Transcript Zusammenfassung Auswertung ENG vs EMG Daten
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 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 Cancer is possible, if …
• the patient with primary parotid cancer presents with normal facial nerve function (as >75% of patients do).
• in cases of uncertainty:
Electromyography
of nerve degeneration.
shows no signs • an
operation microscope
is used.
• 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 …
• 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.
Facial Nerve Repair / Parotid Cancer
EBM Level II-3/III
© Orlando Guntinas-Lichius 2008
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
Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008
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.
• 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.
•
Postoperative radiotherapy
seems not to have a harmful effect on facial function.
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 …
• Upper
lid loading
is a reliable method for eye reanimation.
• Is recommended in combination with nerve reconstruction.
•
Temporalis muscle transposition
is the best choice for reconstruction of the corner of the mouth because of its length and vector.
•
Masseter m. transposition
is second • choice.
Static suspension
is third choice. Autogenic and not alloplastic material is recommended: fascia lata and palmaris longus tendon.
•
Free microvascular muscle transfer
is
EBM Level II-3/III
typically not indicated in parotid cancer patients.
Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008
Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008
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 Facial Nerve Repair / Parotid Cancer © Orlando Guntinas-Lichius 2008