Facial Dysfunction Research Articles

Stab injury to the preauricular region with laceration of the external carotid artery without involvement of the facial nerve: a case report

BackgroundOpen injuries to the face involving the external carotid artery are uncommon. These injuries are normally associated with laceration of the facial nerve because this nerve is more superficial than the external carotid artery. Hence, external carotid artery lesions are usually associated with facial nerve dysfunction. We present an unusual case report in which the patient had an injury to this artery with no facial nerve compromise.Case presentationA 25-year-old Portuguese man sustained a stab wound injury to his right preauricular region with a broken glass. Immediate profuse bleeding ensued. Provisory tamponade of the wound was achieved at the place of aggression by two off-duty doctors. He was initially transferred to a district hospital, where a large arterial bleeding was observed and a temporary compressive dressing was applied. Subsequently, the patient was transferred to a tertiary hospital. At admission in the emergency room, he presented a pulsating lesion in the right preauricular region and slight weakness in the territory of the inferior buccal branch of the facial nerve. The physical examination suggested an arterial lesion superficial to the facial nerve. However, in the operating theater, a section of the posterior and lateral flanks of the external carotid artery inside the parotid gland was identified. No lesion of the facial nerve was observed, and the external carotid artery was repaired. To better understand the anatomical rationale of this uncommon clinical case, we dissected the preauricular region of six cadavers previously injected with colored latex solutions in the vascular system. A small triangular space between the two main branches of division of the facial nerve in which the external carotid artery was not covered by the facial nerve was observed bilaterally in all cases.ConclusionsThis clinical case illustrates that, in a preauricular wound, the external carotid artery can be injured without facial nerve damage. However, no similar description was found in the reviewed literature, which suggests that this must be a very rare occurrence. According to the dissection study performed, this is due to the existence of a triangular space between the cervicofacial and temporofacial nerve trunks in which the external carotid artery is not covered by the facial nerve or its branches.

The rate of facial nerve dysfunction and time to recovery after intraparotid and extraparotid facial nerve exposure and protection in head and neck cutaneous tumor surgery.

Most patients with head and neck skin tumors present with normal facial nerve function. A common treatment strategy for these patients is facial nerve preservation surgery, although the degree to which the nerve is successfully preserved is still unclear. Data on the incidence and recovery of facial nerve dysfunction are woefully lacking in the field of dermato-oncology. In 23 patients with normal preoperative facial nerve function, we retrospectively reviewed twenty-six head and neck surgical interventions that included facial nerve exposure and protection, focusing particularly on the differences in outcome between intraparotid and extraparotid exposure of the facial nerve branches. Eleven of the 26 cases (42.4%) developed transient paresis, but only one (3.8%) developed permanent paresis. Of 41 dissected facial nerve branches, 14 developed transient paresis (34.1%) and one, a marginal mandibular branch, developed permanent paresis (2.4%). The branches most susceptible to developing paresis were the temporal (4/6 branches, 66.7%) and marginal mandibular branches (8/17 branches, 47.1%). Although the rate of paresis was higher, and ensuing recovery period slightly longer in the extraparotid dissection group compared to the intraparotid dissection group, there were no statistically significant differences between the two groups. The extraparotid and intraparotid rates of paresis were 48% (11/23 branches) and 21.1% (4/19 branches), respectively, P=0.139; and the average recovery periods were 10.3 and 9.3weeks, respectively, P=0.64. The functional outcome, regardless of the different sites of facial nerve exposure, was almost always either complete facial nerve sparing or transient dysfunction that resolved within 6months.

Validation of the facial dysfunction domain of the Penn Acoustic Neuroma Quality-of-Life (PANQOL) Scale.

The objective of this study is to evaluate the strength of content validity within the facial dysfunction domain of the Penn Acoustic Neuroma Quality-of-Life (PANQOL) Scale and to compare how it correlates with a facial dysfunction-specific QOL instrument (Facial Clinimetric Evaluation, FaCE). The study design is online questionnaire survey. Members of the British Acoustic Neuroma Association received both PANQOL questionnaires and the FaCE scale. 158 respondents with self-identified facial paralysis or dysfunction had completed PANQOL and FaCE data sets for analysis. The mean composite PANQOL score was 53.5 (range 19.2-93.5), whilst the mean total FaCE score was 50.9 (range 10-95). The total scores of the PANQOL and FaCE correlated moderate (r=0.48). Strong correlation (r=0.63) was observed between the PANQOL's facial dysfunction domain and the FaCE total score. Of all the FaCE domains, social function was strongly correlated with the PANQOL facial dysfunction domain (r=0.66), whilst there was very weak-to-moderate correlation (range 0.01-0.43) to the other FaCE domains. The current study has demonstrated a strong correlation between the facial dysfunction domains of PANQOL with a facial paralysis-specific QOL instrument.

