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NERVUS ALVEOLARIS INFERIOR + NERVUS


LINGUALIS

URSACHEN EINER PERMANENTEN NERVENLÄSION

 Weisheitszahnextraktion
o Inzidenz: NAI: 0,4-13,4% NL: 0-11% 1,2
 Sagittal split ramus osteotomy
o Inzidenz: 2-9% 3-5
 Unterkieferfrakturen
o Inzidenz: 8-67,7% 6,7
 Lokalanästhesie
o Sehr selten < 3x10-5 8
 Implantate
o Inzidenz: 0-13% 9,10
 Tumorexzision

DIAGNOSTIK

 Anamnese
 Klinische Untersuchung
 CNT – clinical neurosensory testing 11
o Level A: Pinsel (directional sense)+ Zweipunktdiskrimination
o Level B: Semmes Weinstein Monofilament (fine touch)
o Level C: Schmerz z.B. mit Thermode
o Sehr zuverlässig bei NL Läsionen
o Zuverlässig bei NL Läsionen bei NAI Läsionen jedoch 23% falsch positiv, 40% falsch negativ
 Diagnostische Nervenblockaden
 Bildgebende Verfahren spielen eine geringe Rolle
12 11

OPERATIONSZEITPUNKT

 Intraoperative iatrogene Nervernläsion -> sofortige Versorgung


 70 Tage bis 6 Monate nach Diagnosezeitpunkt 13-18
 Spätere Operationszeitpunkte können dennoch zu einer Verbesserung führen 19
 Ausnahme: iatrogene Verletzung nach Implantation -> Entfernung innerhalb von 30 Stunden 20

OPERATIONSMETHODEN

 Direkte Naht oder externe Dekompression – beste Ergebnisse 19,21,22


o Etwas schlechtere Ergebnisse bei vorheriger Neuromentfernung 13,22
 Nerve grafting 15,17,23-26
o wenn spannungsfreie Anastomose nicht möglich
o N. suralis, N. auricularis magnus, Veneninterponat, denaturierter Skelettmuskel, Allografts
 Nerve sliding technique 27
o Wenn spannungsfreie Anastomose des NAI nahe zum Foramen mentale nicht möglich
 Allgemein gute Prognose bezüglich Sensorik 60-100%, Diskrimination 0-88,9%
 Prognose abhängig von: Schwere der Läsion / des Traumas, Operationszeitpunkt, Alter des Patienten
28

VIINERVUS FACIALIS
URSACHEN DER IATROGENEN / TRAUMATISCHEN FAZIALISPARESE

KG-Chirurgie

Inzidenz: 2-25% 29

Ersteingriff 9% 30

Folgeeingriff 18% 30

Parotidektomie

Inzidenz – temporär bis 40% 31

Ästhetische Chirurgie

Inzidenz ~ 1% 32

1,989 Patienten 33 vorstellig im Department of Otology and Laryngology, Harvard Medical School,
Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A; Facial Nerve Center, Massachusetts Eye
and Ear Infirmary, Boston, Massachusetts, U.S.A.

DIAGNOSTIK – VORGEHEN BEI TRAUMATISCHER FAZIALISPARESE

Anamnese
körperliche Untersuchung (zentral vs. Peripher)

Fotodokumentation ggf. Video 34

Traumaalgorithmus

Scoring z.B. Brackmann 35

Aktuelle Entwicklung – Software-Video-Analysen 36

Bei iatrogener und traumatischer Läsion Bildgebung verzichtbar

35
S2K -Therapie der idiopathischen Fazialisparese (Bell ́s palsy) (G51.0) gültig bis 30.09.2016

OPERATIONSZEITPUNKT

Iatrogen und traumatisch – so früh wie möglich 37,38

denn…

Nervenregeneration 1mm/Tag 39

Irreversible Muskelatrophie nach 12-18 Monaten 40

Ausnahme: Patienten mit Synkinesien ggf. auch später

OPERATION

Kontinutitätsunterbrechung

Epineurial Naht mit oder ohne Graft – Goldstandard 41 (2-3 Nähte 10/0 Nylon + Fibrinkleber)

Statische Verfahren

Platingewichte 42

minimally invasive asymmetric brow lifting , tarsal strip 43,44

dynamische Verfahren

Freier Gracillis 45,46 (Innervation durch N. massetericus oder Cross-face nerv graft)

Gestielter Temporalis 47
Anschließend ggf Chemodenervation 48

SUPPORTIVE MEDIKAMENTÖSE THERAPIE

S1 Leitlinie der DGN: Anhaltender idiopathischer Gesichtsschmerz Gültig bis: 29. September 2017 49

Unklare Studienlage, ob bei Auftreten oder Prophylaktisch bei Nervenläsionen?

Vorrangig: Ursachenbeseitigung

Keine hohe Evidenz einer pharmakologischen Therapie!

 Trizyklische Antidepressiva (TZA)


 Antikonvulsive Medikamente ggf. in Kombination mit TZA
 Capsaicin-Salbe, Clonidin-Creme

V.a. VZV-Reaktivierung bei delayed onset oder inkompletter Fazialisparese

 Valacyclovir

Allgemein: S3-Leitlinie - Behandlung akuter perioperativer und posttraumatischer Schmerzen gültig bis
01.04.2014 - in Überarbeitung 50

S2K -Therapie der idiopathischen Fazialisparese (Bell ́s palsy) (G51.0) gültig bis 30.09.2016 51

 supportive Maßnahmen – keine Evidenz aber psychologisch günstig


52
NERVUS INFRAORBITALIS

~35% bei Mittelgesichtsfrakturen

NERVUS OCCULOMOTORIUS

~0,5% bei Mittelgesichtsfrakturen

NERVUS OLFACTORIUS

~1,5% bei Mittelgesichtsfrakturen

NERVUS OPTICUS

~1% bei Mittelgesichtsfrakturen

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