Annals of Otology, Rhinology & Laryngology 122(11):695-700. © 2013 Annals Publishing Company. All rights reserved.
Long-Term Outcomes of Facial Nerve Function in Irradiated and Nonirradiated Nerve Grafts Samuel C. Leong, MPhil, FRCS(ORL-HNS); Tristram H. Lesser, MS, FRCS Objectives: We reviewed the long-term results of facial nerve repair in a tertiary head and neck institution in the north of England. Methods: We performed a case notes review of patients who had facial nerve repair over a 10-year period and had completed 24 months of follow-up.
Results: The study population comprised 18 female patients and 24 male patients, with an overall mean age of 53.2 years (range, 16 to 80 years). Of the 24 patients who had a cable nerve graft, the greater auricular nerve was used in 15 cases. The sural nerve was used as the donor in a cross-facial nerve graft in 9 patients. Sixteen patients had transposition nerve repair: hypoglossal and ansa cervicalis in 7 and 9 cases, respectively. Two patients had primary anastomosis after surgery for extensive malignant tumors. In this series, no patients achieved a House-Brackmann (HB) grade of II. Overall, the HB grades III, IV, and V were the best postoperative facial nerve functions achieved in 11.9%, 33.3%, and 26.2% of patients, respectively. Failure (HB grade VI) was observed in 28.6% of patients. More than half of patients (62.5%) who had either a sural nerve cable graft or a faciohypoglossal transposition had a good outcome (HB grade III or IV). Conclusions: In the present series, 45% of patients had an HB grade of III or IV at long-term follow-up. The best outcome (HB grade III) was observed after cross-facial grafting with the sural nerve. Key Words: facial nerve, facial nerve repair, facial paralysis, parotid cancer, radiotherapy.
tion resulted in poorer outcomes, and that most patients would only achieve facial symmetry at rest.
Introduction
Injury to the facial nerve and subsequent inability to perform volitional mimetic movement has a significant impact on quality of life that results in negative effects on social functioning, emotional roles, general mental health, and vitality in comparison to the normal population.1,2 Facial nerve paralysis can occasionally result from the surgical treatment of head and neck cancer. The contemporary literature is replete with often-innovative techniques to reanimate and rehabilitate the paralyzed face, although none fully restore facial function.3
The aim of this study was to review the long-term results of facial nerve repair in our institution over a 10-year period. In addition, a literature review was undertaken in an attempt to clarify whether postoperative radiotherapy was a negative prognosticator for good facial nerve function. Methods and patients
Patients. This was a retrospective review approved by the Clinical Information and Audit Department of the hospital (reference No. 2849). University Hospital Aintree is the tertiary referral center for head, neck, and skull base surgery in the United Kingdom for Merseyside, North Wales, and the Isle of Man. Cases were identified from the Liverpool Head and Neck Cancer electronic database, and cross-referenced with operating room records.
Although reports of large case series exist, many have excluded patients who have had postoperative radiotherapy for malignancy.4,5 Early studies on the effects of radiotherapy on cats suggested that the anticipated results should be equivalent to those of facial nerve cable grafts without postoperative irradiation.6 Subsequent small case series supported this notion, although the results were not compared with those of a nonirradiated cohort.7,8 However, these findings were contradicted by Pillsbury and Fisch,9 who concluded from a series of 42 cases that irradia-
Patients were included if they had a facial nerve repair or nerve graft between January 2001 and December 2010 and had completed a minimum of 2 years of follow-up. The follow-up period was de-
From the Skull Base Unit, Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital Aintree, Liverpool, England. Correspondence: Samuel C. Leong, MPhil, FRCS(ORL-HNS), Dept of Otorhinolaryngology–Head and Neck Surgery, Skull Base Surgery, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.
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fined as the time between facial nerve repair or grafting and the latest clinic review or death. This followup period was not chosen arbitrarily, but was based on the results reported by Malik et al5 that showed that final facial nerve function after repair or grafting was usually observed by 24 months in most patients. Patients who had died but had completed the minimum 2 years of follow-up were also eligible for inclusion. Patients lost to follow-up were excluded, as were those who did not complete 24 months of follow-up. Each patient’s case notes (printed and electronic) were examined for data regarding demographics, tumor type, surgical procedure(s), facial nerve repair technique, and facial functioning according to the House-Brackmann (HB) scale. Surgical Philosophy. All patients had a complete facial paralysis (HB grade VI) caused by the pathologic process and/or surgery undertaken to eradicate the disease. After a variable time interval (ranging from none to several years), the facial nerve was repaired by one of four techniques: end-to-end primary anastomosis, cross-facial nerve graft, ansa cervicalis transposition, or classic faciohypoglossal transposition. All facial nerve repair and/or grafting procedures were performed by the senior surgeon (T.H.L.) with 9-0 sutures (three sutures in the perineurium) with use of either loupe or microscopic magnification. The anastomosis was secured with fibrin glue, which also served to stabilize the nerve graft to surrounding soft tissue. The sural nerve was used in the cross-facial nerve grafts. The patients were reviewed routinely by the skull base multidisciplinary team at 3- to 6-month intervals, as predicated by clinical need. For consistency, facial palsy was assessed against the HB scale by the team, and consensus agreement was reached.