Effects of glass ionomer cement on facial nerve: a clinical and histopathologic evaluation

Objective: The aim of this study was to investigate the clinical and histopathologic effects of glass ionomer cement (GIC) on facial nerve.Methods: Eight Wistar albino rats were included in the study. Under general anesthesia, bilateral facial nerves of rats were dissected. Saline was injected into right facial nerves, while GIC was dropped on left facial nerves. Facial nerve functions of the rats were evaluated using mustache and bling reflex scores everyday along 14 days. On the 14th day, rats were sacrificed, and facial nerves examined in terms of inflammation, granulation tissue, and foreign body reaction. The clinical and histopathologic changes on facial nerves were compared for both groups.Results: In clinical evaluation, facial nerve functions did not significantly differ between two groups (p = .301). On histopathologic examination, bone cement group had significantly more foreign body reaction, granulation tissue, and inflammation compared with the control group (p = .001; p = .002; p = .003, respectively).Conclusions: Bone cement directly applied on the nerve causes foreign body reaction increased inflammation and granulation tissue. Nonetheless it does not lead to a permanent facial nerve dysfunction.

Efficacy and outcomes of facial nerve-sparing treatment approach to cerebellopontine angle meningiomas.

OBJECTIVE Advanced microsurgical techniques contribute to reduced morbidity and improved surgical management of meningiomas arising within the cerebellopontine angle (CPA). However, the goal of surgery has evolved to preserve the quality of the patient's life, even if it means leaving residual tumor. Concurrently, Gamma Knife radiosurgery (GKRS) has become an acceptable and effective treatment modality for newly diagnosed, recurrent, or progressive meningiomas of the CPA. The authors review their institutional experience with CPA meningiomas treated with GKRS, surgery, or a combination of surgery and GKRS. They specifically focus on rates of facial nerve preservation and characterize specific anatomical features of tumor location with respect to the internal auditory canal (IAC). METHODS Medical records of 76 patients with radiographic evidence or a postoperative diagnosis of CPA meningioma, treated by a single surgeon between 1992 and 2016, were retrospectively reviewed. Patients with CPA meningiomas smaller than 2.5 cm in greatest dimension were treated with GKRS, while patients with tumors 2.5 cm or larger underwent facial nerve-sparing microsurgical resection where appropriate. Various patient, clinical, and tumor data were gathered. Anatomical features of the tumor origin as seen on preoperative imaging confirmed by intraoperative investigation were evaluated for prognostic significance. Facial nerve preservation rates were evaluated. RESULTS According to our treatment paradigm, 51 (67.1%) patients underwent microsurgical resection and 25 (32.9%) patients underwent GKRS. Gross-total resection (GTR) was achieved in 34 (66.7%) patients, and subtotal resection (STR) in 17 (33.3%) patients. Tumors recurred in 12 (23.5%) patients initially treated surgically, requiring additional surgery and/or GKRS. Facial nerve function was unchanged or improved in 68 (89.5%) patients. Worsening facial nerve function occurred in 8 (10.5%) patients, all of whom had undergone microsurgical resection. Upfront treatment with GKRS for CPA meningiomas smaller than 2.5 cm was associated with preservation of facial nerve function in all patients over a median follow-up of 46 months, regardless of IAC invasion and tumor origin. Anatomical origin was associated with extent of resection but did not correlate with postoperative facial nerve function. Tumor size, extent of resection, and the presence of an arachnoid plane separating the tumor and the contents of the IAC were associated with postoperative facial nerve outcomes. CONCLUSIONS CPA meningiomas remain challenging lesions to treat, given their proximity to critical neurovascular structures. GKRS is a safe and effective option for managing CPA meningiomas smaller than 2.5 cm without associated mass effect or acute neurological symptoms. Maximal safe resection with preservation of neurological function can be performed for tumors 2.5 cm or larger without significant risk of facial nerve dysfunction, and, when combined with GKRS for recurrence and/or progression, provides excellent disease control. Anatomical features of the tumor origin offer critical insights for optimizing facial nerve preservation in this cohort.

