Facial Nerve Monitoring during Parotidectomy: A Systematic Review and Meta‐analysis
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Objectives: Determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Methods: Systematic review and meta‐analysis. A comprehensive literature search was conducted using the PubMed‐NCBI database from 1970 to 2014. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs. control). Primary and secondary endpoints were defined as immediate postoperative and permanent facial nerve weakness (≥2 House‐Brackmann score), respectively. Results: A total of 1414 articles were reviewed, resulting in 8 articles that met inclusion criteria. In total, 626 patients were included in the final meta‐analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared with the unmonitored group (22.4% vs 35.0%, P =. 001). The incidence of permanent weakness was also lower, but this difference was not statistically significant (4.2% vs 7.6%, P =. 10). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 8 given an absolute risk reduction of 12.6%. This corresponded to a 49% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.51; 95% confidence interval, 0.34 to 0.76, P =. 001). Conclusions: In primary cases of parotidectomy, intraoperative facial nerve monitoring decreases the risk of immediate postoperative facial nerve weakness, but does not appear to influence the final outcome of permanent facial nerve weakness.Keywords:
Facial weakness
Parotidectomy
Facial paralysis
To assess whether continuous facial nerve monitoring during parotidectomy is associated with a lower incidence of facial nerve paresis or paralysis compared with parotidectomy without monitoring and to assess the cost of such monitoring.A retrospective analysis of outcomes for patients who underwent parotidectomy with or without continuous facial nerve monitoring.University medical center.Fifty-six patients undergoing parotidectomy in whom continuous electromyographic monitoring was used and 61 patients in whom it was not used.(1) The incidence of early and persistent facial nerve paresis or paralysis and (2) the cost associated with facial nerve monitoring.Early, unintentional facial weakness was significantly lower in the group monitored by electromyograpy (43.6%) than in the unmonitored group (62.3%) (P=.04). In the subgroup of patients without comorbid conditions or surgeries, early weakness in the monitored group (33.3%) remained statistically lower than the rate of early weakness in the unmonitored group (57.5%) (P=.03). There was no statistical difference in the final facial nerve function or incidence of permanent nerve injury between the groups or subgroups. After multivariate analysis, nonmonitored status (odds ratio [OR], 3.22), advancing age (OR, 1.47 per 10 years), and longer operative times (OR, 1.3 per hour) were the only significant independent predictive variables significantly associated with early postoperative facial weakness. The incremental cost of facial nerve monitoring was $379.The results suggest that continuous electromyographic monitoring of facial muscle during primary parotidectomy reduces the incidence of short-term postoperative facial paresis. Advantages and disadvantages of this technique need to be considered together with the additional costs in deciding whether routine use of continuous monitoring is a useful, cost-effective adjunct to parotid surgery.
Parotidectomy
Paresis
Facial weakness
Facial paralysis
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Parotidectomy
Facial weakness
Facial paralysis
Nerve Injury
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Serial evoked electromyography (EEMG) is a reliable, objective, repeatable test of facial nerve function. It is very important in the initial patient evaluation in determining percent degeneration of the facial nerve. A response of 0-20% will usually result in incomplete return of facial function while responses of 60% or better will usually result in normal function. With viral facial paralysis (Bell's palsy, herpes zoster oticus), serial EEMG after several weeks has little value in predicting the final percent recovery of facial function. If there is no EEMG response, the diagnosis of viral facial paralysis is questionable and serial tests should be done until facial function begins to return. If there is no return of facial function or EEMG responses, the diagnosis is probably a tumor and the nerve should be explored. When surgical manipulation of the facial nerve has resulted in partial facial weakness, EEMG helps predict the degree of recovery of facial function. EEMG results of 60% or better will result in normal facial function while EEMG results of 25% or less will result in incomplete return of facial function. Serial testing is not necessary in this group of patients. After transection and repair of the facial nerve, serial EEMG is of value in showing continuity of the repair. Lack of improvement in EEMG over 5-12 months and no return of facial function indicates poor prognosis.
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Facial weakness
Facial electromyography
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To observe the incidence of facial nerve dysfunction following parotidectomy and the relationship of the extent of parotid gland resection and the histopathology types.Clinical observation of 99 patients who underwent parotid surgery from 1996 to 2000 was studied to analyse the relation between facial nerve dysfunction and the extent of parotidectomy with House-Backmann grading system.The overall incidence of facial dysfunction (HB > 1) was 36.4% for temporary and 3% for permanent dysfunction; Most of the dysfunction were partial and most concerning the marginal mandibular branch (34/99). The temporary facial dysfunction rate in total parotidectomy is higher than that of superficial and local parotidectomy.The dysfunction of facial nerve branches is correlated with the surgical managements. The most facial never dysfunction is temporary. The size of the lesion and the histopathology types will influence the choice of surgical managements. A proper surgical managements would reduce the incidence of facial dysfunction.
