Long-term great auricular nerve morbidity after sacrifice during parotidectomy

Sensation Loss of Auricle Following Ear Surgery by Post-auricular Incision: Our Experience

Post-auricular incisions used for ear surgeries have their distinct advantages and disadvantages. Numbness in post-auricular region or over pinna is a symptom encountered in many patients following surgery via post-auricular incision. We performed this study to investigate this phenomenon of aural numbness in terms of frequency and severity. Design: Prospective study. Setting: This study was conducted in our hospital from 1st December 2015 to 30th November 2016 for a period of 1 year. The period of analysis was 1 month. Subjects: All patients undergoing surgery via post-auricular incision were included in the study. Methods: All the subjects were subjected to touch and pain sensory testing and also symptoms were recorded with the help of visual analog scale. The mean subjective Visual analog scale (VAS) value had significantly reduced after the surgery and it gradually improved over a period of about 6 months when it became near normal. Sensory testing revealed loss of touch and pain sensation in about 67% of patients following the surgery. The sensation recovered over a variable period of time, with about 95% of patients having normal touch and pain sensation 6 months after the surgery. Majority of patients treated with postaural incision develop sensory loss which is likely to recover in 3-6 months. Till that time patients should be counselled properly and appropriate measures should be taken to avoid any complications of sensory loss.

Long-term outcomes and quality of life following parotidectomy for benign disease

Objective

Parotidectomy worsens quality of life (QoL) in the short-term, but the long-term impact is unknown. In this study, we analysed the long-term effects of parotidectomy on QoL.

Methods

In this prospective long-term follow-up study, participants were divided into three groups: short-term (ST) follow-up of six weeks, long-term (LT) follow-up of 13 years and short- and long-term (SLT) follow-up. QoL was assessed using the Parotidectomy Outcome Inventory (POI-8). Parotidectomies were classified based on whether the great auricular nerve (GAN) had been preserved or sacrificed.

Results

In total, 164 observations were analysed, 74 in the LT group, 57 in the ST group and 33 in the SLT group. Hypoaesthesia was a major problem and facial palsy was a minor problem. Pain (p < 0.01) and hypoaesthesia (p < 0.001) were significantly lower after 13 years compared with after six weeks, and QoL was higher after 13 years compared with after six weeks (p = 0.04). The disease-specific impairment rate decreased from 70% at short-term follow-up to 30% at long-term follow-up. Removal of the GAN was associated with hypoaesthesia in the ST group (p = 0.028).

Conclusions

Hypoaesthesia has a long-term impact on the QoL, and this should be emphasised during preoperative discussions.

Case report on ear numbness following deep brain stimulation implantation

Introduction and importance

Case presentation

Clinical discussion

Conclusion

•

Ear numbness is a rare complication after DBS.

•

The likely cause is neural damage during subcutaneous tunneling.

•

In DBS implantation, tunneling below the periosteum can prevent this complication.

The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain

BACKGROUND

Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve.

METHODS

Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer.

RESULTS

The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound.

CONCLUSIONS

This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).

Nerve block as neuropathic pain treatment for the great auricular nerve neuropathy: A case report

OBJECTIVE/BACKGROUND

The great auricular nerve (GAN) is a major sensory branch of the cervical plexus. Painful great auricular neuropathy causes pain circumscribed to the inferior preauricular region, the jaw angle, the ventral pinna, and the mastoid region.

METHODS

We present a 46-year-old woman experiencing facial pain in the bilateral preauricular and infra-auricular region, constant, of abrasive quality without any other associated symptomatology that is triggered or aggravated with cephalic movements, cervical turn, mandibular movement, and palpation on the affected area.

RESULTS

Symptomatic treatment with analgesics, anti-inflammatories, and neuropathic preventive medications was ineffective. However, nerve block anesthetic treatment resulted in complete pain remission.

CONCLUSION

Great auricular neuropathy is an uncommon cause of facial pain; our case report is the first bilateral occurrence reported to date. It should be suspected in patients with circumscribed shooting or lancinating paroxysmal pain in the territory of the GAN. It is characterized by the aggravation of pain with cervical movements and complete relief after anesthetic blockade.

