Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System / Lesões do nervo facial relacionadas à parotidectomia: proposta de um sistema Sunnybrook de graduação facial modificado

ABSTRACT Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. Objective To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch. Methods We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014. Results The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function. Conclusion The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

RESUMO A lesão do nervo facial é a principal complicação neurológica relacionada às parotidectomias e, em geral, o ramo marginal mandibular é o mais frequentemente acometido. Objetivo Testar um Sistema Sunnybrook de Graduação Facial modificado (mS-FGS) como uma nova ferramenta para avaliar a função do nervo facial após a parotidectomia, enfatizando o ramo marginal mandibular. Métodos Estudo retrospectivo, baseado em prontuários de 73 casos (40 do sexo feminino, 18-84 anos, idade média = 53,2), submetidos à parotidectomia, com preservação do nervo facial. Todos os pacientes apresentavam neoplasias parotídeas ou câncer de pele avançado, e foram tratados pela autora principal entre 2006 e 2014. Resultados Neste estudo, os músculos inervados pelo ramo marginal mandibular foram os mais acometidos (72,6% dos casos), principalmente nos pacientes que realizaram esvaziamento cervical (p = 0,023). Os Escores de Movimento Voluntário obtidos pelo sistema modificado foram inferiores aos obtidos pelo original (p < 0,001). As melhores pontuações foram observadas em pacientes com tumores benignos parotídeos e os piores resultados, naqueles com câncer de pele. Pacientes que necessitaram de esvaziamento cervical e ressecção de outras estruturas, além da parótida, apresentaram escores menores (p = 0,031 e p = 0,021), evidenciados apenas pelo sistema modificado. Os tumores malignos geraram escores significativamente menores, independentemente do instrumento empregado. A análise pós fisioterapia envolveu 50 casos. Os piores resultados, após a intervenção fisioterapêutica, também foram observados nos músculos inervados pelo ramo marginal mandibular. Conclusão A avaliação da disfunção facial pós-parotidectomia, através do Sistema Sunnybrook com a modificação proposta permitiu uma apreciação mais detalhada do ramo marginal mandibular, sem prejuízo à avaliação dos demais ramos.

Tumores de glándula parótida: experiencia quirúrgica Hospital Guillermo Grant Benavente / Parotid gland tumors: surgical experience Hospital Guillermo Grant Benavente

RESUMEN Introducción: La glándula parótida es el sitio más común de tumores de glándulas salivales, correspondiendo al 75%-85% de éstos y al 3% de todos los tumores de cabeza y cuello. Ochenta por ciento de ellos corresponden a tumores benignos. Objetivos: Analizar la experiencia quirúrgica en tumores parotídeos operados en el Hospital Guillermo Grant Benavente. Material y método: Revisión de todos los pacientes con tumores parotídeos operados en el Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, del Hospital Guillermo Grant Benavente entre enero del año 2011 y abril del año 2016. Las cirugías fueron realizadas por el mismo equipo quirúrgico. Se registraron datos demográficos, clínicos, quirúrgicos, histológicos y resultados posoperatorios. Resultados: En el periodo descrito se operó un total de 94 pacientes. 84,3% correspondieron a tumores benignos y 15,7% a tumores malignos. El 62,9% corresponde a pacientes de sexo femenino y 37,1% de sexo masculino, representando una relación de 1,69:1. La incidencia de parálisis facial transitoria fue de 16,1%, y de ellos solo un paciente mantuvo una parálisis permanente. Conclusión: Los tumores malignos representaron el 15,7%, siendo menor a lo reportado en la literatura. Se presenta una gran serie de tumores parotídeos tratados quirúrgicamente a nivel nacional, con una baja tasa de complicaciones.

Abstract Introduction: Parotid gland is the most common site of salivary gland tumors, corresponding to 75-85% of these and 3% of all head and neck tumors. 80% of them correspond to benign tumors. Aim: To analyze the surgical experience in parotid tumors operated in the Guillermo Grant Benavente Hospital. Material and Method: Review of all patients with parotid tumors operated in the Otorhinolaryngology and Head and Neck Surgery Unit of Hospital Guillermo Grant Benavente between January 2011 and April 2016. All surgeries were performed by the same surgical team. Demographic, clinical, surgical, histological and postoperative results were recorded. Results: In the period described, a total of 94 patients were operated on. 84.3% corresponded to benign tumors and 15.7% to malignant tumors. 62.9% corresponds to female patients and 37.1% male, representing a ratio of 1.69:1. The incidence of transient facial paralysis was 16.1%, and of these, only one patient maintained permanent paralysis. Conclusions: Malignant tumors represented 15.7% of cases, being less than reported in the literature. This article presents a large series of parotid tumors treated surgically in our country, with a low associated complication rate.