Can floseal\u2122 be applied safely during otologic surgery? Assessment of ototoxicity in a chinchilla animal model

BackgroundIn otologic surgery good visualization is paramount, and patients with bleeding diatheses or who need to be anti-coagulated can present a significant challenge. Here, we determine whether Floseal™, a hemostatic matrix, is ototoxic in a validated animal model.MethodsNine chinchillas housed in the animal care facilities of the Montreal Children’s Hospital Research Institute were used for the study. After a myringotomy incision was made in each tympanic membrane, baseline auditory brainstem response measurements were performed at 8, 20, and 25 kHz. In each animal one ear was randomized to receive Floseal™ to the middle ear cavity, whereas the other ear served as the control and received 0.9% sodium chloride. Outcome measures included early (day 7) and late (day 30) auditory brainstem response, clinical evidence of facial nerve or vestibular disturbance and histological evidence of ototoxity.ResultsThere was no significant hearing threshold shift on auditory brainstem response across all tested frequencies for both experimental and control ear. No animals receiving Floseal™ developed facial or vestibular nerve dysfunction and there was no histological evidence of ototoxicity.ConclusionBased on the preliminary ototoxicity assessment on nine chinchillas, transtympanic Floseal™ does not appear to be ototoxic. More studies are warranted to assess the safety and applicability of the product in humans.

Malignant Symptoms and Signs of Parotid Tumor

There are certain physical findings that help to distinguish benign from malignant parotid tumors. It is well known that pain/tenderness, fixation to surrounding structures, and facial weakness/paralysis are important symptoms and signs associated with parotid cancer. Among 149 cases of parotid cancer, pain/tenderness was present in 79 cases, and fixation to the surrounding structures was noted in 98 cases. Some degree of facial nerve dysfunction was noted in 27 cases, while, on the other hand, none of the 668 patients with benign parotid tumors showed any evidence of facial nerve dysfunction. All of these symptoms/signs associated with malignant parotid tumors were found at higher frequencies in histologically high malignancy grade tumors than in intermediate/low malignancy grade tumors. Adenoid cystic carcinoma is well known to be characterized histologically by perineural spread, and accounts for about 80% of all parotid tumors. Pain/tenderness has been noted in 88% of patients with adenoid cystic carcinoma, a higher rate as compared to that in parotid cancer patients as a whole. Awareness of the symptoms and signs associated with malignancy is the first step towards early diagnosis of malignant parotid tumors.

Weakness of Eye Closure with Central Facial Paralysis after Unilateral Hemispheric Stroke Predicts a Worse Outcome

Upper facial dysfunction is not generally considered a feature of central facial paralysis after unilateral hemispheric stroke; however, weakness of eye closure (WEC) has been observed in some cases. We aimed to investigate the frequency and characteristics of WEC in unilateral stroke and its association with stroke prognosis. Patients with unilateral stroke and central facial paralysis were prospectively recruited within 7 days of onset. Facial paralysis was evaluated via the fourth item in the National Institute of Health Stroke Scale (NIHSS-4) and the Japan Facial Score (JFS) on admission, and at days 7, 14, 21, and 30 after stroke. Eye closure strength was measured daily using an ergometer for 30 days after stroke. Primary outcome was assessed using the modified Rankin Scale (mRS) at 90 and 180 days. Univariate and multivariate analyses were performed to investigate risk factors of WEC. WEC was identified in 16 of 242 patients (6.6%). Baseline characteristics, stroke risk factors, and lesion volume were not significantly different between patients with and patients without WEC. Patients with WEC featured higher NIHSS-4 scores and lower JFS between admission and at 21 days after stroke. Severe central facial paralysis (odds ratio [OR] = 8.1, 95% confidence interval [CI] = 2.3-28.6, P = .001) and right hemispheric stroke (OR = 13.7, 95% CI = 3.7-51.2, P < .001) were potential predictors of WEC. At 180 days after stroke, patients with WEC demonstrated a lower rate of functional independence (mRS = 0-2: 37.5% versus 72.1%, P < .001). WEC, which predicts a worse functional outcome at 180 days after unilateral stroke, demonstrates an association with severe central facial paralysis and right hemispheric stroke.

Patient- versus physician-reported facial disability in vestibular schwannoma: an international cross-sectional study.