Selective Denervation of the Facial Dermato-Muscular Complex in the Rat: Experimental Model and Anatomical Basis

The facial dermato-muscular system consists of highly specialized muscles tightly adhering to the overlaying skin and thus form a complex morphological conglomerate. This is the anatomical and functional basis for versatile facial expressions, which are essential for human social interaction. The neural innervation of the facial skin and muscles occurs via branches of the trigeminal and facial nerves. These are also the most commonly pathologically affected cranial nerves, often requiring surgical treatment. Hence, experimental models for researching these nerves and their pathologies are highly relevant to study pathophysiology and nerve regeneration. Experimental models for the distinctive investigation of the complex afferent and efferent interplay within facial structures are scarce. In this study, we established a robust surgical model for distinctive exploration of facial structures after complete elimination of afferent or efferent innervation in the rat. Animals were allocated into two groups according to the surgical procedure. In the first group, the facial nerve and in the second all distal cutaneous branches of the trigeminal nerve were transected unilaterally. All animals survived and no higher burden was caused by the procedures. Whisker pad movements were documented with video recordings 4 weeks after surgery and showed successful denervation. Whole-mount immunofluorescent staining of facial muscles was performed to visualize the innervation pattern of the neuromuscular junctions. Comprehensive quantitative analysis revealed large differences in afferent axon counts in the cutaneous branches of the trigeminal nerve. Axon number was the highest in the infraorbital nerve (28,625 ± 2,519), followed by the supraorbital nerve (2,131 ± 413), the mental nerve (3,062 ± 341), and the cutaneous branch of the mylohyoid nerve (343 ± 78). Overall, this surgical model is robust and reliable for distinctive surgical deafferentation or deefferentation of the face. It may be used for investigating cortical plasticity, the neurobiological mechanisms behind various clinically relevant conditions like facial paralysis or trigeminal neuralgia as well as local anesthesia in the face and oral cavity.

Minor Parotidectomy Complications: A Systematic Review

OBJECTIVES

To report descriptive statistics for minor parotidectomy complications.

METHODS

A systematic review was performed, selecting 235 studies for analysis. The incidence of complications was tabulated, and descriptive statistics calculated. Outlier studies, 1 standard deviation above the mean, were reexamined to determine potential causal factors for each complication. All studies were examined for statistically significant differences for any potential causal factor.

RESULTS

The pooled incidence of minor complications reported were hematoma 2.9% (95% confidence interval [CI]: 2.4-3.5), wound infection 2.3% (95% CI: 1.8-2.9), sialocele 4.5% (95% CI: 3.5-5.7), salivary fistula 3.1% (95% CI: 2.6-3.7), flap necrosis 1.7% (95% CI: 1.1-2.5), scar issues 3.6% (95% CI: 2.4-5.4), numbness 33.9% (95% CI: 25.6-43.4), and deformity 11.8 (95% CI: 6.9-19.5). Implants result in more wound complications, such as hematoma, sialocele, or salivary fistula. Sialocele and salivary fistula appear more frequently after less extensive parotid surgery, whereas hematoma, wound infections, flap necrosis, and aesthetic considerations are worse with more extensive resections.

CONCLUSIONS

Minor parotidectomy complications are more frequent than generally assumed and related to certain factors that should be investigated. Laryngoscope, 131:571-579, 2021.

Modified Postauricular Incision for Preservation of the Lesser Occipital Nerve and the Great Auricular Nerve in Ear Surgery

OBJECTIVE

To describe the feasibility of preserving the lesser occipital nerve (LON) and the great auricular nerve (GAN) in postauricular incision in ear surgery.

METHODS

The distribution of the LON and the GAN was first identified in human cadavers. Then a clinical study was performed in 34 patients who underwent middle ear surgery between September 2016 and January 2017. Patients were divided into the conventional incision group and the modified incision group, according to incision types, and underwent sensory testing and subjective evaluation of auricular numbness after surgery at different times.

RESULTS

Most frequently, the auricular branches of the LON went into the postauricular groove at the same height of inferior crus of antihelix. The vertical dimension from the intersection of the highest auricular branch of the GAN and postauricular groove to intertragic notch ranged from 5.7 to -4.2 mm. Preservation of the LON and the GAN reduced sensory loss in the modified incision group compared to the conventional incision group.

CONCLUSION

Preservation of the LON and the GAN with modified postauricular incision can reduce postoperative auricular numbness.

Effects of an antiadhesive agent on functional recovery of the greater auricular nerve after parotidectomy: a double-blind randomized controlled trial

PURPOSE

Periauricular sensory deficit occurs frequently after parotidectomy even in cases with preservation of the greater auricular nerve (GAN). This study was performed to evaluate the effects of antiadhesive agent in functional recovery of the GAN after parotidectomy.

