Facial Nerve Management

One of the most crucial decisions in the planning of surgical treatment of parotid gland malignancy is management of the facial nerve. Several decades of controversy in the literature regarding the optimal management of the facial nerve have resulted in a better definition of the indications for preserving, sacrificing, and reconstructing the facial nerve. The current consensus is that the facial nerve should be dissected and preserved, unless it is directly involved by tumor.18,19 Preoperative weakness or paralysis of the facial nerve usually indicates tumor involvement, and in these instances, the nerve should be sacrificed.20 The nerve should also be sacrificed if there is intraoperative evidence of gross invasion or microscopic infiltration of the nerve by tumor, even in the presence of normal preoperative facial nerve function. This is more likely to occur with larger and high-grade tumors, and in tumors that extend from the superficial to the deep lobe transgressing the plane of the facial nerve.18 Surgical margins on both the distal and proximal nerve stumps should be checked because of the possibility of perineural spread for some distance from the area of the primary tumor.14 In certain cases, achieving negative surgical margins on the proximal stump of the facial nerve may require a mastoidectomy and facial nerve dissection along its course in the temporal bone. If the facial nerve is sacrificed, nerve repair may be done by using either direct neurorrhaphy of the cut edges, or a cable graft, depending on the length of the resected segment. Immediate rehabilitation of the paralyzed face requires diligent eye care to prevent exposure keratitis. This involves liberal use of artificial tears, lubricating ointment, and protection with an appropriate eye dressing and eyewear. A temporary tarsorrhaphy may be needed for patients with lower eyelid ectropion. A gold weight implant may be needed in patients with corneal exposure. If the facial nerve is not repaired or grafted, one or more of the surgical procedures for static or dynamic facial rehabilitation of the paralyzed face may be indicated.18

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