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

3. 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). 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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.randomized controlled trial Level II-1: Evidence obtained from well-designed controlled trials without randomization.randomization Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.cohortcase-control 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