종설1 종설2 원저1 원저2 증례1 증례2 증례3 증례4 증례5 J Korean Skull Base Society 13 권 1 호 : 10~15, 2018 인제대학교의과대학일산백병원이비인후과학교실김진 Hypoglossal-facial anastomosis after facial nerve transection Department of Otorhinolaryngology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea Jin Kim The facial nerve reconstruction after facial nerve transection is a hard mission to the clinician. All of the patients who suffer from severe facial paralysis want to have their original facial function even if they had tremendous aggressive disease or surgery. One of the surgical technique for facial reconstruction after facial nerve transection is the hypoglossal-facial anastomosis. This surgical technique provides favorable facial function even after aggressive 교신저자 Jin Kim 논문접수일 : 2018 년 4 월 5 일논문완료일 : 2018 년 4 월 30 일주소 : Department of Otorhinolaryngology, Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea Tel : +82-31-910-7114 Fax : +82-31-910-7518 E-mail : jinsound@gmail.com tumor surgery. But this surgical technique also has a critical defects on tongue movement. The use of hypoglossal nerve could induce other problem in terms of quality of life including disarticulation, leakage on oral feeding and/or biting of their tongue. Another variation techniques rather than classical XII-VII could be recommended for minimizing the hemi-tongue paralysis. Split XII-VII technique, Jump graft XII-VII technique, ansa-facial anastomosis are known to be variation technique that have been developed for reducing such a complication after surgery. In this paper, this author introduces details of surgical techniques and results for maximize the facial function and minimize the hemi-tongue paralysis. Key Words Facial nerve, Facial paralysis, Hypoglossal nerve, Tongue 10 JOURNAL OF KOREAN SKULL BASE SOCIETY MAY Vol. 13 No. 1
INTRODUCTION 설하-안면신경접합술은안면신경이손상이심하여근위부의안면신경을이용할수없거나손상된해부학적위치가근위부의안면신경을이용하여단단문합술이나신경이식술을시행하기가곤란할경우사용할수있는수술방법으로서그역사는약 150년이되었다. 1873년 Schwartze와 Eysell[1] 이화농성중이염과같은이과질환을수술적치료로처음시작하게되면서안면신경이손상되는경우가많이생기게되었다. 이러한안면신경의다양한손상은안면신경수술의새로운시대를맞이하게되었다. 이들은피질골유양동기삭개술 (cortical mastoidectomy) 을현미경의도움없이정과끌로시행을하였고청력저하나안면마비등의합병증이상당히유발되어많은문제가되고있었다. 그러던중 1903년 Drobnik[2] 는이과수술후안면마비가생긴환자를위해안면신경과부신경 (accessory nerve) 을연결하는문합술을처음으로시도하여안면마비의회복을보고하였으며, Ballance[3] 와 Mannasse[4] 도환자들에게안면신경과부신경, 설하신경 (hypoglossal nerve) 혹은설인신경 (glossopharyngeal nerve) 등을연결하는술식을발표하여널리사용되기시작하여설하-안면신경문합술 (hypoglossal-facial anastomosis) 의역사는이과수술의합병증인안면마비를해결하고자시행하는안면신경재건술중그역사가가장오래되었다고볼수있다. 그후 45년뒤인 1927년 Bunnell[5] 은처음으로직접안면신경문합술의성공사례를보고하였다. 그는결손된부위에대해충분한길이를얻고자다른뇌신경과의치환술이아닌안면신경의우회술 (rerouting) 을시도하여직접문합술을시행하였으며, 1932년 Ballance와 Duel[6] 은안면신경의직접문합술이다른뇌신경의치환술보다결과가훨씬월등함을보고하였다. 하지만수상후 30일에서 1년정도의경과된후이거나근위부안면신경을이용할수없는경우에는직접문합술이나신경이식술이다른대뇌신경을이용하여안면운동의재활을도울수있는신경 치환술 (nerve substitution) 보다효과가매우떨어짐을알게되었고지금까지설하신경을이용하여원위부의안면신경을자극하는설하-안면신경문합술 (hypoglossal-facial anastomosis) 이가장많이행하여지고있는술식이되었다. 