腮腺恶性肿瘤术中面神经损伤即刻修复的临床效果

The clinical effect of immediate facial nerve rehabilitation in malignant parotid gland tumor surgery

目的探讨腮腺恶性肿瘤术中即刻进行面神经损伤修复的效果及预后影响因素。方法回顾性分析2004年1月至2020年7月于北京大学口腔医院接受面神经修复手术的腮腺恶性肿瘤患者临床资料, 记录其基本资料、术前和术后面神经功能(HB Ⅰ~Ⅵ级)、神经损伤部位(主干、分支)、手术时机(即刻修复、择期修复)、修复方式(神经吻合术、神经移植桥接术、神经转位术、组织瓣悬吊术)等信息。根据术后患者面神经功能HB评级将其分为HB Ⅰ~Ⅲ级(神经功能恢复满意)和HB Ⅳ~Ⅵ级(神经功能恢复不满意)2组, 分析影响面神经功能预后的可能因素。计量资料比较采用t检验, 计数资料比较采用卡方检验或Fisher确切概率法, P<0.05为差异有统计学意义。结果共纳入89例患者, 男50例, 女39例, 年龄9~82岁, 中位数为49.0岁。术前面神经功能HB评级:Ⅰ级57例, Ⅱ级5例, Ⅲ级8例, Ⅳ级2例, Ⅴ级15例, Ⅵ级2例。57例患者接受了即刻修复手术, 32例患者为择期修复。53例患者面神经损伤部位为主干和(或)颞面干、颈面干, 36例为面神经分支。35例采用神经吻合术, 39例采用神经移植桥接术, 12例接受神经转位术, 3例接受组织瓣悬吊术。术后随访6~72个月, 术后面神经功能HB评级:Ⅰ级6例, Ⅱ级17例, Ⅲ级26例, Ⅳ级27例, Ⅴ级13例。术后49例归为HB Ⅰ~Ⅲ级组, 40例归为HB Ⅳ~Ⅵ级组, 统计分析结果显示:2组患者在年龄、性别方面差异均无统计学意义(P> 0.05);术后HB Ⅰ~Ⅲ级组中进行即刻修复、神经主干损伤、术前HB Ⅰ~Ⅲ级、采用神经吻合术的比例分别为73.5%(36/49)、36.7%(18/49)、89.8%(44/49)、59.2%(29/49), 术后HBⅣ~Ⅵ级组分别为52.5%(21/40)、87.5%(35/40)、65.0%(26/40)、15.0%(6/40), 2组比较差异均有统计学意义(P<0.05或<0.01)。结论腮腺恶性肿瘤术中对面神经缺损进行即刻修复重建可以获得较好的效果;神经损伤部位也可能对面神经功能的预后有影响。

Objective To discuss the effect and prognostic factors of immediate facial nerve rehabilitation in malignant parotid gland tumor surgery.Methods The patients with malignant parotid gland tumor who underwent facial nerve rehabilitation surgery in Peking University School and Hospital of Stomatology from January 2004 to July 2020 were retrospectively analyzed.Their demographic characteristics,preoperative and postoperative facial nerve function according to the House-Brackmann(HB)facial nerve grading system from HB gradeⅠto HB gradeⅥ,injury sites of facial nerve including the trunks injury and branches injury,surgical timing including immediate rehabilitation and elective rehabilitation and rehabilitation methods such as facial nerve anastomosis,nerve transplantation,nerve transfer and muscle flap suspension were recorded.Patients were divided into two groups:satisfactory outcomes with HB gradesⅠ-Ⅲand unsatisfactory outcomes with HB gradesⅣ-Ⅵ,and the factors that may affect the prognosis of facial nerve function were statistically analyzed.T-test was used to compare measurement data,chi-square test or Fisher’s precision probability test was used to compare count data.P<0.05 was considered statistically significant.Results Eighty-nine patients were included in the study,including 50 males and 39 females,aged 9-82 years,the median age was 49.0 years.Preoperative facial nerve function outcomes were HBⅠ(n=57),HBⅡ(n=5),HBⅢ(n=8),HBⅣ(n=2),HBⅤ(n=15)and HBⅥ(n=2).Fifty-seven patients underwent immediate rehabilitation and 32 patients received elective rehabilitation.In 53 cases,the main trunk and/or the temporal and cervical trunk were injured,and 36 cases were branches injury.Facial nerve anastomosis was performed in 35 cases,39 cases required nerve transplantation,12 cases underwent nerve transfer,and 3 cases underwent muscle flap suspension.The follow-up time was 6-72 months.Postoperative facial nerve function outcomes were HBⅠ(n=6),HBⅡ(n=17),HBⅢ(n=26),HBⅣ(n=27),and HBⅤ(n=13).Forty-nine cases were classified as group with postoperative HB gradesⅠ-Ⅲ,and 40 cases were classified as group with postoperative HB gradesⅣ-Ⅵ.Statistical analysis showed that there was no significant difference in terms of age and gender between two groups(P>0.05).Among the patients with postoperative HB gradesⅠ-Ⅲ,73.5%(36/49)of the patients had immediate rehabilitation,36.7%(18/49)of the patients had injury of the nerve trunks,89.8%(44/49)of the patients had preoperative HB gradesⅠ-Ⅲ,and 59.2%(29/49)of the patients had nerve anastomosis.Among the patients with postoperative HB gradesⅣ-Ⅵ,52.5%(21/40)of the patients had immediate rehabilitation,87.5%(35/40)of the patients had injury of the nerve trunks,65.0%(26/40)of the patients had preoperative HB gradesⅠ-Ⅲ,and 15.0%(6/40)of the patients had nerve anastomosis were in the group.There were statistically significant differences between the two groups(P<0.05 or<0.01).Conclusions Immediate reconstruction of the facial nerve defect during the operation of malignant parotid gland tumor can obtain better result.Furthermore,injury sites of facial nerve may affect the prognosis of facial nerve function as well.