OBJECTIVE Patient-reported outcomes are increasingly used in studies of vestibular schwannoma (VS); however, few studies have examined self-evaluated facial nerve function and its relation to physician-reported outcomes. The primary objective of this study was to compare patient self-evaluations of facial disability with physician-evaluated facial nerve status and with self-evaluations of a healthy control group. The second objective was to provide insight into the controversial subject of the optimal initial management of small- and medium-sized VSs; consequently, the authors compared patient-reported facial nerve disability following treatment via observation (OBS), Gamma Knife surgery (GKS), or microsurgery (MS). Lastly, the authors sought to identify risk factors for facial nerve dysfunction following treatment for small- and medium-sized VSs. METHODS All patients with a VS 3 cm or smaller that was singly treated with OBS, GKS, or MS at either of 2 independent treatment centers between 1998 and 2008 were retrospectively identified. Longitudinal facial nerve measures and clinical data, including facial nerve evaluation according to the House-Brackmann (HB) grading system, were extracted from existing VS databases. Supplementing the objective data were Facial Disability Index (FDI) scores, which were obtained via survey of patients a mean of 7.7 years after initial treatment. RESULTS The response rate among the 682 eligible patients was 79%; thus, data from a total of 539 patients were analyzed. One hundred forty-eight patients had been managed by OBS, 247 with GKS, and 144 with MS. Patients who underwent microsurgery had larger tumors and were younger than those who underwent OBS or GKS. Overall, facial nerve outcomes were satisfactory following treatment, with more than 90% of patients having HB Grade I function at the last clinical follow-up. Treatment was the major risk factor for facial nerve dysfunction. Almost one-fifth of the patients treated with MS had an objective decline in facial nerve function, whereas only 2% in the GKS group and 0% in the OBS cohort had a decline. The physical subscale of the FDI in the VS patients was highly associated with HB grade; however, the social/well-being subscale of the FDI was not. Thus, any social disability caused by facial palsy was not detectable by use of this questionnaire. CONCLUSIONS The majority of patients with small- and medium-sized VSs attain excellent long-term facial nerve function and low facial nerve disability regardless of treatment modality. Tumor size and microsurgical treatment are risk factors for facial nerve dysfunction and self-reported disability. The FDI questionnaire is sensitive to the physical but not the social impairment associated with facial dysfunction.

HYPERBARIC OXYGEN THERAPY (HBOT)

The role of steroids in the treatment of Bell’s palsy is well known provided patientspresent within 72hrs of symptoms onset. If patients present late or with severe Bell’s palsythe effect of steroids or other treatment modalities is not yet clear. Aim of this study was toevaluate the effect of HBOT along with oral steroids in treatment of such patients. Setting:Diving department at Armed Forces Hospital King Abdul Aziz Naval Base Jubail, Kingdom ofSaudi Arabia (KSA). Period: January 2010 to Dec. 2015. Methods: Bell’s palsy patients ofage 13 years and above were treated with steroids &amp; HBOT. Prednisolone 60mg was givenorally for one week to all patients &amp; those patients who could tolerate HBOT were selected fortreatment with Hyperbaric Oxygen in a closed chamber at 2.5 ATA, 90 minutes a day and fivedays a week. HBOT was continued till complete recovery or up to 20 sessions before declaringpartial recovery or failure. Assessment was done by physician using House-Brackmanngrading system for Facial nerve dysfunction. Patients were followed up to 3 months beforedeclaring partial recovery or treatment failure. Results: Treatment was started on 125 patientsbut 15 patients could not tolerate HBOT due to ear pain (10 patients) or high blood pressure(5 patients) in the HBOT chamber whereas 10 patients did not show up for follow up so only100 patients completed the treatment. Out of 100, 22(22%) patients had mild (grade I to II), 40patients (40%) had moderate (grade III to IV) and 38 patients (38%) had severe (grade V to VI)Bell’s palsy. Majority of patients (85%) presented after 72hrs of symptoms onset. At 3 monthsof follow up 90% (n=90) patients had full recovery whereas 10% (n=10) patients had partialrecovery. Severity of disease (OR 0.125, CI 0.025---0.6255, p =0.00595) and time between onsetof symptoms and start of treatment &gt;2weeks (OR 0.0966 CI 0.0187---0.4987, p=0.00280) werestatistically significant. Conclusion: Combination of Hyperbaric Oxygen therapy and steroids is

