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