Extratemporal facial nerve grafting and radiotherapy

Postoperative Radiotherapy and Facial Nerve Outcomes Following Nerve Repair: A Systematic Review

OBJECTIVE

To compare outcomes of facial nerve repair or grafting following facial nerve-sacrificing procedures among patients treated with and without postoperative radiotherapy (RT).

DATA SOURCES

PubMed, OVID, Conference Papers Index, Cochrane Library, ClinicalTrials.gov.

REVIEW METHODS

Databases were searched using terms including "facial nerve," "graft," "repair," and "radiotherapy." Abstracts mentioning facial nerve repair and evaluation of facial nerve function were included for full-text review. Studies that utilized the House-Brackmann or similar validated scale for evaluation of postoperative facial nerve function were selected for review. All identified studies were included in a pooled t test analysis.

RESULTS

Twelve studies with 142 patients were included in the systematic review. All 12 studies individually demonstrated no significant difference in facial nerve outcomes between patients who received postoperative radiation and patients who did not. A pooled t test of data from all studies also demonstrated no significant difference in postoperative facial nerve function between the postoperative RT and non-RT groups (t stat = 0.92, p = .36).

CONCLUSION

This analysis, including 12 studies, demonstrated that among patients undergoing facial nerve grafting or repair, there was no significant difference in postoperative facial nerve function between postoperative RT and non-RT patients. Due to the small sample size and variability in study methods, further studies directly comparing outcomes between patients with and without postoperative RT would be beneficial.

Proposals for Standardization of Intraoperative Facial Nerve Monitoring during Parotid Surgery

Intraoperative facial nerve monitoring (FNM) has been widely accepted as an adjunct during parotid surgery to facilitate identification of the facial nerve (FN) main trunk, dissection of FN branches, confirmation of FN function integrity, detection of FN injury and prognostication of facial expression after tumor resection. Although the use of FNM in parotidectomy is increasing, little uniformity exists in its application from the literature. Thus, not only are the results of many studies difficult to compare but the value of FNM technology is also limited. The article reviews the current literature and proposes our standardized FNM procedures during parotid surgery, such as standards in FNM setup, standards in general anesthesia, standards in FNM procedures and application of stimulus currents, interpretation of electrophysiologic signals and prediction of the facial expression outcome and pre-/post-operative assessment of facial expressions. We hope that the FNM standardized procedures will provide greater uniformity, improve the quality of applications and contribute to future research.

Dynamic Reconstruction of the Lower Lip With Free Functioning Gracilis Muscle Transfer

ABSTRACT

The restoration of large full-thickness lip defects still remains a formidable challenge for the reconstructive surgeons. Traumatic injuries, infections and tumors (primarily squamous cell carcinoma) are the most common source of the lip defects. Lower lips are more important in providing oral competence, unfortunately throughout the life-time they are significantly more exposed to ultraviolet radiation and thus are the most common site for the lip cancers (89%). This type of defect requires a complex reconstruction of an adequate sphincter function, defined vermilion, proper oral lining and sufficient mouth opening. To maintain the oral competence, it is of paramount importance to restore the function of orbicularis oris, which principally composes the body of the lip. Currently, the dynamic reconstructions are gaining considerable interest. They enables not only improvement of appearance but also a restoration of function and preservation of health-related quality of life. The use of the free gracilis muscle transfer to reconstruct the lower lip and its dynamic character in contrast to other, static reconstructions can provide the sufficient movement of the lower lip, which does not depend on function of other mimic muscles as it becomes an independent motor unit with its own neurotization. In our opinion the free functioning gracilis muscle flap, due to its anatomic and functional features as well as low-rate donor-site morbidity is the worth considering option for a lower lip reconstruction.

