Amputation neuroma of the great auricular nerve after operations on the parotid gland

Complaints of neuropathic pain, noxious cervical plexus neuropathy and neck tightness are reported by patients who undergo neck dissection: an institutional study and narrative review

There exists a subgroup of patients who undergo neck dissection (ND) who postoperatively complain of either neuropathic pain, dysaesthesia and/or discomfort that is located within the dermatomal distribution of the cervical plexus. The purpose of our study was to determine the prevalence, characteristic, and demographics of these symptoms in our patient cohort. We undertook a retrospective randomised observational cohort study of 105 patients who had undergone ND. The primary predictor variable was the undertaking of a ND. The secondary outcome variable was the complaint of either neuropathic pain or a noxious neuropathy, at a minimum of twelve months after surgery. A recognised symptom questionnaire and a visual analogue score was employed for the purpose of the study. A descriptive and statistical analysis was applied to the assembled data. Twenty patients (19%) complained of either spontaneous (n=9) or evoked (n=11) neuropathic pain that occurred within the surgical site. In addition, 71 patients (68%) described an altered sensation in the dermatomal distribution of the great auricular or tranverse cervical nerves while 70 patients (67%) described the feeling of 'neck tightness'. There were no characteristics of the study cohort that underpinned these results. Neuropathic pain can occur following ND. This can cause distress to a small but defined group of patients. Despite its importance, we found a paucity of studies in the literature that have investigated neuropathic pain following ND. We believe this condition requires more research attention and clinical awareness.

Treatment of great auricular neuralgia with real-time ultrasound-guided great auricular nerve block: A case report and review of the literature

RATIONALE

The great auricular nerve can be damaged by the neck surgery, tumor, and long-time pressure on the neck. But, great auricular neuralgia is very rare condition. It was managed by several medication and landmark-based great auricular nerve block with poor prognosis.

PATIENT CONCERNS

A 25-year-old man presented with a pain in the left lateral neck and auricle.

DIAGNOSIS

He was diagnosed with great auricular neuralgia.

INTERVENTIONS

His pain was not reduced by medication. Therefore, the great auricular nerve block with local anesthetics and steroid was performed under ultrasound guidance.

OUTCOMES

Ultrasound guided great auricular nerve block alleviated great auricular neuralgia.

LESSONS

This medication-resistant great auricular neuralgia was treated by the ultrasound guided great auricular nerve block with local anesthetic agent and steroid. Therefore, great auricular nerve block can be a good treatment option of medication resistant great auricular neuralgia.

Topographic anatomy of the great auricular point: landmarks for its localization and classification

PURPOSE

The great auricular point (GAP) marks the exit of the great auricular nerve at the posterior border of the sternocleidomastoid muscle (SCM). It is a key landmark for the identification of the spinal accessory nerve, and its intraoperative localization is vital to avoid neurological sequelae. This study delineates the topography and surface anatomy landmarks that used to localize the GAP.

METHODS

Thirty cadaveric heminecks were dissected on a layer-by-layer approach. The topography of the GAP was examined relative to the insertion point of the SCM at the clavicle, tip of the mastoid process, and angle of the mandible. The GAP and its relation to the SCM were determined as a ratio of the total length of the SCM.

RESULTS

The GAP was demonstrated to be in a predictable location. The mean length of the SCM was 131.4 ± 22 mm, and the mean distance between the GAP and the mastoid process was found to be 60.4 ± 13.76 mm. The ratio of the GAP location to the total SCM length ranged between 0.33-0.57. The mean distance between the angle of the mandible and the GAP was determined to be 57 ± 22.2 mm. Based on the midpoint of the SCM, the GAP was above it in 66.7 % of subjects and classified to Type A, and below it in 33.3 % of subjects appointed to Type B.

CONCLUSIONS

The anatomical landmarks utilized in this study are helpful in predicting the location of the GAP relative to the midpoint of the SCM and can reduce neural injuries within the posterior triangle of the neck.

Modified superficial parotidectomy: Preserving both the great auricular nerve and the parotid gland fascia

Objective

To reduce the incidence of sensory deficits and Frey's syndrome by modifying the traditional superficial parotidectomy.

Study Design

After raising the skin flap, the parotid gland fascia (PGF) was elevated to form a posterior pedicle fascial flap and then was replaced after the gland removal. The great auricular nerve (GAN) that runs within the PGF was not separated, so both the GAN and the PGF were preserved. Before this modification, the GAN and PGF were examined anatomically. The complication rates in the modified and control groups were compared.

Results

1) The GAN, which runs within the thick and pycnotic PGF, trifurcates into postauricular, preauricular and lobule branches. The modification could be carried out practically based on the anatomy study. 2) Long-term sensory deficit was encountered in 13.3% of the control group, but 0% in the modified one. Frey's syndrome was suffered by 66.7% and 16.7% cases in the control and modified group respectively. The incidence of other complications was not significantly different.

Conclusion

Our modification is practical. It decreases the complications significantly. EBM rating: B-3b

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.

Neurovascular structures of the mandibular angle and condyle: a comprehensive anatomical review

BACKGROUND

Various surgical interventions including esthetic surgery, salivary gland excision, and open reduction of fracture have been performed in the area around the mandibular angle and condyle. This study aimed to comprehensively review the anatomy of the neurovascular structures on the angle and condyle with recent anatomic and clinical research.

