Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington.
Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle.
JAMA Otolaryngol Head Neck Surg. 2018 May 1;144(5):418-426. doi: 10.1001/jamaoto.2018.0054.
Facial vascular anomalies are surgical challenges due to their vascularity and facial nerve distortion. To assist facial vascular anomaly surgical treatment, presurgical percutaneous facial nerve stimulation and recording of compound motor action potentials can be used to map the facial nerve branches. During surgery, the nerve map and continuous intraoperative motor end plate potential monitoring can be used to reduce nerve injury.
To investigate if preoperative facial nerve mapping (FNM) is associated with intraoperative facial nerve injury risk and safe surgical approach options compared with standard nerve integrity monitoring (NIM).
DESIGN, SETTING, AND PARTICIPANTS: This investigation was a historically controlled study at a tertiary vascular anomaly center in Seattle, Washington. Participants were 92 pediatric patients with facial vascular anomalies undergoing definitive anomaly surgery (from January 1, 1999, through January 1, 2015), with 2 years' follow-up. In retrospective review, a consecutive FNM patient cohort after 2005 (FNM group) was compared with a consecutive historical cohort (1999-2005) (NIM group).
Postoperative facial nerve function and selected surgical approach. For NIM and FNM comparisons, statistical analysis calculated odds ratios of nerve injury and operative approach, and time-to-event methods analyzed operative time.
The NIM group had 31 patients (median age, 3.3 years [interquartile range, 2.2-11.4 years]; 20 [65%] male), and the FNM group had 61 patients (median age, 4.4 years [interquartile range, 1.5-11.0 years]; 26 [43%] male). In both groups, lymphatic malformation resection was most common (19 of 31 [61%] in the NIM group and 32 of 61 [52%] in the FNM group), and the median anomaly volumes were similar (52.4 mL; interquartile range, 12.8-183.3 mL in the NIM group and 65.4 mL; interquartile range, 18.8-180.2 mL in the FNM group). Weakness in the facial nerve branches at 2 years after surgery was more common in the NIM group (6 of 31 [19%]) compared with the FNM group (1 of 61 [2%]) (percentage difference, 17%; 95% CI, 3%-32%). Anterograde facial nerve dissection was used more in the NIM group (27 of 31 [87%]) compared with the FNM group (28 of 61 [46%]) (percentage difference, 41%; 95% CI, 24%-58%). Treatment with retrograde dissection without identification of the main trunk of the facial nerve was performed in 21 of 61 (34%) in the FNM group compared with 0 of 31 (0%) in the NIM group. Operative time was significantly shorter in the FNM group, and patients in the FNM group were more likely to complete surgery sooner (adjusted hazard ratio, 5.36; 95% CI, 2.00-14.36).
Facial nerve mapping before facial vascular anomaly surgery was associated with less intraoperative facial nerve injury and shorter operative time. Mapping enabled direct identification of individual intralesional and perilesional nerve branches, reducing the need for traditional anterograde facial nerve dissection, and allowed for safe removal of some lesions after partial nerve dissection through transoral or direct excision.
由于面部血管畸形的血管性和面神经扭曲，其手术极具挑战性。为了协助面部血管畸形的外科治疗，可以在术前进行经皮面神经刺激和复合运动动作电位记录，以绘制面神经分支图。在手术过程中，可以使用神经图和连续的术中运动终板电位监测来减少神经损伤。
研究术前面神经定位（FNM）与术中面神经损伤风险的关系，并与标准神经完整性监测（NIM）相比，研究其与安全手术方法的关系。
设计、设置和参与者：这是一项在华盛顿州西雅图的三级血管畸形中心进行的历史性对照研究。参与者为 92 名患有面部血管畸形的儿科患者，他们接受了明确的异常手术（1999 年 1 月 1 日至 2015 年 1 月 1 日），并进行了 2 年的随访。在回顾性研究中，2005 年后连续的 FNM 患者队列（FNM 组）与连续的历史队列（1999-2005 年）（NIM 组）进行比较。
术后面神经功能和选择的手术方法。对于 NIM 和 FNM 比较，统计分析计算了神经损伤和手术方法的比值比，以及时间事件分析的手术时间。
NIM 组有 31 名患者（中位年龄 3.3 岁[四分位距 2.2-11.4 岁]；20[65%]名男性），FNM 组有 61 名患者（中位年龄 4.4 岁[四分位距 1.5-11.0 岁]；26[43%]名男性）。在两组中，淋巴畸形切除术最常见（NIM 组 19 例[61%]，FNM 组 32 例[52%]），异常体积中位数相似（NIM 组 52.4ml[四分位距 12.8-183.3ml]，FNM 组 65.4ml[四分位距 18.8-180.2ml]）。与 FNM 组（1 例[2%]）相比，NIM 组在术后 2 年时面神经分支无力更为常见（6 例[19%]）（差异百分比，17%；95%CI，3%-32%）。与 FNM 组（28 例[46%]）相比，NIM 组更常采用顺行面神经解剖（31 例[87%]）（差异百分比，41%；95%CI，24%-58%）。在 FNM 组中有 21 例（34%）患者进行了逆行解剖治疗，未识别面神经主干，而 NIM 组中有 0 例（0%）（差异百分比，34%；95%CI，24%-58%）。FNM 组的手术时间明显缩短，而且 FNM 组的患者更有可能更早完成手术（调整后的危险比，5.36；95%CI，2.00-14.36）。
在面部血管畸形手术前进行面神经定位与术中面神经损伤减少和手术时间缩短有关。定位可以直接识别单个病灶内和病灶周围的神经分支，减少对传统顺行面神经解剖的需求，并允许在部分神经解剖后通过经口或直接切除安全地切除一些病变。
