- Email: [email protected]
Pitfalls in monitoring of the facial nerve during operations for parotid cancer
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 55 (2017) 859–872
swelling of the neck, chest pain, and fever. The swelling had been incised at another hospital two weeks previously, but after initial improvement it had increased in size and become more inflamed. He was taking flucloxacillin and phenoxymethylpenicillin prescribed by a general practitioner. His medical history included repair of a patent ductus arteriosus as a child. His temperature was 38.6 ◦ C and oxygen saturation 95% on air. The swelling in his neck was 4 × 3 cm in size, with cellulitis from the submental region to the manubrium, and multiple pustules. An orthopantomogram showed no dental disease. His white cell count was 16.1 × 109 /L and C-reactive protein concentration 271 mg/L. A radiograph of his chest showed consolidation and effusion in the right lower zone. Computed tomography (CT) of the neck showed superficial subcutaneous inflammation and a necrotic submental lymph node, but no collection. CT of the chest showed widespread bilateral pulmonary nodules and pleural effusions. The differential diagnoses were infection and disseminated malignancy. He was given flucloxacillin intravenously, but had further episodes of pyrexia. Fine needle aspiration of the swelling in the neck was not diagnostic, and a core biopsy specimen showed inflammatory tissue only. CT of the abdomen and pelvis showed no primary malignancy. Blood culture grew Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-S aureus), and the flucloxacillin was continued intravenously on the microbiologist’s advice. Respiratory specialists diagnosed necrotising pneumonia secondary to PVL-S aureus. A transthoracic echocardiogram showed no evidence of infective endocarditis. After 11 days the neck swelling became fluctuant, was incised, and pus was drained, a specimen of which grew S aureus. By day 17 the neck swelling had improved and the patient was apyrexial with normal oxygen saturation. He was discharged to continue with flucloxacillin intravenously as an outpatient, and be followed up by the respiratory team. Panton-Valentine leukocidin is a toxin that is produced by a few strains of S aureus, and is associated with highly transmissible and virulent forms of community-acquired methicillin-resistant S aureus. It usually causes minor skin infections, which may be recurrent, but may cause large skin abscesses or skin necrosis.1 Invasive infections and septic emboli may develop, even in healthy subjects, the most serious of which is necrotising pneumonia with a mortality of 43%–56%.2 Treatment of simple PVL-S aureus infections is by control of the source by drainage of pus. Treatment with anti-staphylococcal drugs is an adjunct in complicated cases. We know of only a few case reports of cervicofacial PVL- S aureus. Shivashankar et al3 described a healthy young man in whom a PVL- S aureus-related facial boil led to sepsis, thrombosis of the internal jugular vein and cavernous sinus, and an abscess in the lung (Lemierre syndrome). While S aureus is relatively uncommon in odontogenic abscesses, Hanratty et al3 described three patients with PVL-S aureus infections that arose from a presumed dental source, of whom one died.
863
The prevalence of PVL-S aureus has risen sharply in recent years1 and maxillofacial surgeons should be alert to the possibility of such infections in the head and neck, particularly if the presentation is unusual, as in this case, in which it mimicked disseminated malignancy.
Ethics statement/confirmation of patient’s permission No ethics approval required. Written consent was obtained to use the clinical details.
Conflict of interest We have no conflicts of interest.
Reference 1. Health Protection Agency. Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections in England; 2008. Available at URL: https://www.gov.uk/./panton-valentineleukocidin-pvl-guidance-data-and-analysis Last accessed 31 May 2017. 2. Shivashankar G, Murukesh N, Varma M, et al. Infection by Panton Valentine leukocidin-producing Staphylococcus aureus clinically mimicking Lemierre’s syndrome. J Med Microbiol 2008;57:118–20. 3. Hanratty J, Changez H, Smith A, et al. Panton-Valentine leukocidin positive Staphylococcal aureus infections of the head and neck: case series and brief review of literature. J Oral Maxillofac Surg 2015;73:666–70.
M. Little ∗ N. Renny Oral and Maxillofacial Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS3 4BW ∗ Corresponding
author. E-mail addresses: [email protected] (M. Little), [email protected] (N. Renny) Available online 26 June 2017 http://dx.doi.org/10.1016/j.bjoms.2017.05.016
Pitfalls in monitoring of the facial nerve during operations for parotid cancer Sir, The facial nerve splits into branches within the parotid gland and innervates the muscles of facial expression. Damage to it can result in temporary or permanent facial deformity, asymmetry of the smile, and ocular keratosis. Studies have shown that intraoperative use of a facial nerve monitor can reduce paralysis of the nerve. A 60-year-old man with parotid cancer that involved the lower branches of the facial nerve had a resection of the right parotid and a neck dissection with curative intent. Using the NIM-Response 3.0 (Medtronic, Dublin, Ireland) facial nerve monitor we located a large, rounded, discoloured facial nerve
864
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 55 (2017) 859–872
This case shows the shortcomings of monitoring devices in cancerous tissue. A conduction block in the portion of the involved nerve stops the facial nerve monitor working proximal to that point. This highlights the danger of relying on it during parotid surgery. Studies have shown that in primary parotid surgery, facial nerve monitoring helps to reduce temporary postoperative facial weakness, but does not affect the long-term outcome.1 A facial nerve monitor is of greater benefit during primary total parotidectomy than a superficial parotidectomy or revision.2 Despite the progress of technology, the mainstay of nerve protection should be the use of anatomical landmarks, careful dissection techniques, and gentle manual stimulation while observing facial twitching during operation. Fig. 1. No response from stimulation of the facial nerve trunk when the parotid gland was retracted medially. (Published with the patient’s consent).