Korean-Western Integrative Medicine for Bell’s Palsy: A Review of Randomized Controlled Trials

This review aimed to compare the effectiveness of Korean medicine (KM) with Korean-Western integrative medicine (KWIM) at treating Bell’s palsy. A literature search of several databases for relevant randomized controlled trials was performed. Six studies that compared KM with KWIM to treat Bell’s palsy were included in this review. Acupuncture and steroids were the most commonly used treatments in KWIM. A comparison of the effectiveness of KW with KWIM did not produce consistent results. Both KM and KWIM were useful intreating Bell’s palsy. KWIM was more effective than KM when the Western medicine was a steroid and was given in the early stages of treatment. However, these findings are limited due to the low quality and number of included studies. KM and KWIM are both effective in Bell’s palsy, and KWIM is more effective than KM. However, more high-quality randomized controlled trials are required.

Comprehensive approach to reestablishing form and function after radical parotidectomy

INTRODUCTION

The reconstructive goals following radical parotidectomy include restoration of symmetry, reanimation of the face, and reestablishment of oral competence. We present our experience utilizing the anterolateral thigh (ALT) free flap, orthodromic temporalis tendon transfer (OTTT), and facial nerve cable grafting to reestablish form and function.

MATERIAL AND METHODS

From 2010 to 2016, 17 patients underwent radical parotidectomy followed by immediate reconstruction. An ALT was harvested to accommodate the volume and skin defect. Additional fascia lata and motor nerve to vastus lateralis (MNVL) were obtained. Anastomosis of the ALT to recipient vessels was performed, most commonly using the facial artery and internal jugular vein. OTTT was performed by securing the medial tendon of the temporalis to orbicularis oris through a nasolabial incision. Fascia lata was tunneled through the lower lip, then secured laterally to the temporalis tendon. The MNVL was cable grafted from either the proximal facial nerve or masseteric nerve to the distal facial nerve branches. ALT fascia was suspended to the superficial muscular aponeurotic system.

RESULTS

Average follow up was 19 months. Only one patient failed to achieve symmetry attributed to dehiscence of OTTT. All patients achieved oral competence and dynamic smile with OTTT activation. Facial nerve recovery was seen in 8 patients. 5 reached a House Brackman Score of 3. Two donor site seromas and two wound infections occurred.

CONCLUSION

Simultaneous ALT, OTTT, and facial nerve cable grafting provides early reestablishment of facial symmetry, facial reanimation, and oral competence with minimal morbidity.

Temporal bone malignancies involving the jugular foramen: diagnosis and management

PURPOSE

To describe the diagnosis, management and outcomes of temporal bone malignancies involving the jugular foramen.

MATERIALS AND METHODS

The charts of 12 patients with temporal bone malignancies involving the jugular foramen were reviewed and analyzed.

RESULTS

The most frequent symptoms of temporal bone malignancies involving the jugular foramen were hearing loss (75%), otorrhea (66.67%) and otalgia (66.67%). In addition to the jugular foramen, the most invaded structure was the external auditory canal (91.67%), followed by the middle ear (75%) and facial nerve (58.33%). Four cases (33.33%) were misdiagnosed either with glomus jugulare tumor, Bell's palsy or chronic otitis media. Two patients underwent lateral temporal bone resection, whereas 10 patients underwent subtotal temporal bone resection. The mean follow-up time was 23.83 months (range, 2-85 months). The 2-year disease-free survival rate was 42.3%.

CONCLUSIONS

Temporal bone malignancies involving the jugular foramen had a poor prognosis, especially in patients with squamous cell carcinoma. Misdiagnoses including glomus jugulare tumor, Bell's palsy and chronic otitis media were frequently encountered. Temporal bone malignancies involving the jugular foramen can be resected, and the choice of the surgical approach should be individualized.

