Facial nerve management in parotidectomy

Always attempt to preserve the nerve: If functioning preoperatively, one should aim to have a functioning nerve postoperatively

Intraoperative facial nerve monitoring

Benign salivary tumours

  • Displace, but do not invade nerve
  • Nerve can always be dissected / peeled off tumours

Malignant tumours

  • Functioning, normal looking nerve may be peeled off tumour, and microscopic residuum treated with postoperative radiotherapy
  • If nerve is invaded/encased by tumour
  • Confirm malignancy on frozen section
  • Resect involved segment until free margins on frozen section (perineural spread can extend many centimetres beyond normal looking nerve)
  • Be prepared to dissect the mastoid segment of the nerve if positive margin at stylomastoid foramen
  • Immediately graft resected nerve, unless a small midface branch (cross-innervation in midfacial branches)

No postoperative radiotherapy or frozen section with known malignancy adherent to, or invading nerve

  • May need to be surgically more aggressive
  • Reservations about peeling nerve off tumour – but resect nerve only when the remainder of the operation is likely to achieve clear margins
  • Resect nerve at least 1cm beyond obvious tumour

Index: Clinical Practice Guidelines for Parotid

Resource Appropriate Parotid Guideline Scenarios