근래에는설하-안면신경문합술의가장큰합병증인설하신경손상에의한혀운동장애를최소화하며안면운동의기능을보존하기위한방법이많이소개되고있는데이에대해알아보고자한다 (Table 1). SUBJECT 수술중혹은사고에의해안면신경이부득이하게손상되어절단을결정한후에는안면신경의재건과함께여러추가적인치료를시행함으로써안면운동의기능을증가시킬수있다. 안면신경의성공적인재건을위해서는수술방법도중요하지만원위부말초신경과연결되는근위부안면신경의상태에따라그결과는매우달라진다. 즉손상된안면신경의재건이필요한경우안면신경이절단된시간으로부터재건된시간까지의기간이가장중요한요소로서최대한짧을수록가장좋은결과를얻게되며그최대기간은약 30 일로써, 그이상이되면재건을하더라도안면기능의심각한후유증이남게된다. 하지만수상후 30일에서 1년정도의경과된이후이거나근위부안면신경을이용할수없는경우에는다른대뇌신경을이용하여안면운동의재활을도울수있는신경치환술을시행할수있다.[7] 이중제일많이행하여지는술식으로는설하신경을이용하여원위부의안면신경을자극하는설하-안면신경문합술이있으며, 이때혀의움직임이제한이되는것을피하려면설하-안면신경교차술 (XII-VII cross over technique) 혹은설하-안면신경개입이식술 (XII-VII jump graft) 을하기도한다. 신경치환술을계획할때에는마비된안면부의기능회복과동시에공여부의기능소실을최소화할수있는방법을선택해야한다. 조직학적으로설하신경은순수운동섬유신경으로서안면신경과 Table 1. The facial reanimation procedures depending on the timing of facial nerve transection or injury. The hypoglossal-facial anastomosis and other variations could be applied between 1 month and 1 year after facial nerve transection Reanimation procedure Time from injury Surgical techniques Nerve repair Within 30 days End-to-end anastomosis, interpositional graft, double cable graft Nerve substitution technique 30 days to 1 year XII-VII crossover, XII-VII jump graft, VII-VII cross-face graft, XI-VII crossover Muscle transposition Static suspension More than 1 year Other procedure Possible after 1 month Botox, filler injection Temporalis muscle, masseter muscle, free muscle transposition Brow lift, face lift, blepharoplasty, gold weight, tarsorrhaphy 11
그역할이유사하며약 4-6개의신경다발로구성되어있다. 안면신경의측두골에서나와두꺼운신경외막을형성하는부분과매우유사하며이하선으로들어가기직전의안면신경의단면적보다약 2 mm정도크기때문에신경치환술로사용하기에는매우좋은조건을가지고있다 (Fig. 1). 1. Classic Hypoglossal-facial Anastomosis 안면신경이완전잘리거나심하게손상되어완전한영구적안면마비가예상되는경우안면신경에운동기능을부여하기위해동측혀의운동을희생하며설하신경을접합하는술식으로서손상받은안면신경의근위부를이용하지못할경우이거나손상된안면신경의근위부를이용할수있으나손상된후약한달에서일년정도의기간이지났을경우에시행할수있는방법이라고할수있다. 주로청신경종양등의소뇌교각부위의종양절제술이후이거나광범위측두골절제술, 두개저수술이후, 광범위이하선적출술이후절단된안면신경의근위부를찾기가어렵거나찾아도신경이식술이어려울경우에행하여질수있다. 이수술을하기전에환자는설하신경이절단됨으로써생길수있는여러가지기능적문제를충분히 Fig. 1 알고있어야한다. 예를들어혀운동의장애로생길수있는부정확 한발음과저작문제, 혀의깨물림등이생기는데수술이후안면기 능이좋아지더라도혀운동의장애는환자의삶의질에많은문제를 일어기능적인부분뿐아니라심리적으로나정서적으로받아들일 수있어야한다.[8] 이수술의가장큰딜레마는청신경초종수술하는도중안면신경 이손상을받았으나안면신경이완전잘리지않고긴장손상 (stretch injury), 압박손상 (compressive injury), 열손상 (thermal injury), 압괴손상 (crush injury), 전기적손상 (cauterization injury) 등을 받아기능적회복을약 1 년정도를기다려야할경우에있다. 이러 한손상을받았을경우 1 년이상경과를관찰하며기다려야하나재 생되는신경섬유가충분하지않아적은일부분만이재생이이루어 질경우안면신경이건재하게있더라도안면근육을움직일정도의 전기적신호를전달하지못하여안면기능이좋지않을경우 1 년안 에설하 - 안면신경접합술을시행한것보다못한경우가있기때문 이다. 다만청신경종양수술이후안면신경의건재함이확실히보 장되었을경우는당연히기다려야하는것이원칙이나안면신경을 찾지못하였거나안면신경의단면적 1/3 이상의손상이예상되는 The diameter of hypoglossal nerve and facial nerve. The diameter of facial nerve has a different manner in temporal bone, and after passing from the temporal bone, the facial nerve shows the mature shape of peripheral nerve with thick epineurium and perineurium which is fit for the anastomosis with another nerve. Fig. 2 The location of facial nerve and hypoglossal nerve after extended preauricular-neck incision. The gap between two nerves is estimated about 3 to 4 cm. In case of classic hypoglossal-facial anastomosis, the hypoglossal nerve should be cut as far as the distal part of nerve and be pulled up to the facial nerve trunk for the effective anastomosis with enough length. 12 JOURNAL OF KOREAN SKULL BASE SOCIETY MAY Vol. 13 No. 1
