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

Indications for Preservation, Resection and Reconstruction of the Facial Nerve in Parotid Cancer. Guntinas-Lichius O. Department of Otorhinolaryngology Institute of Phoniatry and Pedaudiology Friedrich-Schiller-University Jena Director: O. Guntinas-Lichius. Background.

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

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  1. Indications for Preservation, Resection and Reconstruction of the Facial Nerve in Parotid Cancer Guntinas-Lichius O Department of Otorhinolaryngology Institute of Phoniatry and Pedaudiology Friedrich-Schiller-University Jena Director: O. Guntinas-Lichius

  2. 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.

  3. an operation microscope is used. 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). • 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

  4. Preservation of the Facial Nerve in Parotid Cancer … • 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. • results often (~50%) in a transient facial paresis, • but seldom (~3%) the patients develop a permanent paresis. EBM Level II-3/III

  5. Resection of the Facial Nerve in Parotid Cancer • is necessary if the nerve is 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. • Criteria: clinical palsy, electrical palsy, signs of infiltration, frozen section. • Only the parts of the nerve are resected that are infiltrated. EBM Level II-1/II-3

  6. 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. Reconstruction of the Facial Nerve in Parotid Cancer • gives best functional results (better than muscle/sling plasty). • should be performed as fast as possible, i.e., at best in one-step procedure with cancer surgery • Primary repair is better than secondary reconstruction. • Postoperative radiotherapy seems not to have a harmful effect on facial function. EBM Level II-3/III

  7. 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

  8. 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. If a nerve reconstruction is not possible … • Is recommended in combination with nerve reconstruction. • Masseter m. transposition is second choice. • Static suspension is third choice. Autogenic and not alloplastic material is recommended: fascia lata and palmaris longus tendon. EBM Level II-3/III • Free microvascular muscle transfer is typically not indicated in parotid cancer patients.

  9. Anmerkungen - werden nicht im Vortrag gezeigt 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

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