Avaliação das complicações pós-operatórias em pacientes idosos submetidos à parotidectomia / Evaluation of postoperative complications in elderly patients submitted to parotidectomy

RESUMO Objetivo: avaliar subtipos histológicos mais incidentes e as principais complicações pós-operatórias em pacientes idosos portadores de tumor de parótida e submetidos à parotidectomia. Métodos: estudo retrospectivo de 57 pacientes idosos submetidos à parotidectomia, no período de 2003 a 2017, no Hospital Municipal São José de Joinville, Santa Catarina, Brasil. Resultados: trinta e três (57,9%) pacientes tinham tumores benignos, sendo o mais frequente o tumor de Warthin, e 17(29,8%) tumores malignos, sendo o carcinoma escamoso o mais frequente. Sete (12,3%) pacientes evoluíram com complicações clínicas, sendo a labilidade pressórica e as complicações respiratórias as mais incidentes em quatro (7%) e três (5,3%) casos, respectivamente. Treze (22,1%) pacientes apresentaram complicações cirúrgicas relacionadas à ferida operatória, sendo o hematoma e a infecção de ferida as mais incidentes, com seis (10,5%) casos cada. Vinte e quatro (42,1%) pacientes tiveram algum grau de disfunção do nervo facial no pós-operatório, sendo o grau III de Brackman-House, em 11 casos (19,3%), o mais frequente. O tempo cirúrgico e a linfadenectomia mostraram associação com complicações clínicas. As principais variáveis que apresentaram associação com complicações cirúrgicas foram: tamanho do tumor, tempo cirúrgico mais longo, reoperação e volume de infusão de cristaloides no transoperatório. Conclusão: as neoplasias parotídeas apresentam perfil diferenciado na população idosa, destacando-se o tumor de Warthin e o carcinoma escamoso. Hematoma e infecção da ferida operatória, e as lesões do nervo facial foram as complicações mais prevalentes no pós-operatório.

ABSTRACT Objective: to evaluate the most incident histological subtypes and the main postoperative complications in elderly patients with parotid tumors submitted to parotidectomy. Methods: we conducted a retrospective study with 57 elderly patients submitted to parotidectomy from 2003 to 2017, at the São José County Hospital of Joinville, Santa Catarina, Brazil. Results: thirty-three (57.9%) patients had benign tumors, the most frequent being Warthin's tumor, and 17 (29.8%), malignant tumors, squamous cell carcinoma being the most frequent. Seven patients (12.3%) presented clinical complications, arterial pressure instability and respiratory complications being the most frequent, in four (7%) and three (5.3%) cases, respectively. Thirteen (22.1%) patients presented complications related to the surgical wound, hematoma and wound infection being the most frequent, with six (10.5%) cases each. Twenty-four (42.1%) patients had some degree of facial nerve dysfunction in the postoperative period, Brackman-House grade III being the most frequent, in 11 cases (19.3%). Surgical time and lymphadenectomy were associated with clinical complications. The main variables that showed an association with surgical complications were tumor size, longer surgical time, reoperation, and perioperative crystalloid infusion volume. Conclusion: parotid neoplasms present a differentiated profile in the elderly population, especially Warthin's tumor and squamous cell carcinoma. Hematoma and infection of the operative wound and facial nerve lesions were the most prevalent complications in the postoperative period.

Hypoglossal-facial anastomosis, tricks and trade

Total removal of difficult tumours at the skull base left behind a traumatized facial nerve previously aggressed by the tumour. Reanimation of the nerve was mandatory in order to recover functional and cosmetic results. Despite an additional XII[th] cranial nerve morbidity, hypoglossal-facial nerve anastomosis was still a gold standard to reach this goal. The authors present their experience in managing 11 cases of facial nerve reanimation after skull base tumour resection by using the descending branch of the hypoglossal nerve as axon donator for direct facial anastomosis. Outcome of facial reanimation according to House-Brackmann classification was good [grade I, II and III] in 5 cases, mild [grade IV] in 3 cases and bad [grade IV and V] in 3 cases. Hemi tongue atrophy occurred in none of our patients. Hypoglossal-facial nerve anastomosis using the descending branch of the XII[th] cranial nerve is an effective procedure to reanimate the facial nerve without additional morbidity. Early reanimation of the facial nerve is the key to offer resumption of normal life for these patients who had already undergone a major neurosurgical procedure