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Incidence of marginal mandibular nerve palsy in neck dissection

Incidence of marginal mandibular nerve palsy in neck dissection. N Amin, H Dixon, N Gibbins , S Lew- Gor Brighton and Sussex University Hospitals United Kingdom. Marginal Mandibular Nerve. Our Project. Limited data Informed consent important part of pre-assessment

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Incidence of marginal mandibular nerve palsy in neck dissection

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  1. Incidence of marginal mandibular nerve palsy in neck dissection N Amin, H Dixon, N Gibbins, S Lew-Gor Brighton and Sussex University Hospitals United Kingdom

  2. Marginal Mandibular Nerve

  3. Our Project • Limited data • Informed consent important part of pre-assessment • Communication errors heart of many complaints

  4. Our Project • Rate of MMN palsy (temporary/permanent) vs. Type of ND

  5. Method • Retrospective 2 year review • 88 neck dissections (ND) reviewed • 4 excluded • 84 total • Pre- and post-operative MMN function including whether the MMN was sacrificed intra-operatively. • Time until palsy resolution • Type of neck dissection • The grade of the operating surgeon • Statistical analysis

  6. AAO-HNS classification of neck dissections • Radical neck dissection (RND)– removal of ipsilateral cervical lymph nodes in levels 1-5 as well as the sternocleidomastoid muscle (SCM), internal jugular vein (IJV) and the spinal accessory nerve (SAN). • Modified radical neck dissection (MRND)– removal of ipsilateral cervical lymph nodes in levels 1-5 with preservation of one or more of the SCM, IJV and SAN. • Selective neck dissection (SND) – there is preservation of one or more groups of lymph nodes as well as the SCM, IJV and SAN. • Extended neck dissection (END) – involves a RND with removal of another group of lymph nodes or another non-lymphatic structure.

  7. Results • 75 patients • 84 neck dissections • Mean age 66.1 (32 – 89 years) • M 4.55:1 F

  8. Results • 20 RND • 20 MRND • 28 SND • 16 END • 8 patients had pre-operative radiotherapy

  9. Results • 10/84 (11.9%) – MMN palsy • 8/84 (9.5%) – permanent • 2/84 (2.4%) – temporary

  10. Results • 57 neck dissections involved level I • Total palsy rate was 10/57 (18.5%) • 14.0% (8/57) – permanent • 3.5% (2/57) – temporary • p-value = 0.046

  11. Results • In RND there was a higher risk of a permanent MMN palsy (20%) compared to MRND (10%), SND (3.6%) or END (6.2%) • 10% risk of a temporary MMN palsy in patients undergoing MRND • Statistically insignificant 3.6% 10% 20% 6.2%

  12. Results • Parotid gland – 2 • Oral cavity – 5 • Larynx – 1

  13. Discussion • Informed consent is a vital part of pre-operative assessment. • Incidence of MMN palsy post level I ND is not widely quoted. • Important patients are aware of potential morbidity and potential treatment options.

  14. Conclusion • If level I dissection is performed, a permanent MMN palsy rate of 14% or 1 in 7 may be quoted to the patient. • Adequate resection of disease in level I and the parotid region may require sacrifice of the MMN.

  15. References • Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751-8. • Hazani R, Chowdhry S, Mowlavi A, Wilhelmi BJ. Bony anatomic landmarks to avoid injury to the marginal mandibular nerve. Aesthet Surg J. 2011 Mar;31(3):286-9. • Batra AP, Mahajan A, Gupta K. Marginal mandibular branch of the facial nerve: An anatomical study. Indian J Plast Surg. 2010 Jan;43(1):60-4. • Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg 1962; 29:266–272 • House JW, Brackman DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985; 93:146–147  • Bron LP, O'Brien CJ. Facial nerve function after parotidectomy. Arch Otolaryngol Head Neck Surg. 1997 Oct;123(10):1091-6. • Møller MN, Sørensen CH. Risk of marginal mandibular nerve injury in neck dissection. Eur Arch Otorhinolaryngol. 2012 Feb;269(2):601-5. • Batstone MD, Scott B, Lowe D, Rogers SN. Marginal mandibular nerve injury during neck dissection and its impact on patient perception of appearance. Head Neck. 2009 May; 31(5):673-8 • Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg. 1995 Apr;22(2):241-51. • Baker BC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg 1979; 64:781–795 • Ducic Y, Young L, McIntyre J. Neck dissection: past and present. Minerva Chir. 2010 Feb;65(1):45-58. • Seddon HJ. Three types of nerve injury. Brain 1943; 66(4): 237-288 • Meier JD, Wenig BL, Manders EC, Nenonene Continuous intraoperative facial nerve monitoring in predicting postoperative injury during parotidectomy, Laryngoscope. 2006 Sep;116(9):1569-72

  16. Thank you for listening Any questions?

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