Facial Dysfunction Research Articles

Modern management of facial palsy: a review of current literature

Facial nerve dysfunction can severely affect a patient's quality of life. The human face is a focal point for communication and expression. The facial nerve carries motor, sensory, and parasympathetic fibres, so facial palsy results in both a functional and cosmetic impairment. Facial weakness secondary to upper motor neurone lesions will not be discussed in this article. Facial nerve palsy is diagnosed upon clinical presentation with weakness of the facial muscles. There may be immobility of the brow, incomplete lid closure, drooping of the corner of the mouth, impaired closure of the lips, dry eye, hyperacusis, impaired taste, or pain around the ear. There are many causes of unilateral facial palsy that should be considered, including idiopathic, traumatic, infective, neoplastic, congenital, and autoimmune (Box 1). Seventy per cent of facial nerve palsies are diagnosed as Bell's palsy1 with 11–40 new cases per 100 000 each year.2 Bell's palsy disproportionately attacks pregnant women and patients with respiratory tract illness. Bilateral facial palsy is far less common (2% of facial palsies) and typically represents a systemic disorder with multiple manifestations. Bell's palsy is also the most common diagnosis in childhood and accounts for 90% of facial paralysis. Up to 10% of patients with Bell's palsy will experience …

A rare case of accessory maxilla and bilateral Tessier no. 7 clefts, a 10-year follow-up

A Tessier no. 7 cleft is a lateral facial cleft which originates from the oral cavity and extends towards the tragus, involving both soft-tissue and skeletal components. A male patient presenting with both maxillary jaw duplication and bilateral Tessier no. 7 clefts, which has been reported only twice in the literature, is described. Bilateral facial clefts, macrostomia and chondro-cutaneous remnants were noted, which were repaired and resected. With further growth, facial asymmetry and asymmetric facial nerve dysfunction became apparent. Radiographic examination showed an accessory maxillary jaw and a flattened and hypoplastic right coronoid process. A maxillary alveolar cleft was also present between the left second bicuspid and the second permanent molar. This case may represent an under-recognized phenotype with an unusual combination of maxillary jaw duplication, macrostomia, Tessier no. 7 clefts, and chondro-cutaneous remnants. A long-term follow-up of these patients is recommended as they often develop craniofacial deformities later in life.

Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as a minimally invasive surgical option for the treatment of medium to large vestibular schwannoma

The paper from Iacoangeli and his colleagues from Ancona and Rome in this issue of Acta Neurochirurgica is timely given the continuing controversy on best treatment options for vestibular schwannomas. Their report is on the preliminary experience with an old approach integrated with the endoscope. The case material includes ten cases of small and medium sized sporadic acoustic neuromas (five cases of 8 and 10 mm, five cases of 11–25 mm), selected on the basis of a favourable anatomy of the temporal bone. It is noteworthy, and rather exceptional in comparison to other’s experiences, that only three cases out of ten had a preoperative normal facial nerve function, while four cases of 11–25 mm had a House-Brackmann (HB) grade 3 and three cases of 10 and 20 mm had a HB grade 2, which makes 70 % of preoperative facial dysfunction in small and medium-size tumors. The surgical outcome was outstanding, with unchanged postoperative facial function (with the exception of the case with preoperative radiotherapy), only one case experiencing a hearing loss from AAORLHNS class B to C, and no instances of deafness. The removal of tumors from the internal auditory canal without a drill meatotomy in this series might have been favoured by a limited extension into the canal. The results on the hearing and facial nerve are superior to the results reported in the literature.

Static Treatment Modalities in Facial Paralysis: A Review

Facial nerve dysfunction can be attributed to several different causes. Several techniques have been developed to help treat the appearance and functional limitation of patients with sequelae of facial nerve dysfunction. There are options regarding static techniques of facial nerve injury treatment that range from facial musculature plication or shortening, fascial sling suspension via allograft or autograft, injectables and implants (ENDURAGen, AlloDerm, LifeCell, Bridgewater, New Jersey, USA) to techniques such as brow lift, open and endoscopic facelifts, and various eyelid surgeries with upper and lower lid procedures. In this review the various static facial nerve treatment modalities are discussed. A comprehensive review of the literature was performed detailing the most common static facial nerve treatment modalities and their known results and complications. There are individual issues associated with facial palsy for which individual solutions must be carefully tailored. Despite the presence of many surgical options, the results of reconstruction are limited. With the rapid advancement of surgical techniques, approaches to the management of facial nerve dysfunction have expanded, helping surgeons to improve and utilize alternative techniques for the treatment of patients with acute and chronic facial paralysis.