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Facial paralysis
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Objectives To determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Data Sources PubMed‐NCBI database from 1970 to 2014. Review Methods A systematic review and meta‐analysis of the literature was conducted. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs control). Primary and secondary end points were defined as immediate postoperative and permanent facial nerve weakness (House‐Brackmann score, ≥2), respectively. Results After a review of 1414 potential publications, 7 articles met inclusion criteria, with a total of 546 patients included in the final meta‐analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared to the unmonitored group (22.5% vs 34.9%; P =. 001). The incidence of permanent weakness was not statistically different in the long term (3.9% vs 7.1%; P =. 18). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 9, given an absolute risk reduction of 11.7% This corresponded to a 47% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.53; 95% CI, 0.35 to 0.79; P =. 002). Conclusion In primary cases of parotidectomy, intraoperative FNM decreases the risk of immediate postoperative facial nerve weakness but does not appear to influence the final outcome of permanent facial nerve weakness.
Facial weakness
Parotidectomy
Facial paralysis
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Facial weakness
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Objectives: Determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Methods: Systematic review and meta‐analysis. A comprehensive literature search was conducted using the PubMed‐NCBI database from 1970 to 2014. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs. control). Primary and secondary endpoints were defined as immediate postoperative and permanent facial nerve weakness (≥2 House‐Brackmann score), respectively. Results: A total of 1414 articles were reviewed, resulting in 8 articles that met inclusion criteria. In total, 626 patients were included in the final meta‐analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared with the unmonitored group (22.4% vs 35.0%, P =. 001). The incidence of permanent weakness was also lower, but this difference was not statistically significant (4.2% vs 7.6%, P =. 10). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 8 given an absolute risk reduction of 12.6%. This corresponded to a 49% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.51; 95% confidence interval, 0.34 to 0.76, P =. 001). Conclusions: In primary cases of parotidectomy, intraoperative facial nerve monitoring decreases the risk of immediate postoperative facial nerve weakness, but does not appear to influence the final outcome of permanent facial nerve weakness.
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Parotidectomy
Facial paralysis
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Facial weakness is another classic neurologic presentation. This man presents with facial weakness and several other neurologic complaints. This case discusses the appropriate approach to assessing a patient with facial weakness, which can be surprisingly challenging. In many instances, the patient, family or other witnesses, and even healthcare providers mistakenly identify which part of the face or even side of the face is weak. Clarifying the localization of facial weakness extends to much more than just looking at the pattern of facial weakness (forehead involvement or sparing) on exam. Ancillary exam testing can solidify the diagnosis of a central versus peripheral etiology of the weakness.
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Abstract The individual with a progressive (weeks to months) facial weakness should be considered to have a tumor involving the facial nerve until proved otherwise. All individuals experiencing a facial paralysis must undergo a thorough neurotologic evaluation to establish the etiology. Bell's palsy is a diagnosis by exclusion. While computerized axial tomography (CAT) scans, polytomography and arteriograms are extremely helpful, these studies very often fail to demonstrate intrinsic tumors involving the facial nerve. For this reason all individuals experiencing a progressive facial paralysis should have an exploration of their facial nerve from the internal auditory canal (IAC) through the stylomastoid foramen into the parotid gland. The purpose of this paper is to present a series of cases of facial paralysis having as their etiology intrinsic or extrinsic neoplasms. Clinical patterns are established, diagnostic protocols formulated and the results of surgical management reviewed.
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Abstract Objectives/Hypothesis: To assess whether the use of continuous intraoperative f/cial nerve monitoring correlates to postoperative facial nerve injury during parotidectomy. Study Design: A retrospective analysis. Methods: Forty‐five consecutive parotidectomies were performed using an electromyograph (EMG)‐based intraoperative facial nerve monitor. Of those, 37 had complete data for analysis. Intraoperative findings and final interpretation of the EMGs were analyzed by a senior neurologist and neurophysiologist. All patients were analyzed, including those with preoperative weakness and facial nerve sacrifice. Results: The overall incidence of facial paralysis (House‐Brackmann scale > 1) was 43% for temporary and 22% for permanent deficits. This includes an 11% incidence of preoperative weakness and 14% with intraoperative sacrifice. An abnormal EMG occurred in only 16% of cases and was not significantly associated with permanent or temporary facial nerve paralysis (χ 2 , P < 1.0; Fisher's exact P < .68). Of the eight patients with permanent paralysis, only two had abnormalities on the facial nerve monitor. Also, only one of five patients with intraoperative sacrifice of the facial nerve had an abnormal EMG. Factors significantly associated with the incidence of facial paralysis include malignancy, advanced age, extent of parotidectomy, and dissection beyond the parotid gland (χ 2 and Fisher's, P < .05). Conclusions: The results suggest that abnormalities on the intraoperative continuous facial nerve monitor during parotidectomy do not predict facial nerve injury. The incidence of permanent and temporary facial nerve paralysis compare favorably with the literature given that this study includes patients with revision surgery, intraoperative sacrifice, and preoperative paralysis. Standard of care implications will be discussed.
Parotidectomy
Facial paralysis
Facial weakness
Nerve Injury
Intraoperative neurophysiological monitoring
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