Facial nerve grading after parotidectomy

Dysfunction of the facial nerve is a common complication of parotidectomy. The functional deficit may be total or partial, and may include all or a single branch of the nerve. Despite a wide variety of the facial nerve grading systems, most of them have a limited utility in patients after parotidectomy. Therefore, existing scales assessing facial nerve function are compared to describe facial nerve outcomes after parotidectomy. The regional House-Brackmann, Sydney, and Yanagihara classification systems were utilized. The post-parotidectomy facial nerve grading system (PPFNGS) was created based on these three grading systems and also used for this study. The facial nerve function was assessed and recorded on the first postoperative day following conservative parotidectomy in 200 patients using all 4 scales by 3 otolaryngologists. The validity of the PPFNGS and existing facial nerve grading systems was examined by assessment of interrater agreement, intraclass correlation coefficient, internal consistency and construct validity. A deficit in the facial nerve function was found in 54 patients (27 %). Although results were consistent in all tested scales, the PPFNGS had a higher interrater agreement than the other three scales. PPFNGS is a new grading system designed for assessing the facial nerve function after parotidectomy in a quantitative and qualitative way and has a higher interrater agreement than other scales used to examine function of the 7th nerve.

Long-Term Outcomes of Facial Nerve Function in Irradiated and Nonirradiated Nerve Grafts

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.

Outcome measures in facial plastic surgery: patient-reported and clinical efficacy measures

OBJECTIVE

To survey the existing literature to identify, summarize, and evaluate procedure- and condition-specific outcome measures for use in facial plastic and reconstructive surgery.

METHODS

A review of the English-language literature was performed to identify outcomes instruments specific for targeted facial plastic surgery interventions and conditions. A search was performed using MEDLINE (1950 to September 2007), CINAHL (Cumulative Index to Nursing & Allied Health) (1982 to September 2007), and PsychINFO (1806 to September 2007). Outcomes instruments were categorized as patient-reported or clinical efficacy measures (observer-reported or objective measures). Instruments were then categorized to include relevant details on the intervention, degree of validation, and subsequent use.

RESULTS

Sixty-eight distinct instruments were identified (23 patient-reported, 35 observer-reported, and 10 objective measures), with some overlap among categories. Most patient-reported measures (76%) and half observer-reported instruments (51%) were developed in the past 10 years. The rigor of validation varied widely among measures, with formal validation being most common among the patient-reported outcome measures.

CONCLUSIONS

Validated outcomes measures are present for many common facial plastic surgery conditions and have become more prevalent during the past decade, especially for patient-reported outcomes. Challenges remain in harmonizing patient-reported, observer-based, and other objective measures to produce standardized clinically meaningful outcome measures.

Adenoid cystic carcinoma of the parotid gland: Anastamosis of the facial nerve with the great auricular nerve after radical parotidectomy

Adenoid cystic carcinoma of the parotid gland is a rare and slowly growing, but highly malignant tumor. Surgical resection of a malignant parotid tumor should include resection of the facial nerve when the nerve is involved in the tumor. Facial nerve reconstruction is required after nerve resection. A 14 year-old female presented with complaints of painless enlargement of the right parotid gland and facial asymmetry. Physical examination revealed a firm mass in the region of the parotid gland as well as right facial paralysis. Biopsy obtained from the mass showed an adenoid cystic carcinoma of the parotid gland. A radical parotidectomy with a modified radical neck dissection was carried out. Grafting material for the facial reconstruction was harvested from the great auricular nerve. The proximal main trunk and each distal branch of the facial nerve were coapted with the greater auricular nerve. The patient received radiotherapy after surgery and was seen to achieve grade IV facial function one year after surgery. Thus, the great auricular nerve is appropriate grafting material for coaptation of each distal branch of the facial nerve.

Preliminary Report of the Effect of High-Dose Adjuvant Intensity Modulated Radiation Therapy on the Sural Nerve Graft for Cavernosal Nerve Sacrifice After Radical Prostatectomy

PURPOSE

A sural nerve graft may replace a killed cavernosal nerve. The effect of intensity-modulated radiation therapy (IMRT) on function of the graft has not been reported.