METHODS

Ninety-eight patients undergoing partial parotidectomy for benign parotid tumors were prospectively enrolled in this multicenter, double-blind randomized controlled study and randomly assigned to either the study or control group. Antiadhesive agent was applied in the study group. The results of sensory tests (tactile, heat, and cold sensitivity) and a questionnaire on quality of life (QoL) were acquired at postoperative 1, 8, and 24 weeks after surgery. Clinical parameters, and the results of the sensory tests and the questionnaire, were compared between the two groups.

RESULTS

A total of 80 patients were finally enrolled. On sensory evaluation, tactile sensation and warm sensation in the ear lobule, and warm sensation in the mastoid area, showed significant improvement at 24 weeks postoperatively in the study group. There were no significant differences between the two groups on any questions in the QoL questionnaire, at any follow-up time point.

CONCLUSIONS

Antiadhesive agents have some positive effects on functional recovery of the GAN after parotidectomy. Therefore, applying antiadhesive agents after parotidectomy can reduce discomfort in patients.

What Is the Lobular Branch of the Great Auricular Nerve? Anatomical Description and Significance in Rhytidectomy

BACKGROUND

Current literature suggests that preserving the lobular branch of the great auricular nerve has greater impact on sensory function of the auricle than preservation of the posterior branch during rhytidectomy. However, no methodology exists to efficiently and accurately determine the topographic location of the lobular branch. This study describes the branching characteristics of the lobular branch and algorithmic surface markings to assist surgeons in preservation of the great auricular nerve during rhytidectomy flap elevation.

METHODS

The lobular branch was dissected in 50 cadaveric necks. Measurements were taken from the lobular branch to conchal cartilage, tragus, and antitragus. The anterior branch was measured to its superficial musculoaponeurotic system insertion, and the posterior branch was measured to the mastoid process. The McKinney point was marked and the great auricular nerve diameter was recorded. Branching pattern and location of branches within the Ozturk 30-degree angle were documented. Basic statistics were performed.

RESULTS

The lobular branch was present in all specimens and distributed to three regions. In 85 percent of specimens, the lobular branch resided directly inferior to the antitragus; in the remaining specimens, it was located directly inferior to the tragus. Preoperative markings consisting of two vertical lines from the tragus and antitragus to the McKinney point can be used to outline the predicted location of the lobular branch.

CONCLUSIONS

This study delineates the location of the lobular branch of the great auricular nerve. The authors translate these findings into a quick and simple intraoperative marking, which can assist surgeons in avoiding lobular branch injury during rhytidectomy dissection.

Sensation loss after superficial parotidectomy: A prospective controlled multicenter trial

BACKGROUND

The purpose of this study was to evaluate the occurrence of hypoesthesia after superficial parotidectomy depending on preservation of posterior branch of the great auricular nerve (GAN).

METHODS

This prospective, controlled, double blind, multicenter trial included 130 patients. The posterior branch was preserved in 93 patients (GAN group), and ligated in 33 patients (non-GAN group). In 4 patients, GAN status was unknown. Included patients underwent sensory testing (TouchTest) and subjective evaluation at 6, 12, and 24 months after surgery.

RESULTS

Better improvement of sensation was present in the GAN group. After 12 months, 59% of the patients in the GAN-group showed positive test results in the lobule, versus 24% of the non-GAN group (p = .013). Additionally, after 24 months, 71% of the patients in the GAN-group showed a positive test in the antitragus, versus 31% in the non-GAN group (p = .045). Hypoesthesia equally limited quality of life in both groups (all p > .05).

CONCLUSION

Preservation of the posterior branch of the GAN led to significantly better improvement of sensation in the lobule and antitragus, and should be recommended during parotidectomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 520-526, 2017.

Parotidectomy combined with identification and preservation procedures of the great auricular nerve

CONCLUSIONS

We found that the great auricular nerve (GAN) passes at the median (m) point between the tips of the mandibular angle and mastoid process. We also established the GAN definitive line using this point for rapid identification of the trunk of the GAN and systematic parotidectomy combined with procedures for identification of the GAN, elevation of the skin flap, and exposure of the parotid capsule, which showed a high rate of preservation of the nerve and the lobular branch.