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The role of steroids in the treatment of Bell’s palsy is well known provided patientspresent within 72hrs of symptoms onset. If patients present late or with severe Bell’s palsythe effect of steroids or other treatment modalities is not yet clear. Aim of this study was toevaluate the effect of HBOT along with oral steroids in treatment of such patients. Setting:Diving department at Armed Forces Hospital King Abdul Aziz Naval Base Jubail, Kingdom ofSaudi Arabia (KSA). Period: January 2010 to Dec. 2015. Methods: Bell’s palsy patients ofage 13 years and above were treated with steroids &amp; HBOT. Prednisolone 60mg was givenorally for one week to all patients &amp; those patients who could tolerate HBOT were selected fortreatment with Hyperbaric Oxygen in a closed chamber at 2.5 ATA, 90 minutes a day and fivedays a week. HBOT was continued till complete recovery or up to 20 sessions before declaringpartial recovery or failure. Assessment was done by physician using House-Brackmanngrading system for Facial nerve dysfunction. Patients were followed up to 3 months beforedeclaring partial recovery or treatment failure. Results: Treatment was started on 125 patientsbut 15 patients could not tolerate HBOT due to ear pain (10 patients) or high blood pressure(5 patients) in the HBOT chamber whereas 10 patients did not show up for follow up so only100 patients completed the treatment. Out of 100, 22(22%) patients had mild (grade I to II), 40patients (40%) had moderate (grade III to IV) and 38 patients (38%) had severe (grade V to VI)Bell’s palsy. Majority of patients (85%) presented after 72hrs of symptoms onset. At 3 monthsof follow up 90% (n=90) patients had full recovery whereas 10% (n=10) patients had partialrecovery. Severity of disease (OR 0.125, CI 0.025---0.6255, p =0.00595) and time between onsetof symptoms and start of treatment &gt;2weeks (OR 0.0966 CI 0.0187---0.4987, p=0.00280) werestatistically significant. Conclusion: Combination of Hyperbaric Oxygen therapy and steroids is

P19.02 Clinical and radiological long term outcome of acoustic neuromas (Koos grade I - IV) after stereotactic radiosurgery

AbstractIntroduction:In the management of acoustic neuroma (AN) stereotactic radiosurgery (SRS) has evolved as widely accepted treatment option for small-sized tumors (Koos I and II). For larger AN (Koos III and IV) microsurgery is treatment of choice. However, for patients not suitable for microsurgery SRS might also be an alternative that balances tumor control, hearing preservation and adverse effects. The purpose of this analysis was to evaluate the efficacy and toxicity of SRS for different Koos grades including AN Koos III and IV.Methods:In this single center retrospective analysis (1991 - 2015) we included all patients with previously untreated AN who underwent single session LINAC or Cyberknife® based SRS with a minimum follow-up of 3 months. Patient data were analyzed and correlated (Pearson`s coefficient) with the different Koos grades in terms of radiological tumor control, preservation of serviceable hearing, course of median pure tone averages (PTA) and adverse events rated by Common Terminology Criteria for Adverse Events (CTCAE; v4.03).Results:301 patients (f:m = 151:150, median age 59 years ±13.6, range 17–84) were identified with a mean follow-up of 50.9 months (range 3–265). Mean tumor volume was 1.85 ml ±2.4 (range 0.1–23.7, the mean marginal dose was 12.4 Gy ± 0.8 (range 11–20) and the prescription isodose was 69.3 % ± 12.5 (range 32.9–86.2). With regard to the Koos classification 52 patients were considered as grade I, 162 as grade II, 42 and 45 as grade III and IV, respectively.At last follow-up after SRS 94% of the patients showed radiological tumor control. There was no significant correlation (p < 0.113) between Koos grades I/II vs III/IV and radiological tumor control.Median PTA of Koos I/II tumors increased about 49% (37,2 dB prior to SRS up to 55,6 dB at last follow-up). In case of Koos III/IV tumors the increase of median PTA was similar (47%; 46,2 dB up to 68,2 dB).The rate of transient facial nerve dysfunction CTCAE grade 1 or 2 in Koos I/II tumors was 2.3% and 4.6% in Koos III/IV. Permanent facial nerve dysfunction CTCAE grade 1 was observed in one patient with Koos grade I and III, respectively. Transient trigeminal nerve impairment CTCAE grade 1/2 occurred with 3.7% in Koos I/II and with 6.9% in Koos III/IV. Four patients (4.6%) with Koos III/IV tumors had permanent trigeminal nerve impairment CTCAE grade 1/2.Conclusion:SRS for AN shows reliable long term tumor control and a high rate of hearing preservation and without considerable permanent side effects. Therefore, SRS can be proposed as safe and effective treatment option for AN, even with higher Koos grades.