MATERIALS AND METHODS

Between 1998 and 2001, 8 patients (9 nerve grafts) were treated with postoperative IMRT (mean dose, 70 Gy). Two patients had neoadjuvant Lupron 30 mg 2 months prior to radiation. Potency was defined as ability to achieve spontaneous erection sufficient for vaginal penetration. Median follow-up was 31.6 months.

RESULTS

Five patients (62.5%) who had erectile function after prostatectomy preserved spontaneous erectile function after radiation. Of these, 3 patients had both nerves resected (two receiving unilateral grafts and one receiving bilateral grafts) and 2 others had one graft and one nerve preserved. The impotent patients were impotent after surgery.

CONCLUSION

High-dose postprostatectomy IMRT does not place sural nerve grafts at greater risk for failure. Larger numbers of patients are needed to confirm these encouraging, preliminary findings.

Popliteal sarcomas: presentation, prognosis, and limb salvage

Soft tissue sarcomas of the popliteal fossa are rare diseases. Resection is challenging because of their extracompartmental location and proximity to neurovascular structures. Their prognosis is inferior to intracompartmental extremity soft tissue sarcomas. We ascertained the mode of initial presentation, the rates of local recurrence and distant metastasis, and the morbidity and complications of limb salvage procedures. We retrospectively analyzed the data of 29 consecutive patients operated on between 1989 and 2003. The median followup was 79 months. Sixteen, five, and eight patients were diagnosed with high-, intermediate-, and low-grade tumors, respectively. High-grade tumors were smaller than low- and intermediate-grade tumors. Thirty-one percent of patients presented with localized pain. Of the 26 patients who had primary limb salvage resections, 14 had negative surgical margins, six had close margins, and six had positive margins. Seventeen patients were treated with radiotherapy and 10 patients received chemotherapy. The local recurrence rate was 10.3%, four patients with high-grade tumors had distant metastasis, and the limb-salvage rate was 86.2%. Postoperatively, six patients experienced wound dehiscence and four had mild flexion contractures. Soft tissue sarcomas of the popliteal fossa have an atypical presentation. Limb salvage can be accomplished in most patients with low morbidity and good systemic and local control.

Free Vascularized Nerve Grafting for Immediate Facial Nerve Reconstruction

OBJECTIVES/HYPOTHESIS

To obtain better functional results after reconstruction to treat facial palsy in the patients with preoperative and intraoperative factors that might inhibit functional recovery, the authors have used free vascularized nerve grafts to immediately reconstruct severed facial nerves.

STUDY DESIGN

The indications for vascularized nerve grafts were 1) scarred recipient bed attributable to previous operations, 2) a history of previous irradiation at the wound, 3) facial skin defects over the nerve graft after tumor ablation, 4) patient age greater than 60 years, and 5) preoperative facial palsy.

METHODS

Four types of free vascularized nerves were used. Functional recovery after reconstruction could be assessed with two facial nerve grading systems.Ten patients who underwent immediate reconstruction of severed facial nerve after ablative surgery of malignant tumors of the parotid gland were reviewed.

RESULTS

Functional recovery after reconstruction could be assessed with the House-Brackmann grading system and a 40-point grading system in 6 of the 10 patients after a mean follow-up period of 29.8 months (range, 10-60 mo). Results with the House-Brackmann system were grade II in 1 patient, grade III in 4 patients, and grade IV in 1 patient; scores on the 40-point grading system were 20 in 1 patient, 22 in 3 patients, 24 in 1 patient, and 28 in 1 patient.

CONCLUSION

The study results indicated that muscle movement recovers satisfactorily after free vascularized nerve grafting. Although a study comparing vascularized nerve grafts and conventional nerve grafts would be necessary to confirm the superiority of vascularized nerve grafts, free vascularized nerve grafts are effective for immediate reconstruction of the severed facial nerve in patients with preoperative and intraoperative factors that might inhibit functional recovery.

