Girish Bharadwaj

Techniques for dissection of the facial nerve in benign parotid surgery: a cross specialty survey of oral and maxillofacial and ear nose and throat surgeons in the UK

We investigated techniques of dissection of the facial nerve currently being used in parotid surgery for benign disease in oral and maxillofacial (OMF) and ear, nose and throat (ENT) surgery. A postal questionnaire was sent to 300 OMF and 300 ENT consultants and 49% were returned(171(57%) OMF and 123 (41%) ENT. The antegrade technique was used routinely by 209 surgeons (87%), the retrograde technique by 9 (4%), and both techniques combined by 21 surgeons (9%). The antegrade technique was used by 135 surgeons (56%) for revision parotidectomy, by 193 (81%) for limited superficial parotidectomy, by 173 (72%) for obese patients with large tumours and by 75 (31%) for injury to the facial nerve. The retrograde technique was used by 21 surgeons (9%) for revision parotidectomy, by 22 (9%) for limited superficial parotidectomy, by 15 (6%) for obese patients with large tumours and by 29 surgeons (12%) for injury to the facial nerve. A combination of techniques was chosen by 83 surgeons (35%) in revision parotidectomy, by 24 surgeons (10%) in limited superficial parotidectomy, by 51 surgeons (21%) in obese patients with large tumours and by (56%) surgeons 135 for injury to the facial nerve.

Comparison of facial nerve injury and recovery rates after antegrade and retrograde nerve dissection in parotid surgery for benign disease: prospective study over 4 years

The facial nerve can be dissected using an antegrade or retrograde approach. Antegrade dissection is the established technique and retrograde dissection is used less often. Recent publications have drawn attention to the potential value of the retrograde technique particularly if direct identification of the nerve trunk is difficult, and in revision procedures. We prospectively studied 43 consecutive procedures in 40 patients who had parotidectomy over a 4-year period, and evaluated and compared rates of temporary and permanent nerve injury, and nerve recovery after antegrade and retrograde dissection in operations for benign parotid disease. Each patient was allocated randomly to the antegrade (n=20) or retrograde (n=20) groups. Three patients were excluded. All patients had peroperative nerve monitoring and were followed up at 1 week, 1 month, 3 months, or to full recovery of the nerve. The House-Brackmann (HB) grading system was used to assess the degree of injury to the nerve. A high rate of serious nerve injury (HBIII or above) was associated with retrograde dissection at 1 week. Serious nerve injuries (HBIII or above) were slow to recover after the antegrade technique at 3 months. There was no difference between groups in the rates of full nerve recovery at 6 months.

Tumour recurrence after surgical removal of parotid pleomorphic salivary adenoma using a retrograde facial nerve dissection technique.

Recurrence after surgical removal of parotid pleomorphic salivary adenoma using retrograde facial nerve dissection is not well researched. We adopted retrograde nerve dissection for parotid surgery for benign disease as a standard procedure in 1995. The objective of this study was to establish the rate of recurrence of primary tumours associated with the technique after removal of parotid pleomorphic salivary adenoma. We recruited 59 patients over a 16-year (1995-2011) period and collected the data prospectively. Eight patients were excluded as they had died or had been lost to follow up. Male:female ratio was 16:35 and age range was 15-69 years. The mean tumour size as measured on magnetic resonance imaging (MRI) was 27.4mm. Thirty-eight patients had superficial parotidectomy, 8 had total parotidectomy, and 5 had partial superficial parotidectomy. Mean follow up from the date of operation was 104 months (median 98, range 17-171). All patients were reviewed and examined in 2011 to establish whether the tumour had recurred. One patient had developed a solitary nodular recurrence 8 years after the initial procedure. Recurrence was 2%. The rate of clinically apparent recurrence after parotidectomy for pleomorphic salivary adenoma in this study is low and is comparable with others reported.

A presentation of facial necrotizing fasciitis with orbital involvement

Necrotizing fasciitis is a rare, severe, life-threatening soft tissue infection. Rapid progression and systemic illness are recognized features of the condition in which a high index of suspicion is essential to prompt early diagnosis and ensure a favourable outcome. Management necessitates immediate and aggressive surgical and antimicrobial treatment. This case report describes the rare presentation of facial necrotizing fasciitis with orbital involvement that required initial and subsequent widespread surgical resection within the first 24 h of admission, including unilateral enucleation of infected orbital contents.