

• in cases of uncertainty: Electromyography shows no signs of nerve degeneration.

• there is no intraoperative microscopic suspicion of tumour infiltration of the nerve.

EBM Level III

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Preservation of the Facial Nerve in Parotid Cancer …

• results often (~50%) in a transient facial paresis,

• but seldom (~3%) the patients develop a permanent paresis.

• in patients with normal facial function does not lead to inferior disease-free and overall survival than it would be after resection of the intact nerve.

EBM Level II-3/III

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Resection of the Facial Nerve in Parotid Cancer

• is necessary if the nerve is infiltrated.

• Criteria: clinical palsy, electrical palsy, signs of infiltration, frozen section.

• Only the parts of the nerve are resected that are infiltrated.

• Because: Negative margins are very important for disease-free survival. And from the oncological point of view facial nerve infiltration is not different from any other tumor infiltration site.

EBM Level II-1/II-3

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Reconstruction of the Facial Nerve in Parotid Cancer

• should be performed as fast as possible, i.e., at best in one-step procedure with cancer surgery

• gives best functional results (better than muscle/sling plasty).

• Primary repair is better than secondary reconstruction.

• Postoperative radiotherapy seems not to have a harmful effect on facial function.

• The defect often concerns the facial nerve fan. This could be repaired optimally by interposition grafts, hypoglossal-facial nerve jump anastomosis or a combined approach.

EBM Level II-3/III

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

If only secondary reconstruction is possible …

• Because the patients fails the selections criteria for primary repair: extension of the nerve defect, localization, prognosis, age, general health status, wishes, status of the mimic muscles, it should be noted:

• The optimal time window for direct facial nerve suture or nerve grafting closes after 6 months.

• In such situation, up to 2 years after injury, a hypoglossal-facial nerve jump anastomosis should be considered.

EBM Level II-3/III

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

If a nerve reconstruction is not possible …

• Masseter m. transposition is second choice.

• Is recommended in combination with nerve reconstruction.

• Static suspension is third choice. Autogenic and not alloplastic material is recommended: fascia lata and palmaris longus tendon.

• Free microvascular muscle transfer is typically not indicated in parotid cancer patients.

• Upper lid loading is a reliable method for eye reanimation.

• Temporalis muscle transposition is the best choice for reconstruction of the corner of the mouth because of its length and vector.

EBM Level II-3/III

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008

Empfehlung D:

Level 1: Es gibt ausreichende Nachweise für die Wirksamkeit aus systematischen Überblicksarbeiten (Meta-Analysen) über zahlreiche randomisiert-kontrollierte Studien.

Level 2: Es gibt Nachweise für die Wirksamkeit aus zumindest einer randomisierten, kontrollierten Studie.

Level 3: Es gibt Nachweise für die Wirksamkeit aus methodisch gut konzipierten Studien, ohne randomisierte Gruppenzuweisung.

Level 4a: Es gibt Nachweis für die Wirksamkeit aus klinischen Berichten.

Level 4b: Stellt die Meinung respektierter Experten dar, basierend auf klinischen Erfahrungswerten bzw. Berichten von Experten-Komitees.

Recommendation USA

Level I: Evidence obtained from at least one properly designed randomized controlled trial.

Level II-1: Evidence obtained from well-designed controlled trials without randomization.

Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Anmerkungen - werden nicht im Vortrag gezeigt