Association Between Facial Nerve Monitoring With Postoperative Facial Paralysis in Parotidectomy.

Electrophysiologic facial nerve monitoring is becoming an established intraoperative aid to assist the surgeon in facial nerve trunk or branch location and dissection. Limited studies have addressed the postoperative outcomes of parotid surgery with and without monitoring. To examine the influence of intraoperative facial nerve monitoring on postoperative facial nerve function and procedure duration in parotid surgery. An 8-year retrospective review of parotidectomies performed at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Münster. The study analyzed 120 patients undergoing parotidectomy without monitoring from January 1, 1988, to December 31, 1991, and 147 patients undergoing parotidectomy with monitoring from January 1, 2003, to December 31, 2006. The patients were further subdivided in partial parotidectomy (PP) (n = 222) and total parotidectomy (TP) (n = 45) groups. An evaluation of operative time was performed to test the hypothesis of shorter duration of surgery with facial nerve monitoring. Final follow-up was completed on December 31, 2008, and data were analyzed from June 1 to December 31, 2013. Comparison of the incidence of facial nerve dysfunction and operative time between the PP and TP subgroups with and without monitoring. A total of 267 patients (127 men [47.6%] and 140 women [52.4%]; mean [SD] age, 51.3 [17.6] years; range, 3-90 years) were included in the analysis. A significant reduction in postoperative facial nerve dysfunction with the use of nerve monitoring could be seen in the PP group (46 of 99 without monitoring [46.5%] vs 18 of 123 with monitoring [14.6%]; P = .001). A similar finding was evident in the TP group when comparing moderate and severe nerve dysfunction (9 of 21 without monitoring [42.9%] vs 2 of 24 with monitoring [8.3%]; P = .01). The mean (SD) operative time in the PP subgroup without nerve monitoring was 115.3 (37.8) minutes; with nerve monitoring, 110.1 (33.6) minutes. The mean (SD) operative time in the TP subgroup without nerve monitoring was 134.5 (50.4) minutes; with nerve monitoring, 158.3 (56.3) minutes. There was no statistical difference between these groups. Facial nerve monitoring in primary parotid surgery for benign and malignant disease does not necessarily reduce the operative time, but the rate of transient postoperative facial nerve dysfunction or the grade of palsy is reduced.

Stereotactic radiosurgery for recurrent vestibular schwannoma after previous resection

OBJECTIVE The goal of this retrospective cohort study was to assess long-term outcomes in patients with vestibular schwannoma (VS) who underwent stereotactic radiosurgery (SRS) after initial microsurgical resection. METHODS From the authors' database of 1770 patients with VS, the authors retrospectively analyzed data from 173 Gamma Knife SRS procedures for VS after 1 (128 procedures) or multiple (45 procedures) microsurgical resections. The median length of the interval between the last resection and SRS was 42 months (range 2-329 months). The median length of clinical follow-up was 74 months (range 6-285 months). Progression-free survival after SRS was determined with Kaplan-Meier analysis. RESULTS At the time of SRS, the hearing of 161 patients (93%) was Gardner-Robertson Class V, and 81 patients (47%) had facial neuropathy (i.e., facial function with House-Brackmann [HB] grades of III-VI), 87 (50%) had trigeminal neuropathy, and 71 (41%) reported imbalance or disequilibrium disorders. The median tumor volume was 2.7 cm3 (range 0.2-21.6 cm3), and the median dose to the tumor margin was 13 Gy (range 11-20 Gy). Radiosurgery controlled growth of 163 (94%) tumors. Progression-free survival after SRS was 97% at 3 years, 95% at 5 years, and 90% at 10 years. Four patients with delayed tumor progression underwent repeat SRS at a median of 35 months (range 23-64 months) after the first SRS. Four patients (2.3%) with tumor progression underwent repeat resection at a median of 25 months (range 19-33 months). Among the patients with any facial dysfunction (indicated by HB grades of II-VI), 19% had improvement in this condition after SRS, and 5.5% with some facial function (indicated by HB grades of I-V) developed more facial weakness. Among patients with trigeminal neuropathy, 20% had improvement in this condition, and 5.8% developed or had worsened trigeminal neuropathy after SRS. CONCLUSIONS Stereotactic radiosurgery offered a safe and effective long-term management strategy for VS patients whose tumors remained or recurred after initial microsurgery.