Imaging the Facial Nerve: A Contemporary Review

Imaging plays a critical role in the evaluation of a number of facial nerve disorders. The facial nerve has a complex anatomical course; thus, a thorough understanding of the course of the facial nerve is essential to localize the sites of pathology. Facial nerve dysfunction can occur from a variety of causes, which can often be identified on imaging. Computed tomography and magnetic resonance imaging are helpful for identifying bony facial canal and soft tissue abnormalities, respectively. Ultrasound of the facial nerve has been used to predict functional outcomes in patients with Bell's palsy. More recently, diffusion tensor tractography has appeared as a new modality which allows three-dimensional display of facial nerve fibers.

Imaging of Auriculotemporal Nerve Perineural Spread

Importance: Adenoid cystic carcinomas are relatively rare tumors, notorious for wide local infiltration and perineural spread. Perineural extension commonly occurs along branches of the trigeminal and facial nerves, and its presence represents a poor prognostic factor with implications upon treatment approach. Observations: We report a case of a 61-years-old female presenting with worsening left facial numbness and weakness. On magnetic resonance imaging, the patient was found to have perineural spread of a left parotid tumor along the auriculotemporal nerve. There was involvement of the V2 and V3 branches of the trigeminal nerve. An ultrasoundguided biopsy of the mass demonstrated adenoid cystic carcinoma. Conclusions and relevance: The auriculotemporal nerve may serve as a route for tumor spread, particularly in the setting of head and neck malignancy. Moreover, this particular suspicion should be raised when patients with known malignancy experience concomitant trigeminal (V) and facial (VII) nerve dysfunction.

Surgical management of posterior petrous meningiomas

Background and purposeThe aim of the study is to present our experience in the surgical treatment of posterior petrous meningiomas in regard to clinical presentation, surgical anatomy, complications and long-term functional postoperative results. Material and methodsA series of 48 consecutive patients operated on for posterior petrous meningiomas at the authors’ institution between 2002 and 2011 is reported. The main symptom on first admission was hypoacusis, impairment of the fifth cranial nerve and cerebellar ataxia. The tumour was found to be attached to the premeatal dura in 46%, the inframeatal dura in 29% and the postmeatal dura in 25% of cases. Tumour resection was categorized as grade I in 16 patients, grade II in 29 patients, grade III in 1 patient and grade IV in 2 patients, according to the Simpson classification system. The petrosal approach and retrosigmoid approach were suitable for posterior petrous meningiomas. ResultsPostoperative facial nerve dysfunction appeared in 8 and further deteriorated in 2 patients. Hearing function deteriorated after surgery in 8 and improved in 2 cases. Perioperative death occurred in two patients. Tumour recurrence was observed in two patients, and both underwent a second operation and postoperative stereotactic radiotherapy. ConclusionsSurgical treatment of posterior petrous meningiomas has become increasingly safe but these tumours still remain a surgical challenge because of the relatively high incidence of permanent complications associated with their removal. The site of displacement of the cranial nerves depending on the dural origin of the tumour has the most influence on the related difficulties in its removal.