It was the practice of this skull base unit to undertake facial nerve repair at the time of malignant tumor extirpation whenever possible, if sacrifice of the facial nerve was deemed necessary to achieve adequate oncological resection. This decision was routinely made after case discussion by the skull base multidisciplinary team to decide treatment management, and full informed consent was obtained from all patients before surgery. All of these patients had postoperative radiotherapy to both the primary site and the ipsilateral neck (54 to 60 Gy in 1.8- to 2.0Gy fractions). Other patients who had facial nerve repair were those who presented to the unit with a skull base fracture or after surgical procedures in the mastoid or cerebellopontine angle. All of these patients had a comprehensive neurophysiological workup before facial nerve surgery, which was un-
dertaken 12 to 16 months after the onset of complete facial palsy. This interval was used to allow for the possibility of spontaneous return of facial nerve function. Literature Search. A literature search of the US National Library of Medicine (PubMed) database using a combination of MeSH terms (facial nerve, radiotherapy) was undertaken to identify other studies that reported comparative outcomes following radiotherapy. The search was limited to English-language articles. For the purpose of comparison, good and poor surgical outcomes were defined as having HB grades of III or IV and V or VI, respectively. Statistical Analysis. Data were collated in a database and analyzed with SigmaPlot version 12 (Systat Software, Inc, Chicago, Illinois). Correlations between parameters and end points were assessed by Pearson’s χ2 test or, when there were fewer than 10 subjects in any cell of a 2 × 2 grid, by the 2-tailed Fisher exact test. The Mann-Whitney U test was used to assess the difference between two samples of independent observations. A p value of less than or equal to 0.05 was deemed to be statistically significant. Results
Patient Demographics. A total of 55 patients were identified from the database. Of these, 42 patients fulfilled the inclusion criteria and were included in this study (Table 1). No patients were lost to follow-up. Of the 13 patients who were excluded, 6 died within 24 months, and 4 had not completed 24 months of follow-up. In the remaining 3 cases, nerve repair was not performed because of the proximal extent of tumor invasion. The study population comprised 18 female and 24 male patients, with an overall mean age of 53.2 years (range, 16 to 80 years). Twenty-one patients (14 male) received radiotherapy after facial nerve repair, whereas the other 21 patients (10 female) did not have radiotherapy. The mean age of the radiotherapy cohort (mean, 64.5 years; range, 19 to 80 years) was significantly higher (p < 0.05) than that of the cohort who did not have postoperative radiotherapy (mean, 41.9 years; range, 16 to 74 years). The mean follow-up period for the entire study cohort was 49.2 months (range, 24 to 140 months).
Cause of Facial Nerve Palsy. Most cases of facial paralysis were due to surgical intervention to eradicate disease. The cause of paralysis was the pathologic process itself in only 4 cases (skull base fracture, facial neuroma). Vestibular schwannoma and temporal bone and parotid malignancies were the
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Leong & Lesser, Nerve Graft Irradiation Table 1. Demographics and clinical details of study cohort
Total (N = 42)
Postoperative Radiotherapy
No Radiotherapy
Gender (No. of patients) Male 24 14 10 Female 18 7 11 Age (y) Mean 53.2 64.5 41.9 Range 16 to 80 19 to 80 16 to 74 Follow-up (mo) Mean 49.2 38.8 60.0 24 to 140 24 to 95 24 to 140 Range Causes of facial palsy (No. of patients) Vestibular schwannoma 10 10 Chronic suppurative otitis media 3 3 Skull base fracture 2 2 Facial nerve neuroma 2 2 Glomus jugulare 1 1 Meningioma 1 1 Medulloblastoma 1 1 Astrocytoma 1 1 Temporal bone squamous cell carcinoma 9 9 Parotid mucoepidermoid carcinoma 5 5 Parotid squamous cell carcinoma 4 4 Primitive neuroectodermal carcinoma 1 1 Parotid acinic cell carcinoma 1 1 Parotid carcinoma ex pleomorphic adenoma 1 1
p
NS
Long-Term Outcomes of Facial Nerve Function in Irradiated and Nonirradiated Nerve Grafts Samuel C. Leong, MPhil, FRCS(ORL-HNS); Tristram H. Lesser, MS, FRCS Objectives: We reviewed the long-term results of facial nerve repair in a tertiary head and neck institution in the north of England. Methods: We performed a case notes review of patients who had facial nerve repair over a 10-year period and had completed 24 months of follow-up.