Conflict of interest trunk intraoperatively, and when we stimulated both it and the distal cervicomandibular branches, there were no signals and his face did not twitch (Fig. 1). A response was elicited on the nerve monitor and facial twitching was seen only when we stimulated the distal segments of the frontozygomatic and temporal branches of the nerve (Fig. 2). These were found in parotid tissue that was macroscopically tumour-free. We had cross-checked the monitor consistently throughout the procedure, replaced the probe, and used a testing unit to ensure optimum function. The lower branches of the facial nerve were sacrificed as part of the resection of the tumour. If we had relied on the facial nerve monitor alone, then the upper branches may also have been lost.
We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission Ethics approval not needed. We have obtained the patient’s permission.
Reference 1. Sood AJ, Houlton JJ, Nguyen SA, et al. Facial nerve monitoring during parotidectomy: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 2015;152:631–7. 2. Guntinas-Lichius O, Eisele DW. Facial nerve monitoring. Adv Otorhinolaryngol 2016;78:46–52.
S. Kassam S. Chegini ∗ M. Kumar Northwick Park Hospital, Watford Rd, Harrow HA1 3UJ ∗ Corresponding author. E-mail address: [email protected] (S. Chegini) Available online 23 August 2017 http://dx.doi.org/10.1016/j.bjoms.2017.06.001
If trainers regularly validate trainees’ eLogbook records, they will spot a trainee who is not keeping theirs up-todate Sir,
Fig. 2. Response from stimulation of the temporal branch of the facial nerve, after the parotid gland had been resected (published with the patient’s consent).
The months of June and July are the season of the Annual Review of Competence Progression. During the last few weeks we have both participated in two different processes of review, during which a trainee in Oral and Maxillofacial
swelling of the neck, chest pain, and fever. The swelling had been incised at another hospital two weeks previously, but after initial improvement it had increased in size and become more inflamed. He was taking flucloxacillin and phenoxymethylpenicillin prescribed by a general practitioner. His medical history included repair of a patent ductus arteriosus as a child. His temperature was 38.6 ◦ C and oxygen saturation 95% on air. The swelling in his neck was 4 × 3 cm in size, with cellulitis from the submental region to the manubrium, and multiple pustules. An orthopantomogram showed no dental disease. His white cell count was 16.1 × 109 /L and C-reactive protein concentration 271 mg/L. A radiograph of his chest showed consolidation and effusion in the right lower zone. Computed tomography (CT) of the neck showed superficial subcutaneous inflammation and a necrotic submental lymph node, but no collection. CT of the chest showed widespread bilateral pulmonary nodules and pleural effusions. The differential diagnoses were infection and disseminated malignancy. He was given flucloxacillin intravenously, but had further episodes of pyrexia. Fine needle aspiration of the swelling in the neck was not diagnostic, and a core biopsy specimen showed inflammatory tissue only. CT of the abdomen and pelvis showed no primary malignancy. Blood culture grew Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-S aureus), and the flucloxacillin was continued intravenously on the microbiologist’s advice. Respiratory specialists diagnosed necrotising pneumonia secondary to PVL-S aureus. A transthoracic echocardiogram showed no evidence of infective endocarditis. After 11 days the neck swelling became fluctuant, was incised, and pus was drained, a specimen of which grew S aureus. By day 17 the neck swelling had improved and the patient was apyrexial with normal oxygen saturation. He was discharged to continue with flucloxacillin intravenously as an outpatient, and be followed up by the respiratory team. Panton-Valentine leukocidin is a toxin that is produced by a few strains of S aureus, and is associated with highly transmissible and virulent forms of community-acquired methicillin-resistant S aureus. It usually causes minor skin infections, which may be recurrent, but may cause large skin abscesses or skin necrosis.1 Invasive infections and septic emboli may develop, even in healthy subjects, the most serious of which is necrotising pneumonia with a mortality of 43%–56%.2 Treatment of simple PVL-S aureus infections is by control of the source by drainage of pus. Treatment with anti-staphylococcal drugs is an adjunct in complicated cases. We know of only a few case reports of cervicofacial PVL- S aureus. Shivashankar et al3 described a healthy young man in whom a PVL- S aureus-related facial boil led to sepsis, thrombosis of the internal jugular vein and cavernous sinus, and an abscess in the lung (Lemierre syndrome). While S aureus is relatively uncommon in odontogenic abscesses, Hanratty et al3 described three patients with PVL-S aureus infections that arose from a presumed dental source, of whom one died.