경우안면신경치환술을고려할수있다 (Fig. 2).[9] 2. Split Hypoglossal-facial Anastomosis 설하신경이절단된경우반쪽의혀의마비 (hemi-tongue paralysis) 가유발이되는데약 25% 에서는심한위축이오기도하여구음장애, 저작장애등의기능적장애를일으키기도한다. 이러한치명적인부작용을최소화하기위해설하신경을반으로나누어안면신경의기능과설하신경의기능을반으로나누는수술방법이바로 split 설하-안면신경문합술이다. 이수술방법으로대부분이이환된부위의혀운동은기능적으로보존이될수있으며, 안면기능도최대 House-Brackmann Grade III까지가질수있다.[10] 하지만수술결과가수술자의경험과및수술시설하신경및안면 Fig. 3 신경의손상정도에따라예측하기가어려우며일정하지않은것이 큰단점이라고할수있다.[11] 하지만현재제일많이쓰이는방법 으로서반으로나누어진설하신경의단면과안면신경의주신경의 단면면적이차이가있어반으로나누어진설하신경의단면을비스 듬히절단 (bevel shape) 한이후에안면신경과의문합을시행하는 것이바람직하다 (Fig. 3). 3. Jump Graft Hypoglossal-facial Anastomosis 안면신경의재건을위해설하신경을이용하여혀운동의장애가 생기는경우를최소화하기위해시행하는방법으로서설하신경과 안면신경사이에다른제 3 의신경을이어주는술식이다. 설하신경 에약 1/3 정도의단면적을절개후 V 자의웨지모양의홈을만들 For the minimize of hemitongue paralysis, the half of the hypoglossal nerve is cut in diameter and pulled up to the main trunk of facial nerve. The operator should be careful not to injure the nerve fiber in splitting the nerve trunk. Because the diameter of pulled-divided nerve of hypoglossal nerve is not enough to make a coaptation with the main trunk of facial nerve, the cut edge of pulled nerve should be trimmed in bevel shape to ensure the same diameter of endings of two nerves. Fig. 4 The jump graft hypoglossal-facial anastomosis. After making the V-wedge shape on the hypoglossal nerve by transection of 1/3 diameter, the greater auricular nerve is harvested on the part of proximal portion of wedge and main trunk of facial nerve with enough length. 13
고신경개입술을시행하는데대부분이 7-10 cm의길이의대이개신경 (greater auricular nerve) 을같은수술시야에서얻을수있기때문에사용한다.[12] 대이개신경의단면적은안면신경의주분지보다약간작을수있기때문에신경의끝을비스듬히다듬어안면신경과문합술을시행할수있다. 이수술의가장큰장점은혀운동의장애를최소화할수있으나안면신경의재건측면에서는그효과가좋지않은단점이있다. 즉안면근육이충분한힘을받지못하여안면근육의처짐이나위축이올수있어, 영양상태가좋지않아혀운동장애가문제가될수있을것으로여겨지는노인을제외하고는잘사용하지않는술식이라할수있다 (Fig. 4). 4. Ansa Cervical-facial Anastomosis 경신경고리 (ansa cervicalis, ansa hypoglossi) 는설골근군가운데흉골설골근, 견갑설골근, 흉골갑상근를지배하는신경으로서일측의신경이절단되어도발성에큰지장이없는경우가많이있다. 하지만그굵기가불규칙한경우가많이있는데안면신경의주분지와연결할수있을정도로그단면적이크거나혹은안면신경의주분지가아닌가지분지를연결하고자할경우설하신경을대신하여유용하게쓰일수있다. 이술식은설하신경을대신하여쓸수있기때문에혀운동장애의후유증이거의없다는장점이있으나그단면적이크지않을경우에는주분지에연결하는용도로서는사용하기가매우어렵다. 주로안면신경의 upper branch는건재하니 lower branch가기능하지못할심한손상이있을경우매우유용하게쓰일수있으며그단면적역시가지분지와매우동일하다. 경신경고리를최대한원위부에서절단하면그길이를충분히얻어안면신경의주분지까지올릴수있기때문에수술적방법도다른술식에비해간편하다. 