Results: The study population comprised 18 female patients and 24 male patients, with an overall mean age of 53.2 years (range, 16 to 80 years). Of the 24 patients who had a cable nerve graft, the greater auricular nerve was used in 15 cases. The sural nerve was used as the donor in a cross-facial nerve graft in 9 patients. Sixteen patients had transposition nerve repair: hypoglossal and ansa cervicalis in 7 and 9 cases, respectively. Two patients had primary anastomosis after surgery for extensive malignant tumors. In this series, no patients achieved a House-Brackmann (HB) grade of II. Overall, the HB grades III, IV, and V were the best postoperative facial nerve functions achieved in 11.9%, 33.3%, and 26.2% of patients, respectively. Failure (HB grade VI) was observed in 28.6% of patients. More than half of patients (62.5%) who had either a sural nerve cable graft or a faciohypoglossal transposition had a good outcome (HB grade III or IV). Conclusions: In the present series, 45% of patients had an HB grade of III or IV at long-term follow-up. The best outcome (HB grade III) was observed after cross-facial grafting with the sural nerve. Key Words: facial nerve, facial nerve repair, facial paralysis, parotid cancer, radiotherapy.
tion resulted in poorer outcomes, and that most patients would only achieve facial symmetry at rest.
Introduction
Injury to the facial nerve and subsequent inability to perform volitional mimetic movement has a significant impact on quality of life that results in negative effects on social functioning, emotional roles, general mental health, and vitality in comparison to the normal population.1,2 Facial nerve paralysis can occasionally result from the surgical treatment of head and neck cancer. The contemporary literature is replete with often-innovative techniques to reanimate and rehabilitate the paralyzed face, although none fully restore facial function.3
The aim of this study was to review the long-term results of facial nerve repair in our institution over a 10-year period. In addition, a literature review was undertaken in an attempt to clarify whether postoperative radiotherapy was a negative prognosticator for good facial nerve function. Methods and patients
Patients. This was a retrospective review approved by the Clinical Information and Audit Department of the hospital (reference No. 2849). University Hospital Aintree is the tertiary referral center for head, neck, and skull base surgery in the United Kingdom for Merseyside, North Wales, and the Isle of Man. Cases were identified from the Liverpool Head and Neck Cancer electronic database, and cross-referenced with operating room records.
Although reports of large case series exist, many have excluded patients who have had postoperative radiotherapy for malignancy.4,5 Early studies on the effects of radiotherapy on cats suggested that the anticipated results should be equivalent to those of facial nerve cable grafts without postoperative irradiation.6 Subsequent small case series supported this notion, although the results were not compared with those of a nonirradiated cohort.7,8 However, these findings were contradicted by Pillsbury and Fisch,9 who concluded from a series of 42 cases that irradia-
Patients were included if they had a facial nerve repair or nerve graft between January 2001 and December 2010 and had completed a minimum of 2 years of follow-up. The follow-up period was de-
From the Skull Base Unit, Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital Aintree, Liverpool, England. Correspondence: Samuel C. Leong, MPhil, FRCS(ORL-HNS), Dept of Otorhinolaryngology–Head and Neck Surgery, Skull Base Surgery, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.
695
Downloaded from aor.sagepub.com at NORTHERN KENTUCKY UNIV on July 4, 2015
696
696
Leong & Lesser, Nerve Graft Irradiation
fined as the time between facial nerve repair or grafting and the latest clinic review or death. This followup period was not chosen arbitrarily, but was based on the results reported by Malik et al5 that showed that final facial nerve function after repair or grafting was usually observed by 24 months in most patients. Patients who had died but had completed the minimum 2 years of follow-up were also eligible for inclusion. Patients lost to follow-up were excluded, as were those who did not complete 24 months of follow-up. Each patient’s case notes (printed and electronic) were examined for data regarding demographics, tumor type, surgical procedure(s), facial nerve repair technique, and facial functioning according to the House-Brackmann (HB) scale. Surgical Philosophy. All patients had a complete facial paralysis (HB grade VI) caused by the pathologic process and/or surgery undertaken to eradicate the disease. After a variable time interval (ranging from none to several years), the facial nerve was repaired by one of four techniques: end-to-end primary anastomosis, cross-facial nerve graft, ansa cervicalis transposition, or classic faciohypoglossal transposition. All facial nerve repair and/or grafting procedures were performed by the senior surgeon (T.H.L.) with 9-0 sutures (three sutures in the perineurium) with use of either loupe or microscopic magnification. The anastomosis was secured with fibrin glue, which also served to stabilize the nerve graft to surrounding soft tissue. The sural nerve was used in the cross-facial nerve grafts. The patients were reviewed routinely by the skull base multidisciplinary team at 3- to 6-month intervals, as predicated by clinical need. For consistency, facial palsy was assessed against the HB scale by the team, and consensus agreement was reached.
