耳大神经移植桥接修复面神经缺损84例疗效分析

Greater auricular nerve interposition grafting in the treatment of facial nerve defect:an analysis of 84 cases

目的评价耳大神经移植桥接修复面神经缺损的疗效,分析预后相关因素。方法回顾性收集并分析2010年1月至2021年12月在解放军总医院耳鼻咽喉头颈外科接受耳大神经移植桥接修复各种病因导致面神经缺损患者的临床资料,评价手术疗效。采用单因素及多因素有序logistic回归分析术后面神经功能的相关因素。结果共纳入84例患者,男39例(46.4%),女45例(53.6%),年龄(38.6±12.6)岁。引起面神经缺损的原发疾病包括面神经肿瘤54例(64.3%),其他肿瘤5例(6.0%),中耳手术医源性损伤19例(22.6%),胆脂瘤6例(7.1%)。术前面瘫时间[M(Q_(1),Q_(3))]6(1,12)个月。术前面神经功能按House-Brackmann(HB)分级Ⅰ级7例(8.3%),Ⅱ级6例(7.1%),Ⅲ级11例(13.1%),Ⅳ级14例(16.7%),Ⅴ级19例(22.6%),Ⅵ级27例(32.1%)。术后HBⅢ级46例(54.8%),Ⅳ级26例(31.0%),Ⅴ级12例(14.3%),术后面神经功能分级整体较术前下降(Z=-4.264,P<0.001)。术前较高面神经功能分级(OR=1.423,95%CI:1.031~1.966,P=0.032)和术前较长面瘫时间(OR=1.020,95%CI:1.007~1.034,P=0.003)是术后较高面神经功能分级的相关因素。性别、年龄、侧别、面瘫发生方式、面肌电图结果、手术入路、近端吻合口位置、面神经缺损长度、吻合口固定方式均与术后面神经功能分级无明显相关性(均P>0.05)。结论耳大神经移植桥接修复面神经缺损的最好疗效为HBⅢ级,半数以上患者可恢复至该水平。术前较高面神经功能分级和术前较长面瘫时间是较差预后的危险因素。

Objective To evaluate the effect of greater auricular nerve interposition grafting in the treatment of facial nerve defect,and explore the prognostic factors.Methods The clinical data of patients who received greater auricular nerve interposition grafting in the Department of Otolaryngology Head and Neck Surgery of the Chinese PLA General Hospital from January 2010 to December 2021 were retrospectively collected,and efficacy of the surgery was evaluated.Univariate and multivariate ordinal logistic regression models were used to determine the prognostic factors.Results Eighty-four patients were collected,of whom 39(46.4%)were male and 45(53.6%)were female,with an average age of(38.6±12.6)years.Facial nerve defect was caused by four kinds of primary diseases:benign facial nerve tumor(54 cases,64.3%),other tumors(5 cases,6.0%),iatrogenic facial nerve injury in middle ear surgery(19 cases,22.6%),and cholesteatoma(6 cases,7.1%).The median preoperative facial paralysis duration was 6(1,12)months.Preoperatively,there were 7(8.3%)patients of House-Brackmann(HB)gradeⅠ,6(7.1%)of gradeⅡ,11(13.1%)of gradeⅢ,14(16.7%)of gradeⅣ,19(22.6%)of gradeⅤ,and 27(32.1%)of gradeⅥ.Postoperatively,there were 46(54.8%)patients recovered to gradeⅢ,26(31.0%)to gradeⅣ,and 12(14.3%)to gradeⅤ,and the overall postoperative HB grade declined compared with the preoperative HB grade(Z=-4.264,P<0.001).For all kinds of primary diseases,higher preoperative HB grade(OR=1.423,95%CI:1.031-1.966,P=0.032)and longer preoperative facial paralysis duration(OR=1.020,95%CI:1.007-1.034,P=0.003)correlated with poorer prognosis.Gender,age,side,facial paralysis onset(sudden or progressive),facial electromyography result(fibrillation potential),surgical approach,location of proximal anastomosis,length of facial nerve defect,and anastomosis technique were not correlated with postoperative facial function grade(all P>0.05).Conclusions The best outcome of great auricular nerve interposition grafting in the treatment of facial nerve defect is HBⅢ,which could be obtained by more than half of the patients.Higher preoperative HB grade and longer preoperative facial paralysis duration are risk factors to a poorer prognosis.