incidence of marginal mandibular nerve palsy in neck dissection n.
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Incidence of marginal mandibular nerve palsy in neck dissection. N Amin, H Dixon, N Gibbins , S Lew- Gor Brighton and Sussex University Hospitals United Kingdom. Marginal Mandibular Nerve. Our Project. Limited data Informed consent important part of pre-assessment

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incidence of marginal mandibular nerve palsy in neck dissection

Incidence of marginal mandibular nerve palsy in neck dissection

N Amin, H Dixon, N Gibbins, S Lew-Gor

Brighton and Sussex University Hospitals

United Kingdom

our project
Our Project
  • Limited data
  • Informed consent important part of pre-assessment
  • Communication errors heart of many complaints
our project1
Our Project
  • Rate of MMN palsy (temporary/permanent) vs. Type of ND
method
Method
  • Retrospective 2 year review
  • 88 neck dissections (ND) reviewed
  • 4 excluded
  • 84 total
    • Pre- and post-operative MMN function including whether the MMN was sacrificed intra-operatively.
    • Time until palsy resolution
    • Type of neck dissection
    • The grade of the operating surgeon
  • Statistical analysis
aao hns classification of neck dissections
AAO-HNS classification of neck dissections
  • Radical neck dissection (RND)– removal of ipsilateral cervical lymph nodes in levels 1-5 as well as the sternocleidomastoid muscle (SCM), internal jugular vein (IJV) and the spinal accessory nerve (SAN).
  • Modified radical neck dissection (MRND)– removal of ipsilateral cervical lymph nodes in levels 1-5 with preservation of one or more of the SCM, IJV and SAN.
  • Selective neck dissection (SND) – there is preservation of one or more groups of lymph nodes as well as the SCM, IJV and SAN.
  • Extended neck dissection (END) – involves a RND with removal of another group of lymph nodes or another non-lymphatic structure.
results
Results
  • 75 patients
  • 84 neck dissections
  • Mean age 66.1 (32 – 89 years)
  • M 4.55:1 F
results1
Results
  • 20 RND
  • 20 MRND
  • 28 SND
  • 16 END
  • 8 patients had pre-operative radiotherapy
results2
Results
  • 10/84 (11.9%) – MMN palsy
  • 8/84 (9.5%) – permanent
  • 2/84 (2.4%) – temporary
results3
Results
  • 57 neck dissections involved level I
  • Total palsy rate was 10/57 (18.5%)
  • 14.0% (8/57) – permanent
  • 3.5% (2/57) – temporary
  • p-value = 0.046
results4
Results
  • In RND there was a higher risk of a permanent MMN palsy (20%) compared to MRND (10%), SND (3.6%) or END (6.2%)
  • 10% risk of a temporary MMN palsy in patients undergoing MRND
  • Statistically insignificant

3.6%

10%

20%

6.2%

results5
Results
  • Parotid gland – 2
  • Oral cavity – 5
  • Larynx – 1
discussion
Discussion
  • Informed consent is a vital part of pre-operative assessment.
  • Incidence of MMN palsy post level I ND is not widely quoted.
  • Important patients are aware of potential morbidity and potential treatment options.
conclusion
Conclusion
  • If level I dissection is performed, a permanent MMN palsy rate of 14% or 1 in 7 may be quoted to the patient.
  • Adequate resection of disease in level I and the parotid region may require sacrifice of the MMN.
references
References
  • Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg 2002;128:751-8.
  • Hazani R, Chowdhry S, Mowlavi A, Wilhelmi BJ. Bony anatomic landmarks to avoid injury to the marginal mandibular nerve. Aesthet Surg J. 2011 Mar;31(3):286-9.
  • Batra AP, Mahajan A, Gupta K. Marginal mandibular branch of the facial nerve: An anatomical study. Indian J Plast Surg. 2010 Jan;43(1):60-4.
  • Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg 1962; 29:266–272
  • House JW, Brackman DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985; 93:146–147 
  • Bron LP, O'Brien CJ. Facial nerve function after parotidectomy. Arch Otolaryngol Head Neck Surg. 1997 Oct;123(10):1091-6.
  • Møller MN, Sørensen CH. Risk of marginal mandibular nerve injury in neck dissection. Eur Arch Otorhinolaryngol. 2012 Feb;269(2):601-5.
  • Batstone MD, Scott B, Lowe D, Rogers SN. Marginal mandibular nerve injury during neck dissection and its impact on patient perception of appearance. Head Neck. 2009 May; 31(5):673-8
  • Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg. 1995 Apr;22(2):241-51.
  • Baker BC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg 1979; 64:781–795
  • Ducic Y, Young L, McIntyre J. Neck dissection: past and present. Minerva Chir. 2010 Feb;65(1):45-58.
  • Seddon HJ. Three types of nerve injury. Brain 1943; 66(4): 237-288
  • Meier JD, Wenig BL, Manders EC, Nenonene Continuous intraoperative facial nerve monitoring in predicting postoperative injury during parotidectomy, Laryngoscope. 2006 Sep;116(9):1569-72