OBJECTIVE

The aim of this study was to improve parotidectomy and the rate of preservation of the GAN.

METHODS

This study comprised 74 consecutive patients who were scheduled to have parotidectomy for benign tumors at our department between November 2011 and April 2014. We examined whether our GAN definitive line including the m point was useful to identify the trunk of the GAN and whether anterograde dissection of the nerve could be performed simultaneously with skin flap elevation and exposure of the parotid capsule and contributed to preservation of the trunk to the lobular branch.

RESULTS

The trunk was identified under the GAN definitive line drawn preoperatively in 97.3% of cases (72/74). Combined surgery was successfully performed with a 95.9% (71/74) preservation rate of the GAN including the lobular branch.

Great auricular nerve preservation during parotidectomy for benign tumors

The great auricular nerve, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the sternocleidomastoid muscle. In few years, many experiences by different authors concerning the issue of great auricular nerve integrity during parotidectomy were published in the literature. The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery.

Sensory dysfunction and quality of life after great auricular nerve sacrifice during parotidectomy: our experience

OBJECTIVE

This study aimed to investigate the impact on patients' quality of life of great auricular nerve sacrifice during parotidectomy.

METHODS

A retrospective review was conducted of 191 consecutive patients who underwent parotidectomy with great auricular nerve sacrifice between 2006 and 2011. Residual sensory dysfunction and its impact on quality of life was analysed using an eight-item quality of life survey.

RESULTS

In all, 139 out of 191 patients (72.8 per cent) experienced one or more abnormal sensations in the ear or neck region after surgery. There was a moderate inverse correlation between the number of abnormal sensations and time elapsed since surgery. Moreover, the degree of discomfort correlated significantly with the frequency of symptom occurrence (p < 0.001), duration of the abnormal sensation (p < 0.001) and size of the affected area (p < 0.001).

CONCLUSION

Sacrifice of the great auricular nerve has only a small impact on patient quality of life; their daily activities are not significantly affected.

Great auricular nerve preservation in parotid gland surgery: Long-term outcomes

OBJECTIVES/HYPOTHESIS

To assess sensory outcomes and quality of life (QoL) in two groups of patients with and without great auricular nerve (GAN) preservation during parotidectomy.

STUDY DESIGN

Retrospective chart review.

METHODS

The posterior branch of the GAN was preserved in 42 patients (group A) and sacrificed in 13 (group B). Tactile, heat, and cold sensitivities were investigated by dividing GAN territory into seven areas. Comparisons between operated (OS) and nonoperated sides (NS) within each group, and between the OS of the two groups were made. The QoL questionnaire was administered.

RESULTS

In group A, normal tactile, heat, and cold sensitivities ranged from 16.7% to 66.7%, 11.9% to 73.8%, and 21.4% to 81%, respectively, in different OS areas. Significant differences between OS and NS were found, except for the preauricular superior area. In group B, normal tactile, heat, and cold sensitivities ranged from 0% to 61.5%, 0% to 53.8%, and 7.7% to 76.9%, respectively, in different OS areas. Significant differences between OS and NS were found except for the preauricular superior (tactile sensitivity), and preauricular superior and helix/concha areas (cold sensitivity). Comparing the OS tactile and thermic sensitivities between the two groups, only the lobule area showed differences. The preauricular inferior area was different only for heat. The QoL questionnaire showed different hypoesthesia extension between the two groups. All other items were comparable.

CONCLUSIONS

Sensory deficits are commonly reported despite GAN preservation. Lobule and preauricular inferior areas showed differences in terms of tactile and thermic sensitivities, with better outcomes in group A. QoL seems tolerable despite GAN sacrifice.

LEVEL OF EVIDENCE

4

Surgical decompression of the great auricular nerve: a therapeutic option for neurapraxia following rhytidectomy

BACKGROUND

Great auricular nerve injuries are the most frequent nerve injuries following rhytidectomy, occurring at a rate of 6 percent. Short-scar techniques may decrease visualization and increase the risk of injury/compression of the great auricular nerve. Recent reviews have identified that great auricular nerve injury can contribute to long-term paresthesias and allodynia in a majority of patients. Identification of this injury, with subsequent exploration, wide release, and decompression, should be performed.

METHODS

Four patients with injury of the great auricular nerve were referred for persistent allodynia as a complication of short-scar rhytidectomy. Following confirmation of a Tinel sign over the great auricular nerve, each patient underwent subsequent exploration and neurolysis.

