KISEP Head and Neck Korean J Otolaryngol 1999;42: 이하선악성종양에서신경이식술을통한안면신경재건 유승주 1 장영 1 고경석 2 김상윤 1 Facial Nerve Reconstruction with Nerve Graft f

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1 KISEP Head and Neck Korean J Otolaryngol 1999;42: 이하선악성종양에서신경이식술을통한안면신경재건 유승주 1 장영 1 고경석 2 김상윤 1 Facial Nerve Reconstruction with Nerve Graft following Ablative Parotid Surgery Seung Joo Yoo, MD 1, Young Chang, MD 1, Kyung Suck Koh, MD 2 and Sang Yoon Kim, MD 1 1 Department of Otolaryngology, 2 Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea ABSTRACT Background and ObjectiveSacrifice of the facial nerve may be unavoidable during parotid resections for malignancy. In these cases, facial nerve reconstruction is helpful to minimize postoperative facial dysfunction. Many surgical techniques have been described to improve the dysfunction of facial nerve but immediate nerve suture, or grafting if direct suture is not possible, achieves the best results and allows maximal return of function. Materials and MethodsWe retrospectively studied 8 patients with parotid malignancies undergoing ablative parotid surgery with sacrifice of the seventh cranial nerve and facial nerve reconstruction with interposition graft between 1992 and They had been followed up for at least 6 months. Seven patients were reconstructed with simple interposition graft and the other was reconstructed with end-to-side facial-hypoglossal interposition graft. All the patients were treated with adjuvant radiotherapy. Each patient was evaluated on the basis of facial symmetry, eye closure and smile by means of photograph taken on the follow-up visit. ResultFacial symmetry, eye closure, and smile were improved satisfactorily in five, six, and four patients respectively. Recovery of patients who have had preoperative facial paralysis exhibited rather poor results. ConclusionNerve grafting performed immediately after resection of the tumor can provide a significant improvement of function in patients with sacrifice of the facial nerve. Korean J Otolaryngol 1999;42: KEY WORDSFacial nerve reconstruction Nerve graft Parotid gland. 495

2 Table 1. The grading system of postoperative facial expression Facial symmetry asymmetric symmetric partially asymmetric Eye closure normal Cmin-complete closure with minimal effort Cmax-complete closure with maximal effort partial closure none Smile poor good excellent Table 2. Patients profile No. Pathology Donor nerve Proximal site Distal site 1 mucoepidermoid carcinoma L/G great auricular n. extratemporal Zygomatic & buccal 2 mucoepidermoid carcinoma H/G great auricular n. extratemporal Zygomatic & buccal 3 mucoepidermoid carcinoma H/G great auricular n. mastoid Zygomatic & buccal 4 mucoepidermoid carcinoma H/G great auricular n. extratemporal Zygomatic & buccal 5 adenoid cystic carcinoma sural n. extratemporal Zygomatic & buccal 6 adenoid cystic carcinoma sural n. CN XII Zygomatic & buccal 7 epithelial-myoepithelial carcinoma Recurred great auricular n. extratemporal Zygomatic 8 adenocarcinoma great auricular n. mastoid Zygomatic & marginal CN XIIhypoglossal nerve, Mucoepidermoid carcinoma L/GLow grade mucoepidermoid carcinoma, Muc oepidermoid carcinoma H/GHigh grade mucoepidermoid carcinoma Table 3. Results No. Preop Facial symmetry Eye closure Smile RTcGY F/U Mo 1 II symmetric Cmin good I symmetric Cmin good outside 14 3 I partially Cmax poor V asymmetric none poor I symmetric Cmin good IV asymmetric Cmax poor I symmetric Cmin good V asymmetric none poor Preoppreoperative House-Brackmann grade, RTpostoperative radiotherapy, F/U Mofollow-up period months 496 Korean J Otolaryngol 1999;42:

신경이식술을 위한 공여신경(donor nerve)으로 2예 3곳을 봉합하였다(Fig. 1).

portion)가 2예였으며, 안면신경의 원위 부와 설하신경의 측부를 연결하는 신경이식술(end-toside cable graft)을 통하여 재건한 경우가 1예 있었다.

협골분지만 재건한 상피-근상피암종 1예는 안면신경 을 보존하였던 타병원에서의 일차수술 후 종양이 재발하여 재수술을 시행한 경우였다(Table 2).

3 유승주 외 선 전절제술 및 안면신경 절제와 재건술이 시행되었다. 점 itudinal interfascicular dissection) 신경초문합(perine- 액표피양암종 4예 중 3예는 high grade, 1예는 low grade ural anastomosis)을 시행하였고 10-0 nylon을 이용하여 였다. 신경이식술을 위한 공여신경(donor nerve)으로 2예 3곳을 봉합하였다(Fig. 1). 안면신경의 외측두부(extrate- 에서는 비복신경을, 6예에서는 대이개신경을 이용하였으며 mporal portion)에서 절제하여 재건한 경우가 5예, 내측두 재건하려는 분지의 수에 따라 공여신경을 나누어(long- 부(intratemporal portion)가 2예였으며, 안면신경의 원위 부와 설하신경의 측부를 연결하는 신경이식술(end-toside cable graft)을 통하여 재건한 경우가 1예 있었다. 안 면신경의 분지 중 협골분지와 볼분지만을 재건한 예가 5예, 협골분지와 하악연분지(marginal mandibular branch)를 재건한 예가 1예, 협골분지만 절제 후 재건한 예가 1예였 다. 협골분지만 재건한 상피-근상피암종 1예는 안면신경 을 보존하였던 타병원에서의 일차수술 후 종양이 재발하여 재수술을 시행한 경우였다(Table 2). 술 전 안면신경마비의 정도는 House-Brackmann grading system으로 하였으며 4예에서 grade Ⅰ, 1예에서 Fig. 1. Nerve graft in situ. The longitudinal interfascicular dissection and perineural anastomosis are performed. A C grade Ⅱ, 나머지 3예는 grade Ⅳ, 또는 Ⅴ였다. 8예 모두 에서 술 후 방사선 치료가 시행되었고, 방사선 치료는 술 B Fig. 2. Facial expressions of the patient who received total parotidectomy and was reconstructed with great auricular nerve graft nineteen months ago. (a) Facial symmetry, (b) Eye closure, (c) Smile. 497