또한 split 설하-안면신경문합술과같이시행할수도있는데반으로쪼개어서올린설하신경은아랫분지로경신경고리는윗분지로연결하여혀의운동장애를최소화하면서 Fig. 5 Ansa cervicalis-facial anastomosis. Ansa cervicalis is also available for facial nerve reconstruction without any complication of tongue deviation. The diameter of ansa cervialis is fit for that of one branch of facial nerve. Some variation techniques for facial reconstruction without hemi-tongue paralysis could be applied. Fig. 6 CLASSIC Xll-Vll SPLIT Xll-Vll JUMP GRAFT Xll-Vll SEGMENTAL SPLIT ANSA-FACIAL 1. split and ansa 2. Jump graft 3. Split The surgical techniques of XII-VII anastomosis and many variations. The tongue movement can be preserved for articulation or feeding after variation technique. Fig. 7 Before After Before After Before After Ansa-facial, split & ansa-facial, ansa-segmental anastomosis. Facial movement can be increased to House-Brackmann Grade III and the tongue movement can be also preserved. 14 JOURNAL OF KOREAN SKULL BASE SOCIETY MAY Vol. 13 No. 1
안면신경의기능을최대한보존하는방법을시행할수도있다. 안면근육에전달되는전기생리학적인힘도 jump graft보다더좋은것으로저자는경험하고있다 (Fig. 5). 설하-안면신경문합술은안면신경이절단되어원위부를이용할수없는경우매우유용한술식이다. 하지만매우치명적인합병증인혀운동장애는또다시삶의질을저하시키기때문에여러가지변이된술식이있으며, 안면신경의기능을최대한보존하며혀운동의장애를최소화하기위해많은변형된술식을권하는바이다 (Fig. 6, 7). CONCLUSIONS 설하-안면신경접합술은안면신경절단이후근위부를이용할수없을경우약 30일에서 1년이내에시행할수있는유용한안면신경재건술이다. 전통적인수술방법은안면기능의보존측면에서는좋은결과를가져올수있으나, 심한혀운동장애와위축을유발하여또다시삶의질을떨어뜨리기때문에다른변형된술식으로적용할수있다. 다양한수술방법을고려하여적용한다면안면신경의기능을최대한보존하면서혀운동장애를최소화하여안면신경절단후에도환자의삶의질은매우향상될수있다. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Schwartze HH, Eysell CG. Uber die kunstliche eroffnung des warzenfortsatzes. Arch Ohrenheilk 1873;7:157-62. 2. Drobnik A. L'etat actuel de la chirurgie nerveuse. Paris, FR: J. Rueff; 1903. 3. Ballance C. Essays on the surgery of the temporal bone. New York, NY: Macmillan; 1919. 4. Mannasse P. Ueber vereinigung des N. facialis mit dem N. accessorius durch die nervenpfropfung. Arch F Klin Chir 1900;62:805-34. 5. Bunnell S. Suture of the facial nerve within the temporal bone; with a report of the first successful case. Surg Gynecol Obstet 1927;45:7-12. 6. Ballance C, Duel AB. The operative treatment of facial palsy. Arch Otolaryngol 1932;15:1-70. 7. Bascarevi V, Samardzi M, Rasuli L, Simi V. Reconstructive surgery of facial nerve injuries. Acta Chir Iugosl 2003;50:63-7. 8. Socolovsky M, Martins RS, di Masi G, Bonilla G, Siqueira M. Treatment of complete facial palsy in adults: comparative study between direct hemihypoglossal-facial neurorrhaphy, hemihipoglossal-facial neurorrhaphy with grafts, and masseter to facial nerve transfer. Acta Neurochir (Wien) 2016;158:945-57; discussion 57. 9. Falbe-Hansen J, Hermann S. Hypoglosso-facial anastomosis. A follow-up study of 25 patients. Acta Neurol Scand 1967;43:472-8. 10. Han JH, Suh MJ, Kim JW, Cho HS, Moon IS. Facial reanimation using hypoglossal-facial nerve anastomosis after schwannoma removal. Acta Otolaryngol 2017;137:99-105. 11. Kunihiro T, Kanzaki J, O-uchi T. Hypoglossal-facial nerve anastomosis. Clinical observation. Acta Otolaryngol Suppl 1991;487:80-4. 12. Linnet J, Madsen FF. Hypoglosso-facial nerve anastomosis. Acta Neurochir (Wien) 1995;133:112-5. 15