Intraoperatives Neuromonitoring des temporalen Astes des Nervus facialis in der Dermato-Chirurgie in modifizierter Lokalanästhesie

Zusammenfassung

Im Schläfenbereich entstehen häufig Basalzellkarzinome und Plattenepithelkarzinome.

Aufgrund der oberflächlichen Lokalisation des temporalen Astes (TA]) des Nervus facialis ist dieser bei Hautkrebsoperationen gefährdet. Obwohl nur selten über permanente Nervenlähmung berichtet wurde, führt die Verletzung des Nerven zu einem eingeschränkten Gesichtsfeld und entstellendem Aussehen durch die ipsilaterale Paralyse des Musculus frontalis mit Brauenptosis. Um eine intraoperative Nervenschädigung zu vermeiden, ist neben der strikten subkutanen Präparation eine Identifikation des Nervs anhand des intraoperativen Neuromonitorings (IOM) sinnvoll. Dies war bisher nur in Vollnarkose möglich, da Lokalanästhesie häufig zu vorübergehenden Lähmung führte.

Hier wird ein neues Vorgehen vorgestellt, das ein intraoperatives Neuromonitoring in örtlicher Betäubung erlaubt.

Abstract

The temporal area is a frequent site for basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs). Due to the superficial location of the temporal branch (TB) the nerve is at risk during skin cancer surgery. Although there are only casuistic reports about permanent nerve paralysis, it leads to compromised upper visual field and facial disfigurement due to ipsilateral paralysis of the frontalis muscle with ptosis of the eyebrow. For the protection of the TB limited preparation strictly to the superficial subcutaneous level is mandatory. In order to improve safety, additionally the identification of the nerve by intraoperative nerve monitoring (ION) is reasonable. So far ION was applied only in general anaesthesia, but not with local anaesthesia, because of the temporary paralysis of the nerve.

We present a new procedure, that allows ION in local anaesthesia in skin cancer surgery.

• Literatur

• 1 Lawrence CM, Haniffa M, Dahl MGC. Formalin-fixed tissue Mohs surgery (slow Mohs) for basal cell carcinomas: 5-year follow-up data. Br J Dermatol 2009; 160: 573-580
• 2 Lim P, Paver R, Penas PF. Mohs micrographic surgery at the Skin and Cancer Foundation Australia, 10 yerars later (1997 vs 2007). J Am Acad Dermatol 2010; 63: 832-835
• 3 Woerle B, Heckmann M, Konz B. Micrographic surgery of basal cell carcinomas of the head. Recent Results Cancer 2002; 160: 219-224
• 4 Grabski WJ, Salasche SJ. Management of temporal nerve injuries. The Journal of dermatologic surgery and oncology 1985; 11.2: 145
• 5 Ingraffea AA, Gloster Jr HM. Complications of Mohs Micrographic Surgery. Mohs Micrographic Surgery. London: Springer; 2012: 383-394
• 6 Voth H, Grunewald S, Miller B et al. Direktes Brauenlift zur Korrektur der unilateralen Brauenptosis infolge Stirnastläsion nach Hauttumorchirurgie im Schläfen- oder Stirnbereich. JDDG 2015; 13: 1298-1301
• 7 Bernstein L, Nelson RH. Surgical anatomy of the extraparotid distribution of the facial nerve. Arch Otolaryngol 1984; 110: 177
• 8 Ishikawa Y. An anatomical study on the distribution of the temporal branch of the facial nerve. J Craniomaxillofac Surg 1990; 18: 287
• 9 Sadoughi B, Hans S, de Mones E et al. Preservation of the marginal mandibular branch of the facial nerve using a plexus block nerve stimulator. Laryngoscope 2006; 116: 1713-1716
• 10 Coldiron B. Office surgical incidents:19 month of Florida data. Dermatol Surg 2002; 28: 710-713
• 11 Kurlander DE, Collins AB, Bordeaux JS. Direct Brow Lift After Mohs-Induced Temporal Nerve Transection. Dermatol Surg 2013; 39: 1132-1134
• 12 Freilinger G, Gruber H, Happak W et al. Surgical anatomy of the mimic muscle system and the facial nerve: Importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 1987; 80: 686-690
• 13 Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg 1995; 22: 241-251
• 14 Ozersky D, Baek SM, Biller HF. Percutaneous identification of the temporal branch of the facial nerve. Ann Plast Surg 1980; 4: 276
• 15 Perez-Rull J, Brette MD, Levignar J et al. Surgical landmarks of the temporo-frontal branch of the facial nerve. Ann Chir Plast Esth 1992; 37: 11
• 16 Pitanguy I, Ramos AS. The frontal branch of the facial nerve: The importance of its variations in the face lifting. Plast Reconst Surg 1966; 38: 352
• 17 Ichimura K, Nibu K, Tanaka T. Nerve paralysis after surgery in the submandibular triangle: review of University of Tokyo Hospital experience. Head Neck 1997; 19: 48-53
• 18 Timmermann W, Hamelmann WH, Thiede A. Schilddrüsenchirugie: Neuromonitoring zur Schonung des Nervus recurrens. Deutsche Ärzteblatt 2004; 101: A1341-1345
• 19 Flukes S, Ling SS, Leahy T et al. Intraoperative nerve monitoring in otolaryngology. A survey of clinical practice patterns. International Journal of Otolaryngology and Head & Neck Surgery 2013; 2: 21-26
• 20 Inabnet WB, Murry T, Dhiman S et al. Neuromonitoring of the external branch of the superior laryngeal nerve during minimally invasive thyroid surgery under local anesthesia: A prospective study of 10 patients. Laryngoscope 2009; 119: 597-601
• 21 Lifante JC, McGill J, Murry T et al. A prospective, randomized trial of nerve monitoring of the external branch of the superior laryngeal nerve during thyroidectomy under local/regional anesthesia and IV sedation. Surgery 2009; 146: 1167-1173
• 22 Barth GA. Die Kokarden-Technik. Eine Variante der 3D Histologie-gestützten Chirurgie mit geschlossenen Wunden. JDDG 2013; 11: 1177-1183
• 23 Love JT, Marchbanks JR. Injury to the facial nerve associated with the use of a disposable nerve stimulators. Otolaryngology 1978; 86: 61-64