Objective facial paralysis grading based onP face and eigenflow

To provide physicians with an objective and quantitative measurement of single-sided facial paralysis, the paper presents a computer-based approach that is different from the nine existing, subjective and hand-performed international scales, such as House-Brackman. For voluntary expressions of a patient, this approach used Pface, which stems from Dface, to measure the asymmetry between two sides of the face and used eigenflow to measure the expression variations between the patient and normal subjects. The results from Pface and eigenflow were then combined by the support vector machine produce to Pdegree. A study of 25 subjects revealed that Pdegree could differentiate paralysis states (Pdegree > or = 0) and normal states (Pdegree < 0), with the ability to grade facial paralysis automatically. Moreover, the Pface of specific facial areas can be used in the supervision of the rehabilitation process.

Effects of External Beam Radiation in the Rat Tibial Nerve after Crush, Transection and Repair, or Nerve Isograft Paradigms

INTRODUCTION

In head and neck surgery, radiation therapy is often administered to an injured nerve. Previous studies have examined the effects of either preoperative or postoperative radiation on nerve regeneration in rodents. In these studies, histomorphometric analysis was performed up to 8 month postoperatively. Given the exceptional neuroregenerative capacity of rodents, significant differences in nerve regeneration may go undetected if nerves are evaluated at such distant postoperative time points. This study is designed with a more appropriate model and investigates the effects of radiation after three common nerve injury paradigms.

METHODS

Sixty-four Lewis rates were randomized to 8 groups corresponding to uninjured, tibial nerve crush, transection and repair, or reconstruction with isografts. Half of the animals in each of these paradigms (n = 8 per group) were treated with 10 Gy of external beam radiation to the site of nerve injury at 7 days postoperatively. On postoperative day 28, functional recovery and histomorphometric assessment was performed.

RESULTS

For a given paradigm of nerve injury, no significant differences in nerve fiber number, neural density, neural debris, or fiber width were noted between the control and radiated groups, and radiation did not affect functional recovery.

CONCLUSION

Radiation had no discernible effect on nerve regeneration or functional recovery in the rodent nerve injury models studied. All assessments were made at time points suitable for detecting differences in nerve regeneration between groups. These findings suggest that administration of radiation to fields containing injured peripheral nerve is unlikely to adversely affect functional outcomes.

An analysis of facial nerve function in irradiated and unirradiated facial nerve grafts

PURPOSE

The effect of high-dose radiation therapy on facial nerve grafts is controversial. Some authors believe radiotherapy is so detrimental to the outcome of facial nerve graft function that dynamic or static slings should be performed instead of facial nerve grafts in all patients who are to receive postoperative radiation therapy. Unfortunately, the facial function achieved with dynamic and static slings is almost always inferior to that after facial nerve grafts. In this retrospective study, we compared facial nerve function in irradiated and unirradiated nerve grafts. METHODS AND MATERIALS The medical records of 818 patients with neoplasms involving the parotid gland who received treatment between 1974 and 1997 were reviewed, of whom 66 underwent facial nerve grafting. Fourteen patients who died or had a recurrence less than a year after their facial nerve graft were excluded. The median follow-up for the remaining 52 patients was 10.6 years. Cable nerve grafts were performed in 50 patients and direct anastomoses of the facial nerve in two. Facial nerve function was scored by means of the House-Brackmann (H-B) facial grading system. Twenty-eight of the 52 patients received postoperative radiotherapy. The median time from nerve grafting to start of radiotherapy was 5.1 weeks. The median and mean doses of radiation were 6000 and 6033 cGy, respectively, for the irradiated grafts. One patient received preoperative radiotherapy to a total dose of 5000 cGy in 25 fractions and underwent surgery 1 month after the completion of radiotherapy. This patient was placed, by convention, in the irradiated facial nerve graft cohort.