METHODS AND RESULTS

We provide detailed information about the branching and distributing patterns of the neurovascular structures at the mandibular angle and condyle, with reported data of measurements and proportions from previous anatomical and clinical research. Our report should serve to help practitioners gain a better understanding of the area in order or reduce potential complications during local procedures. Reckless manipulation during mandibular angle reduction could mutilate arterial branches, not only from the facial artery, but also from the external carotid artery. The transverse facial artery and superficial temporal artery could be damaged during approach and incision in the condylar area. The marginal mandibular branch of the facial nerve can be easily damaged during submandibular gland excision or facial rejuvenation treatment. The main trunk of the facial nerve and its upper and lower distinct divisions have been damaged during parotidectomy, rhytidectomy, and open reductions of condylar fractures.

CONCLUSION

By revisiting the information in the present study, surgeons will be able to more accurately prevent procedure-related complications, such as iatrogenic vascular accidents on the mandibular angle and condyle, complete and partial facial palsy, gustatory sweating (Frey syndrome), and traumatic neuroma after parotidectomy.

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

Anatomic and histological study of great auricular nerve and its clinical implication

BACKGROUND

The great auricular nerve (GAN) is often sacrificed during parotidectomy, rhytidectomy, and platysma flap operation. Transection of the nerve results in a wooden numbness of preauricular region, pain, and neuroma. The aim of this study was to describe the branching patterns and distribution area of the GAN.

METHODS

Twenty-five embalmed, adult hemifacial Korean cadavers (16 males, nine females; mean age 62.5 years) were used in this study. The branching of the GAN was determined through careful dissection. The histological structure of the GAN was also examined by harvesting and sectioning specimens, and then viewing them with the aid of a light microscope.

RESULTS

The branching pattern of the anterior, posterior, deep, and superficial branches of the GAN could be classified into five types: type I (20%), where the deep branches arose from the anterior branch; type II (24%), where all branches originated at the same point; type III (28%), where the deep branch arose from the posterior branch; type IV (8%), where the superficial branches arose from the posterior branch; and type V (20%), where the anterior and posterior branches ran independently. A connection between the GAN and the facial nerve trunk was observed in all specimens, and a connection with the auriculotemporal nerve was observed in a few specimens. The total fascicular area of both regions decreased from proximal (1.42 mm2) to distal (0.60 mm2). There were 2.5 and 5 fascicles in the proximal and distal regions, respectively.

CONCLUSION

The results reported herein will help toward preservation of the GAN during surgery in the region of the parotid gland. Furthermore, the histologic findings suggest that the GAN would be a good donor site for nerve grafting.

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.

Chronic daily headaches secondary to greater auricular and lesser occipital neuromas following endolymphatic shunt surgery

In head and neck surgery, peripheral sensory nerves are at risk for traumatic injury. These injuries are known to be peripheral triggers of chronic headaches if left untreated or unrecognised. We report the case of a patient that presented with a severe headache, nausea and emesis of 2 years duration following endolymphatic shunt placement for Meniere's disease. Nerve blockade suggested a peripheral trigger, and surgical exploration of the incision site revealed traumatic neuromas of the greater auricular and lesser occipital nerves. Subsequent nerve resection yielded complete symptomatic relief. This is the first case report of a peripherally triggered migraine headache due to the development of neuromas of the greater auricular and lesser occipital nerves, also representing a previously unreported complication of endolymphatic shunt placement. It is recommended that in patients presenting with intractable migraines and a history of head and neck surgery, diagnostic nerve blockage be used to assess for neuromas.

Mechanism of traumatic neuroma development

We suggest that symptomatic traumatic neuromas - benign lesions of incompletely understood etiology - develop when neural fiber regeneration occurs in the presence of excessive fibrous tissue proliferation. Subsequent contraction of wound and scar myofibroblasts leads to compression of the regenerating nerve fibers and further stimulation of the overgrowth of their perineurial cells as a protective response. This chronic process leads to a slow enlargement of the proliferating mass and the typical histological picture of a traumatic neuroma, in which multiple interlacing fascicles of nerve fibers are encased in condensed fibrous tissue. To avoid the development of a traumatic neuroma, we propose that an injured or a transected nerve should be placed out of the site of potential excessive fibroproduction and/or that all external factors leading to excessive fibroproduction development be eliminated from the wound site.

SENSATION RECOVERY IMPROVED BY GREAT AURICULAR NERVE PRESERVATION IN PAROTIDECTOMY: A PROSPECTIVE DOUBLE-BLIND STUDY

BACKGROUND

The great auricular nerve (GAN) is frequently sacrificed during parotidectomy and causes sensory disturbance of the auricle. Our study is to investigate whether GAN preservation can improve the sensory recovery.

METHODS

Patients undergoing superficial or total conservative parotidectomy for benign tumours were recruited consecutively from November 1998 to September 2001. Different sensory methods (light touch, two-point discrimination and sharp pain) of the auricle were evaluated by a designated physiotherapist preoperatively as well as at 1, 3, 6 and 12 months postoperatively. The patients and the physiotherapist were blinded to the integrity of the GAN. Long-term subjective assessment was also carried out beyond 2 years postoperatively.

RESULTS

A total of 21 patients were recruited for the study. GAN were preserved in 10 patients. The mean follow up was 16 months (12-42 months). There was no difference in sex distribution, type of operation and pathology of parotid tumour between the two groups. No postoperative mortality occurred and postoperative morbidity did not differ between the two groups. Patients with GAN preserved had significantly better light touch and sharp pain recovery at 1 year postoperatively. Subjective assessment of sensory dysfunction also favoured GAN preservation.

CONCLUSION

Great auricular nerve preservation minimizes the postoperative sensory disturbance and should be considered whenever tumour clearance is not compromised.