It was the practice of this skull base unit to undertake facial nerve repair at the time of malignant tumor extirpation whenever possible, if sacrifice of the facial nerve was deemed necessary to achieve adequate oncological resection. This decision was routinely made after case discussion by the skull base multidisciplinary team to decide treatment management, and full informed consent was obtained from all patients before surgery. All of these patients had postoperative radiotherapy to both the primary site and the ipsilateral neck (54 to 60 Gy in 1.8- to 2.0Gy fractions). Other patients who had facial nerve repair were those who presented to the unit with a skull base fracture or after surgical procedures in the mastoid or cerebellopontine angle. All of these patients had a comprehensive neurophysiological workup before facial nerve surgery, which was un-
dertaken 12 to 16 months after the onset of complete facial palsy. This interval was used to allow for the possibility of spontaneous return of facial nerve function. Literature Search. A literature search of the US National Library of Medicine (PubMed) database using a combination of MeSH terms (facial nerve, radiotherapy) was undertaken to identify other studies that reported comparative outcomes following radiotherapy. The search was limited to English-language articles. For the purpose of comparison, good and poor surgical outcomes were defined as having HB grades of III or IV and V or VI, respectively. Statistical Analysis. Data were collated in a database and analyzed with SigmaPlot version 12 (Systat Software, Inc, Chicago, Illinois). Correlations between parameters and end points were assessed by Pearson’s χ2 test or, when there were fewer than 10 subjects in any cell of a 2 × 2 grid, by the 2-tailed Fisher exact test. The Mann-Whitney U test was used to assess the difference between two samples of independent observations. A p value of less than or equal to 0.05 was deemed to be statistically significant. Results
Patient Demographics. A total of 55 patients were identified from the database. Of these, 42 patients fulfilled the inclusion criteria and were included in this study (Table 1). No patients were lost to follow-up. Of the 13 patients who were excluded, 6 died within 24 months, and 4 had not completed 24 months of follow-up. In the remaining 3 cases, nerve repair was not performed because of the proximal extent of tumor invasion. The study population comprised 18 female and 24 male patients, with an overall mean age of 53.2 years (range, 16 to 80 years). Twenty-one patients (14 male) received radiotherapy after facial nerve repair, whereas the other 21 patients (10 female) did not have radiotherapy. The mean age of the radiotherapy cohort (mean, 64.5 years; range, 19 to 80 years) was significantly higher (p < 0.05) than that of the cohort who did not have postoperative radiotherapy (mean, 41.9 years; range, 16 to 74 years). The mean follow-up period for the entire study cohort was 49.2 months (range, 24 to 140 months).
Cause of Facial Nerve Palsy. Most cases of facial paralysis were due to surgical intervention to eradicate disease. The cause of paralysis was the pathologic process itself in only 4 cases (skull base fracture, facial neuroma). Vestibular schwannoma and temporal bone and parotid malignancies were the
Downloaded from aor.sagepub.com at NORTHERN KENTUCKY UNIV on July 4, 2015
697
697
Leong & Lesser, Nerve Graft Irradiation Table 1. Demographics and clinical details of study cohort
Total (N = 42)
Postoperative Radiotherapy
No Radiotherapy
Gender (No. of patients) Male 24 14 10 Female 18 7 11 Age (y) Mean 53.2 64.5 41.9 Range 16 to 80 19 to 80 16 to 74 Follow-up (mo) Mean 49.2 38.8 60.0 24 to 140 24 to 95 24 to 140 Range Causes of facial palsy (No. of patients) Vestibular schwannoma 10 10 Chronic suppurative otitis media 3 3 Skull base fracture 2 2 Facial nerve neuroma 2 2 Glomus jugulare 1 1 Meningioma 1 1 Medulloblastoma 1 1 Astrocytoma 1 1 Temporal bone squamous cell carcinoma 9 9 Parotid mucoepidermoid carcinoma 5 5 Parotid squamous cell carcinoma 4 4 Primitive neuroectodermal carcinoma 1 1 Parotid acinic cell carcinoma 1 1 Parotid carcinoma ex pleomorphic adenoma 1 1
p
NS