RESULTS

Potential prognostic factors for facial nerve function such as age, gender, extent of surgery at the time of nerve grafting, preoperative facial nerve palsy, duration of preoperative palsy if present, or number of previous operations in the parotid bed were relatively well balanced between irradiated and unirradiated patients. However, the irradiated graft group had a greater proportion of patients with pathologic evidence of nerve invasion (p = 0.007) and unfavorable type of nerve graft (p = 0.04). Although the irradiated graft cohort had more potentially negative prognostic factors, there was no difference in functional outcome (H-B Grade III or IV) between irradiated and unirradiated graft patients. H-B Grades III, IV, V, and VI were the best postoperative facial nerve functions achieved in 35%, 39%, 13%, and 13% of patients, respectively. The patient with preoperative radiotherapy never recovered any facial nerve function (H-B Grade VI). Median time to best facial nerve function after surgery was longer in the irradiated patients (13.1 vs. 10.8 months), but this was not statistically significant (p = 0.10). Presence of preoperative facial nerve palsy (p = 0.005), duration of preoperative palsy (p = 0.003), and age greater than 60 years at the time of grafting (p = 0. 04) were all negative prognostic factors for achieving a functional facial nerve on univariate analysis. Analysis of age as a continuous variable (p = 0.12) and pathologic evidence of nerve invasion (p = 0. 1) revealed a trend toward negative prognostic factors. Gender, number of previous operations in the parotid bed, extent of surgery at the time of nerve grafting, and type of grafting procedure were not significant prognostic factors. Whether radiotherapy was delivered less than 6 weeks after nerve grafting or more than 6 weeks had no impact on achievement of a functional facial nerve.

CONCLUSION

Negative prognostic factors for achieving a functional facial nerve in our series include the presence of preoperative facial nerve palsy, duration of preoperative palsy, and age greater than 60 years. Radiotherapy was not a negative prognostic factor. Comparing irradiated and unirradiated grafts revealed no difference in best facial nerve function achieved, despite the presence of a greater proportion of negative prognostic factors in

Management of facial nerve paralysis

Facial paralysis is a dreaded complication of parotid surgery. It can lead to a variety of troubling symptoms in the patient, such as ocular problems and nasal obstruction. It can also have a significant emotional impact on the patient because of facial disfigurement and difficulties with communication, eating, and drinking. Successful outcome for patients inflicted with facial paralysis depends on proper selection of the appropriate rehabilitation technique. This article discusses the acute and late management of facial paralysis resulting from parotid surgery.

Facial nerve function after petrosectomy

OBJECTIVES

Evaluation of facial nerve function after petrosectomy in a patient series with facial nerve denudation-decompression, forward or backward rerouting, and facial nerve suture and grafting.

STUDY DESIGN

Fifty-six patients with petrosectomies performed for 24 benign and 9 malignant tumors of the petrous bone, 13 malignant tumors of the parotid gland or of the infratemporal spaces with infiltration of the petrous bone, 8 traumatic facial nerve disruptions, and 2 osteoradionecroses were retrospectively evaluated with respect to facial nerve function. Sixteen cases involved a partial, 25 a subtotal, and 15 an extended subtotal petrosectomy.

METHODS

The treatment of the facial nerve included 15 denudation-compressions, 23 denudation-compressions with rerouting, 4 primary sutures, and 14 nerve grafts. The House-Brackmann grading system was used for facial nerve evaluation.

RESULTS

Normal or nearly normal facial nerve function was obtained in facial nerve denudation-decompression with and without rerouting (House-Brackmann Grade I or II) except in cases of malignant tumors and osteoradionecrosis, where preoperative impaired function remained. Satisfactory results were obtained with nerve suturing and nerve grafting after petrous bone fracture (Grade III or IV, in one case practically Grade II) except in a case of late repair 3 years after the trauma (Grade V). Variable results were obtained with nerve grafting in cases with tumor infiltration: Satisfactory results (5 of Grade III or IV) were obtained when the tumor was healed and also when postoperative radiotherapy was applied; poor results were obtained in the case of tumor recurrence (6 of Grade V or VI).