Effectiveness of facial exercise therapy for facial nerve dysfunction after superficial parotidectomy: a randomized controlled trial

Objectives: To compare the effectiveness of a daily home-based facial exercise therapy with a supervised rehabilitation technique for the treatment of postoperative facial dysfunction in patients undergoing conventional superficial parotidectomy. Design: Prospective, randomized trial, controlled. Setting: Surgery and Rehabilitation Units, university hospital. Subjects: Consecutive patients (n=79, mean age 48 years) who underwent superficial parotidectomy with facial nerve dissection were randomly divided into two groups. Intervention: Control group (CG) were given a daily homework manual to perform ordinary postoperative facial mimic exercises autonomously in front of the mirror at home. Experimental group (EG) patients with moderate-severe paresis received supervised rehabilitation therapy that consisted in weekly sessions with facial exercises and massages and performed daily facial exercises at home. EG patients with slight paresis were instructed to undertake self-massage and mirror exercises. Main outcome measures: Postoperative dysfunction of facial nerve and branches was quantified measuring the prevalence, magnitude and duration of paresis by the House-Brackmann Facial Nerve Grading System up to 12th months. Results: Facial paresis incidence at 1st week was 77.2%, being the marginal-mandibular nerve the most affected (64.5%). No statistically significant differences were found at any time of the study when comparing the frequency, magnitude and duration of paresis between EG and CG and among patients who had presented moderate-severe paresis. In the absence of intraoperative nerve injury, complete recovery of facial mobility was observed within 12 months, regardless of treatment group. Conclusion: Rehabilitation therapy and mirror facial exercises performed autonomously at home were equally effective for postoperative functional recovery.

Clinical comparison of two subtypes of cystic vestibular schwannoma: surgical considerations and outcomes

Cystic vestibular schwannoma (CVS) is classified as Type A and Type B based on the overall cyst location and cyst wall thickness in magnetic resonance imaging. A retrospective analysis was performed to compare surgical considerations and outcomes between Type A and Type B groups of CVS. We selected 188 patients diagnostic for CVS with surgical resection, and divided them into Type A and Type B groups. General information, preoperative symptoms, the result of neuroimaging, and audiological tests were recorded. Surgical approach, completeness of tumor resection, and intraoperative facial nerve (FN) integrity were taken down. After operation, the short-term and long-term FN functions, complications, and recurrence rate were evaluated. The total tumor removal rate in Type A group was higher than that in Type B group (86.1 vs 72.5%, p=0.021). Anatomical FN integrity was preserved in 173 patients (92.0%), with no significant differences between Type A and Type B. FN function was better in Type A group at hospital discharge. Besides, a good FN function rate was inversely proportional to the tumor size. The long-term FN function and all of the complications had no significant differences between the two groups. Patients in the Type B group are prone to have a lower total tumor removal rate and transient FN dysfunction. The long-term FN function was similar in both groups. Tumor size is another important indication of FN function. All postoperative complications occurred in patients with a tumor larger than grade 3, regardless of the subtypes of CVS.

Modified tragus edge approach for mid-level or low condylar fractures

The aim of this study was to evaluate and report a modified tragus edge approach (MTEA) for surgical access to mid-level or low condylar fractures. The MTEA was used on 45 patients (59 sides). All of the patients were reviewed for scarring, parotid fistula, facial nerve function, occlusion, deviation, and limitation of mouth opening (MO). Forty-one patients (64 sides) with middle or low level condylar fractures who underwent surgery by retromandibular approach during the same period were selected for comparison. In the MTEA group, scars were not obvious and there was no parotid fistula. The occlusion of four cases (8.9%) was not ideal, but returned to normal after 2 weeks of intermaxillary traction. Temporary facial nerve damage was present on two sides (3.4%). MO was not deviated in any patient, but was limited in the first 2 weeks after operation in three cases (6.7%). The risks of facial nerve dysfunction and parotid fistula were much higher in the retromandibular approach group than in the MTEA group, while the risks of malocclusion and limitation of MO were similar. MTEA is safe and has good aesthetic outcomes. MTEA represents an appropriate surgical access to mid-level and low condylar fractures.