cable graft with sural nerve thirteen months ago.

(pre-operative), (d) Eye closure with maximal effort (post-operative).

으며, 눈감기는 4예에서 Cmin, 2예에서 Cmax, 2예 에서 안 감김 의 소견을 보였고, 웃기는 4예에서 양 결 과 호, 4에서 불량 의 소견을 보였다(Fig. 2)(Table 3).

4 이하선 악성종양에서 안면신경 재건 A B C D Fig. 3. Facial expressions of the patient who were perform-ed total parotidectomy and end-to-side facial-hypoglossal cable graft with sural nerve thirteen months ago. (a) Facial symmetry (pre-operative), (b) Facial symmetry (postoperative), (c) Eye closure with minimal effort (pre-operative), (d) Eye closure with maximal effort (post-operative). 후 약 4내지 6주에 시작하였으며 원발부위에 5940 대칭, 1예에서 약간 비대칭, 3예에서 비대칭 이었 6480 cgy의 방사선을 조사하였다(Table 3). 으며, 눈감기는 4예에서 Cmin, 2예에서 Cmax, 2예 에서 안 감김 의 소견을 보였고, 웃기는 4예에서 양 결 과 호, 4에서 불량 의 소견을 보였다(Fig. 2)(Table 3). 술 전 안면신경의 마비가 있었으며 수술장 소견상 슬상 이식된 안면신경의 기능의 회복은 대개 술 후 3개월 정 신경절(geniculate ganglion)보다 근위부까지 암조직 침윤 도에서 시작되어 서서히 회복되었으며 술 후 6개월이 지난 이 있었던 1예에 있어서는 비복신경을 이용하여 안면신경 후에야 만족스러운 정도의 회복을 보였다. 분지들을 설하신경 측부에 신경초문합함으로써 안면신경 최종 추적시의 소견에서 안면의 대칭정도는 4예에서 498 기능을 술 전과 같이 유지하였고 Cmax 정도로 눈감기 기 Korean J Otolaryngol 1999;42:

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6 REFERENCES 1) Fisch U, Rouleau M. Facial nerve reconstruction. J Otolaryngol ) Stephanian E, Sekhar LN, Janecka IP, Hirsch B. Facial Nerve Repair by Interposition Nerve Graft Results in 22 Patients. Neurosurgery ) Vaughan ED, Richardson D. Facial nerve reconstruction following ablative parotid surgery. Br J Oral Maxillofac Surg ) Choi G, Kim HY, Yoo DH, Jung KY, Choi JO. Facial Nerve Graft in Parotid Malignancy. Korean J Otolaryngol ) Sobol SM, May M, Mester M. Early facial reanimation following radical parotid and temporal bone tumor resections. Am J Surg ) Fisch U, Lansr MJ. Facial nerve grafting. Otolaryngol Clin North Am ) Armstrong JG, Harrison LB, Spiro RH, et al. Malignant tumors of major salivary gland origin. Arch Otolaryngol Head Neck Surg ) Ball ABS, Fish S, Thomas JM. Malignant epithelial parotid tumor: A rational treatment policy. Br J Surg ) Borthne A, Kjellevold K, Kaalhus O, et al. Salivary gland malignant neoplas Treatment and Prognosis. Int J Radiat Oncol Biol Phys ) Cueva RA, Robbins KT, Martin CPJ. Lower cervial cutaneous sensory nerves An alternative for facial nerve cable grafting. Otolaryngol Head Neck Surg ) House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg ) Ferreira MC, Besteiro JM, Tuma P. Results of Reconstruction of the Facial nerve. Microsurgery : ) May M, Sobol SM, Mester SJ. Hypoglossal-facial nerve interpositonal-jump graft for facial reanimation without tongue atrophy. Otolaryngol Head Neck Surg ) Atlas MD, Lowinger DSG. A New Technique for Hypoglossal- Facial Nerve Repair. Laryngoscope Korean J Otolaryngol 1999;42:

KISEP Abstract 안면신경초종의치료경험 전영명 박기현 이진석 전상훈 The Management of Facial Nerve Schwannoma Young-Myoung Chun, M.D., Keehyun Park, M.D., Jin-Suk Le

KISEP Abstract 안면신경초종의치료경험 전영명 박기현 이진석 전상훈 The Management of Facial Nerve Schwannoma Young-Myoung Chun, M.D., Keehyun Park, M.D., Jin-Suk Le KISEP 40 7 1997 Abstract 안면신경초종의치료경험 전영명 박기현 이진석 전상훈 The Management of Facial Nerve Schwannoma Young-Myoung Chun, M.D., Keehyun Park, M.D., Jin-Suk Lee, M.D., Sang-Hoon Chun, M.D. Department of Otolaryngology,