CONCLUSIONS

Our results show that petrosectomy with denudation-decompression of the facial nerve with or without rerouting usually results in a normal mimic of the face. When the facial nerve is disrupted by trauma or when the nerve is infiltrated by tumor, early reconstruction with nerve suture or grafting mostly leads to a partial and quite acceptable reinnervation of the face.

Facial nerve rehabilitation after radical parotidectomy

OBJECTIVE

Examine functional outcomes in patients undergoing radical parotidectomy and facial nerve grafting. Identify factors that may affect rehabilitation in these patients.

STUDY DESIGN

Retrospective chart review and photographic analyses of 12 patients undergoing radical parotidectomy with interposition nerve grafts for facial nerve reconstruction.

METHODS

Data obtained for each patient regarding age, sex, histology of parotid neoplasm, cable graft source, administration of postoperative radiotherapy, and treatment for eye rehabilitation. Functional outcomes were assessed with the House-Brackmann grading system at 6 months, 1 year, and 2 years after surgery.

RESULTS

All nerve grafts were harvested from cervical plexus sensory nerves with microscopic epineural repair performed for all neurorrhaphies. Overall, 9 of 12 patients achieved a grade III 2 years after surgery. All patients under age 30 obtained a grade III. Of the seven patients receiving postoperative radiation, five achieved a grade III. Older patients often required surgical procedures to facilitate eye closure.

CONCLUSIONS

Facial nerve rehabilitation after radical parotidectomy can be successfully achieved with cervical plexus interposition nerve grafts. Postoperative radiotherapy did not appear to affect return of function, and younger patients consistently achieved good functional outcomes after nerve grafting. Older patients frequently require surgical procedures for eye rehabilitation after radical parotidectomy.

Comparative value of facial nerve grading systems

The Fisch Detailed Evaluation of Facial Symmetry (DEFS) and House-Brackmann grading system (HBGS) were compared by statistical examination for their reliability and interobserver variability. Furthermore, the correlation and agreement with a standard global evaluation were compared. Therefore 47 patients with facial palsy of different cause have been evaluated with the two systems, and the global overall evaluation was done by five otolaryngologists familiar with facial palsy. The DEFS showed a high reliability of 0.93 compared with a reliability of 0.77 with the HBGS (international standard requires a reliability of at least 0.8). The mean interobserver variability is 5.24% (SD = 3.2%) with the DEFS and 9.26% (SD = 5.0%) with the HBGS; with a confidence interval of 95%, it is 11.6% and 19.26%. The correlation of both gradings with the global evaluation was high, with r = 0.98 and r = 0.97. The DEFS shows an excellent agreement with the global overall evaluation in 41 (87%) of 47 cases and the HBGS in 32 (66%) of 47 cases.

Evaluation of 242 consecutive parotidectomies performed for benign and malignant disease

Between 1987 and 1992, one surgeon performed 242 parotidectomies in 229 patients. Among 97 patients with benign disease, pleomorphic adenoma (46) and sialo-adenitis (28) predominated, while metastatic melanoma (22) and squamous cell carcinoma (21) were the most common diagnoses among 132 patients with malignancy. The extent of parotidectomies were: 114 'appropriate' resections, 77 complete superficial parotidectomies, 35 near-total conservative and 14 radical total resections. The facial nerve was sacrificed in 19 operations and reconstructed in four. One hundred and five patients had a concomitant neck dissection and 45 patients had adjuvant radiotherapy. Postoperative facial nerve function was normal in 90% of patients with localized tumours and 55% of patients overall. Patients with sialo-adenitis or deep lobe tumours and those having a neck dissection were at greatest risk of facial weakness despite nerve preservation. At a median follow up of 34 months, 13 patients had developed tumour recurrence and attempts at salvage surgery have generally been disappointing.

Surgical treatment of tumours of the skull base

OBJECTIVE

To describe the special features of surgical removal of tumours of the skull base and to review a series of patients treated for skull base tumours.

DESIGN

A retrospective review of patients followed up for between six months and six years.