Complications after surgery for benign parotid gland neoplasms: A prospective cohort study.

Prospective studies on procedure-specific incidences of complications after benign parotid surgery are lacking. Predictive factors for postoperative facial dysfunction remain controversial. We conducted a prospective study on 132 patients undergoing parotid surgery for benign parotid neoplasms. We analyzed complication rates and assessed risk factors of postoperative transient facial palsy. Facial palsy rate was 40.2% on the first postoperative day, 28.3% at 2 weeks, 3.9% at 6 months, and 1.6% at 12 months. Immediate postoperative palsy rates in subgroups of partial superficial parotidectomy, superficial parotidectomy, extended parotidectomy, and ECD were 41.5%, 43.8%, 53.8%, and 6.3%, respectively. Age, duration of surgery, and use of ultrasound knife were identified as risk factors for transient facial palsy. Depending on the operation type, up to half of the patients experience facial palsy after benign parotid surgery. Higher age and longer duration of operation increase the risk. The role of operative instrumentation requires further studies. © 2016 Wiley Periodicals, Inc. Head Neck 39: 170-176, 2017.

Masseteric-facial nerve neurorrhaphy: results of a case series.

OBJECTIVE Facial palsy is a well-known functional and esthetic problem that bothers most patients and affects their social relationships. When the time between the onset of paralysis and patient presentation is less than 18 months and the proximal stump of the injured facial nerve is not available, another nerve must be anastomosed to the facial nerve to reactivate its function. The masseteric nerve has recently gained popularity over the classic hypoglossus nerve as a new motor source because of its lower associated morbidity rate and the relative ease with which the patient can activate it. The aim of this work was to evaluate the effectiveness of masseteric-facial nerve neurorrhaphy for early facial reanimation. METHODS Thirty-four consecutive patients (21 females, 13 males) with early unilateral facial paralysis underwent masseteric-facial nerve neurorrhaphy in which an interpositional nerve graft of the great auricular or sural nerve was placed. The time between the onset of paralysis and surgery ranged from 2 to 18 months (mean 13.3 months). Electromyography revealed mimetic muscle fibrillations in all the patients. Before surgery, all patients had House-Brackmann Grade VI facial nerve dysfunction. Twelve months after the onset of postoperative facial nerve reactivation, each patient underwent a clinical examination using the modified House-Brackmann grading scale as a guide. RESULTS Overall, 91.2% of the patients experienced facial nerve function reactivation. Facial recovery began within 2-12 months (mean 6.3 months) with the restoration of facial symmetry at rest. According to the modified House-Brackmann grading scale, 5.9% of the patients had Grade I function, 61.8% Grade II, 20.6% Grade III, 2.9% Grade V, and 8.8% Grade VI. The morbidity rate was low; none of the patients could feel the loss of masseteric nerve function. There were only a few complications, including 1 case of postoperative bleeding (2.9%) and 2 local infections (5.9%), and a few patients complained about partial loss of sensitivity of the earlobe or a small area of the ankle and foot, depending on whether great auricular or sural nerves were harvested. CONCLUSIONS The surgical technique described here seems to be efficient for the early treatment of facial paralysis and results in very little morbidity.

Extracapsular Dissection with Facial Nerve Dissection for Benign Parotid Tumors

Poster published by the Christiana Care Learning Institute ABSTRACT Technique and outcomes for Extracapsular Dissection with Facial Nerve Dissection for benign parotid tumors are reported. This technique, not previously published, uses standard surgical landmarks to identify and ante-­‐grade dissect the facial nerve trunk. The branches of the facial nerve are dissected up to the anterior extracapsular margin of the tumor, than the tumor is dissected with a thin 1-­‐2 mm layer of parenchyma and fascia around it. This technique is compared to the authors previously reported series on Partial Superficial Parotidectomy with ante-­‐grade facial nerve dissection with a 1-­‐2 cm layer of normal parotid tissue around the tumor. Extracapsular Dissection with Facial nerve Dissection for benign parotid tumors resulted in significantly lower rates of transient facial nerve dysfunction, and sialocele compared to Partial Superficial Parotidectomy without increasing permanent facial nerve dysfunction and thus far recurrence. Longer follow-­‐ up is necessary to more accurately define the recurrence rate of this technique.