863
The prevalence of PVL-S aureus has risen sharply in recent years1 and maxillofacial surgeons should be alert to the possibility of such infections in the head and neck, particularly if the presentation is unusual, as in this case, in which it mimicked disseminated malignancy.
Ethics statement/confirmation of patient’s permission No ethics approval required. Written consent was obtained to use the clinical details.
Conflict of interest We have no conflicts of interest.
Reference 1. Health Protection Agency. Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections in England; 2008. Available at URL: https://www.gov.uk/./panton-valentineleukocidin-pvl-guidance-data-and-analysis Last accessed 31 May 2017. 2. Shivashankar G, Murukesh N, Varma M, et al. Infection by Panton Valentine leukocidin-producing Staphylococcus aureus clinically mimicking Lemierre’s syndrome. J Med Microbiol 2008;57:118–20. 3. Hanratty J, Changez H, Smith A, et al. Panton-Valentine leukocidin positive Staphylococcal aureus infections of the head and neck: case series and brief review of literature. J Oral Maxillofac Surg 2015;73:666–70.
M. Little ∗ N. Renny Oral and Maxillofacial Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS3 4BW ∗ Corresponding
author. E-mail addresses: [email protected] (M. Little), [email protected] (N. Renny) Available online 26 June 2017 http://dx.doi.org/10.1016/j.bjoms.2017.05.016
Pitfalls in monitoring of the facial nerve during operations for parotid cancer Sir, The facial nerve splits into branches within the parotid gland and innervates the muscles of facial expression. Damage to it can result in temporary or permanent facial deformity, asymmetry of the smile, and ocular keratosis. Studies have shown that intraoperative use of a facial nerve monitor can reduce paralysis of the nerve. A 60-year-old man with parotid cancer that involved the lower branches of the facial nerve had a resection of the right parotid and a neck dissection with curative intent. Using the NIM-Response 3.0 (Medtronic, Dublin, Ireland) facial nerve monitor we located a large, rounded, discoloured facial nerve
864
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 55 (2017) 859–872
This case shows the shortcomings of monitoring devices in cancerous tissue. A conduction block in the portion of the involved nerve stops the facial nerve monitor working proximal to that point. This highlights the danger of relying on it during parotid surgery. Studies have shown that in primary parotid surgery, facial nerve monitoring helps to reduce temporary postoperative facial weakness, but does not affect the long-term outcome.1 A facial nerve monitor is of greater benefit during primary total parotidectomy than a superficial parotidectomy or revision.2 Despite the progress of technology, the mainstay of nerve protection should be the use of anatomical landmarks, careful dissection techniques, and gentle manual stimulation while observing facial twitching during operation. Fig. 1. No response from stimulation of the facial nerve trunk when the parotid gland was retracted medially. (Published with the patient’s consent).
Conflict of interest trunk intraoperatively, and when we stimulated both it and the distal cervicomandibular branches, there were no signals and his face did not twitch (Fig. 1). A response was elicited on the nerve monitor and facial twitching was seen only when we stimulated the distal segments of the frontozygomatic and temporal branches of the nerve (Fig. 2). These were found in parotid tissue that was macroscopically tumour-free. We had cross-checked the monitor consistently throughout the procedure, replaced the probe, and used a testing unit to ensure optimum function. The lower branches of the facial nerve were sacrificed as part of the resection of the tumour. If we had relied on the facial nerve monitor alone, then the upper branches may also have been lost.
We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission Ethics approval not needed. We have obtained the patient’s permission.
Reference 1. Sood AJ, Houlton JJ, Nguyen SA, et al. Facial nerve monitoring during parotidectomy: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 2015;152:631–7. 2. Guntinas-Lichius O, Eisele DW. Facial nerve monitoring. Adv Otorhinolaryngol 2016;78:46–52.
S. Kassam S. Chegini ∗ M. Kumar Northwick Park Hospital, Watford Rd, Harrow HA1 3UJ ∗ Corresponding author. E-mail address: [email protected] (S. Chegini) Available online 23 August 2017 http://dx.doi.org/10.1016/j.bjoms.2017.06.001
If trainers regularly validate trainees’ eLogbook records, they will spot a trainee who is not keeping theirs up-todate Sir,
Fig. 2. Response from stimulation of the temporal branch of the facial nerve, after the parotid gland had been resected (published with the patient’s consent).
The months of June and July are the season of the Annual Review of Competence Progression. During the last few weeks we have both participated in two different processes of review, during which a trainee in Oral and Maxillofacial