SETTING

A unit specialising in surgery of the skull base at a tertiary referral centre.

PATIENTS

Sixty-six patients with skull base tumours were referred to the unit between February 1984 and December 1989.

INTERVENTIONS

Fifty-six of the patients underwent complete or partial surgical removal of the tumour. Radiotherapy was used as primary treatment in 10 patients, for tumour recurrence in four patients and as adjuvant postoperative treatment in 10 patients.

RESULTS

In the majority of patients the tumours were benign and have been controlled or are considered cured. Of the seven patients with malignant tumours five have died and two are long-term survivors (one has multiple metastases). Three patients with histologically "benign" tumours died of multiple metastases. There have been a total of 10 deaths in the series but only one occurred in the perioperative period. Cranial nerve palsy was the major postoperative complication.

CONCLUSION

Modern microsurgical techniques and modern anaesthesia and intensive care skills lead to a cure in many patients with skull base tumours previously considered inoperable.

Effect of prior radiotherapy on postsurgical wound infection

Radiotherapy causes both epithelial and endothelial damage acutely with the subsequent development of interstitial and perivascular fibrosis. These effects may lead to decreased blood flow, delayed wound healing, and a delay in achieving normal wound tensile strength. In a retrospective study of wound infections that developed in 23 of 354 patients (6%) accrued in a series of prospective, randomized antibiotic trials, the incidence of wound infection in patients receiving prior radiotherapy (7.6%) was not statistically different from the incidence of wound infection observed in patients who had had no prior radiotherapy (6.3%). Wound infection that developed in patients after radiotherapy tended to be associated with increased hospitalization, an increased rate of fistulization, and more frequently required secondary surgical repair. It is concluded that major head and neck procedures can be accomplished without an absolute increase in the incidence of wound infection. However, when postoperative complications occur, it may result in a significant increase in morbidity.

Experience with the resection of parapharyngeal cancers via the infratemporal fossa approach

Between 1982 and 1984, a modified infratemporal fossa approach was used to resect cancers with extensive primary or secondary involvement of the infratemporal fossa and parapharynx in 10 patients. Nine patients exhibited persistent or recurrent disease of the upper aerodigestive tract and posterior cranial fossa following planned, curative-intent therapy; the remaining patient had a carcinoma ex-pleomorphic adenoma of the deep lobe of the parotid gland with a significant infratemporal fossa extension. Considered to have "unresectable" tumors, by traditional methods, 7 of the 10 patients underwent an en-bloc resection of their lesions with tumor-free margins. Tumor was present at the margins of the specimens in the other 3 patients. Two of the 10 patients died early in the postoperative period of medical complications. Another died 5 months postoperatively of a tumor-induced internal carotid artery rupture at the level of the foramen lacerum. A fourth patient died of his disease 6 months following his resection. One patient is alive, but has metastatic meningioma 2 years after surgery. The 5 remaining patients are without evidence of disease, with a mean follow up of 2 years. Indications for and refinements of the operative technique, particularly those related to the repair of such extensive ablative defects, are outlined on the basis of this early experience.

Results of surgery alone and surgery combined with postoperative radiotherapy in the treatment of cancer of the parotid gland

Seventy-seven patients with primary malignant parotid tumors were studied and the various factors relative to their disease, as well as their treatment, were analyzed. Because of the retrospective nature of this study, no attempt was made to compare surgery alone with surgery and postoperative radiation, but it was interesting to reflect on the relative and absolute indications for the use of combined treatment versus surgery alone. The above-clavicle control in this group of patients was excellent, and the relatively low incidence of distant metastases reflect that optimal local control was closely correlated with survival. Sacrifice of the facial nerve should not be routinely based on the histologic characteristics of the tumor but rather on the findings at the time of surgery. Elective regional node dissection was indicated as a staging adjuvant and to provide extra exposure and soft tissue margins of excision in large tumors without producing any significant additional morbidity.