RESULTS

Diagnosis of compression and suture impingement was confirmed at exploration, and extensive decompression was performed with care taken to protect the nerve from postoperative scar formation. All patients noted postoperative improvement in symptoms, with nearly complete resolution at 6 months.

CONCLUSIONS

Minimally invasive techniques may impart increased risk of nerve injury in exchange for reduced scar length. In instances of great auricular nerve injury, progressive metabolic changes and increased vascular permeability allow for inflammatory cellular influx and fibrin deposition, compounding nerve dysfunction and symptomatic complaints. Noninvasive modalities may not alleviate complaints of pain and hyperesthesia, particularly in the event of suture compression. Persistent injuries can affect quality of life, with intrusive thoughts about symptoms, or an inability to perform grooming activities. Exploration and decompression of the great auricular nerve may offer a long-term solution for the patient with postrhytidectomy allodynia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

A failsafe method to avoid injury to the great auricular nerve

BACKGROUND

The great auricular nerve (GAN) is the most commonly injured nerve during facelift surgery. Although rare, injury can result in long-term sequelae.

OBJECTIVES

Previous reports have described the nerve's location at the midbelly of the sternocleidomastoid muscle (SCM) or at its emergence from underneath the SCM. The purpose of our study was to identify the superior course of the great auricular nerve as it applies to facelift.

METHODS

Thirteen fresh cadavers were dissected. A vertical line through the midlobule was drawn perpendicular to the Frankfort's horizontal, acting as a reference to the course of the GAN. Transparent paper overlay tracings were then done to record each nerve's location. The distance from the bony external auditory canal (EAC) to the nerve was measured at the anterior muscle border, at the midbelly of the SCM, and as the nerve emerged from under the SCM. Branching patterns of the nerve and its relation to the external jugular vein were identified.

RESULTS

In 100% of the dissections, the superior course of the GAN fell within a 30-degree angle constructed using the vertical limb perpendicular to the Frankfurt horizontal and a second limb drawn posteriorly from the midlobule. The distance from the EAC to the nerve was 4.9 ± 1.1 cm at the anterior muscle border, 7.3 ± 1.0 cm at the midbelly of the SCM, and 9.8 ± 1.2 cm at the GAN's emergence from under the SCM. Four types of branching patterns were identified.

CONCLUSIONS

The 30-degree angle described above rapidly and accurately identifies the nerve's location.

Preservation of greater auricular nerve during parotidectomy: sensation, quality of life, and morbidity issues. A systematic review

BACKGROUND

Our objectives were to assess the evidence of preservation of the greater auricular nerve in parotidectomy with regard to morbidity and quality of life.

METHODS

This was a systematic review. Inclusion criteria were: English literature, prospective and retrospective studies. Exclusion criteria were: single case reports, "teaching" reviews. Outcome measures were: tactile sensation, pain, thermal sensitivity, and quality of life.

RESULTS

Although quality of life does not seem to be adversely affected when the greater auricular nerve is sacrificed, preservation of the posterior branch was recommended in 8 studies. When preserving the nerve, the incremental operative time increase is no more than 10 to 5 minutes after a rapid learning curve.

CONCLUSIONS

There is level Ib evidence that preservation of the greater auricular nerve minimizes the postoperative sensory disturbance and should be considered whenever tumor clearance is not compromised. There is no evidence that overall quality of life is affected when the greater auricular nerve is sacrificed.

Cutaneous sensory deficit following post-auricular incision

Introduction:

Post-auricular incisions are performed for a range of otological procedures. Anecdotally, many patients suffer some numbness of the pinna or post-auricular skin post-operatively, but for most this appears to reduce with time. This study aimed to investigate this phenomenon.

Methods:

A single centre, questionnaire-based study was undertaken, assessing the presence of numbness beyond eight months post-surgery, its location, how it changed, and its impact on the patient. Patients whose numbness had resolved provided details of any temporary deficit. Data were acquired for 35 primary and 16 revision procedures.

Results and conclusion:

Sixty-nine per cent of patients undergoing primary surgery experienced post-operative numbness. Twenty-six per cent had continued numbness after at least eight months' recovery, but only 3 per cent were constantly aware of the deficit. Of those with an ongoing deficit, 78 per cent felt there had been a reduction in the severity, and 67 per cent in the area size, over time. Recovery appeared to be slightly worse in revision cases.