Facial Nerve Schwannoma Arising From the Cerebellopontine Angle

A 74-year-old female suffered hearing disturbance in the right ear persisting for several years, followed by sudden onset of right facial nerve palsy. Her symptoms gradually worsened and neuroradiological imaging revealed a 4-cm cerebellopontine angle (CPA) tumor. Intraoperatively, the tumor was found to originate from the facial nerve. Total removal of the tumor was achieved, followed by a split hypoglossal-facial nerve anastomosis. Facial nerve schwannomas are rare and extremely difficult to preoperatively distinguish from vestibular schwannomas, especially if arising from the CPA and the internal auditory canal. However, preoperative diagnosis of facial nerve schwannomas is important because functional preservation of the facial nerve is more challenging than for vestibular schwannomas. Facial nerve palsy is one of the most unique symptoms in patients with facial nerve schwannomas, but is rare with vestibular schwannomas. Facial nerve schwannomas should be included in the differential diagnosis of CPA tumors with atypical clinical manifestations, and patients should be informed before surgery of the possibility of facial nerve dysfunction and the consequent need for facial nerve graft or reconstruction.

Radiologic Characteristics in a Case of Facial Nerve with Multisegment Involvement

Facial nerve schwannomas are rare benign neoplasms that originate from Schwann cells at any point along the course of the facial nerve. Only few studies have reviewed the natural course of the facial nerve schwannomas. The tumor is usually very slow-growing, and the growth rate was estimated as 0.7-2.6 mm/year. Clinically, the patients may present with wide range of facial dysfunction, ranging from asymptomatic to total facial palsy. Other possible symptoms include hearing loss, vestibular dysfunction or palpable parotid mass, depending on the size and location of the tumor. Implementation of high resolution magnetic resonance (MR) imaging with gadolinium enhancement has enabled detailed examination along the whole length of facial nerve, and multisegment involvement has been highlighted as a distinct feature of the facial nerve schwannomas. Computed tomography (CT) studies and MR imaging play pivotal roles in evaluating the extent of the benign tumor. Although surgical exploration and pathologic evaluation confirms the disease ex-tent, expectant management is a feasible treatment option and the timing of surgical intervention remains to be individualized to each patient. Thus, information provided by imaging studies is crucial for optimal treatment planning. We report a case of facial nerve schwannoma that involves multiple segments along the nerve from the internal auditory canal to intraand extra-temporal portions. CT and MR studies have demonstrated distinct features of the disease in different segments of the involved facial nerve.

Hearing preservation in patients with vestibular schwannoma treated with Gamma Knife surgery

Hearing loss after Gamma Knife surgery (GKS) in patients with vestibular schwannoma has been associated with radiation dose to the cochlea. The purpose of this study was to evaluate serviceable hearing preservation in patients with VS who were treated with GKS and to determine if serviceable hearing loss can be correlated with the dose to the cochlea. Forty patients with vestibular schwannoma with serviceable hearing were treated using GKS with a median marginal dose of 12.5 Gy (range 12.5-13 Gy) to the 50% isodose volume. Audiometry was performed prospectively before and after GKS at 1, 3, and 6 months, and then every 6 months thereafter. Hearing preservation was based on pure tone average (PTA) and speech discrimination (SD). Serviceable hearing was defined as PTA less than 50 dB and SD greater than 50%. The median cochlear maximum and mean doses were 6.9 Gy (range 1.6-16 Gy) and 2.7 Gy (range 0.7-5.0 Gy), respectively. With a median audiological follow-up of 35 months (range 6-58 months), the 1-, 2-, and 3-year actuarial rates of maintaining serviceable hearing were 93%, 77%, and 74%, respectively. No patient who received a mean cochlear dose less than 2 Gy experienced serviceable hearing loss (p = 0.035). Patients who received a mean cochlear dose less than 3 Gy had a 2-year hearing preservation rate of 91% compared with 59% in those who received a mean cochlear dose of 3 Gy or greater (p = 0.029). Those who had more than 25% of their cochlea receiving 3 Gy or greater had a higher rate of hearing loss (p = 0.030). There was no statistically significant correlation between serviceable hearing loss and age, tumor size, pre-GKS PTA, pre-GKS SD, pre-GKS Gardner-Robertson class, maximum cochlear dose, or the percentage of cochlear volume receiving 5 Gy. On multivariate analysis there was a trend toward significance for serviceable hearing loss with a mean cochlear dose of 3 Gy or greater (p = 0.074). Local control was 100% at 24 months. No patient developed facial or trigeminal nerve dysfunction. With a median mean cochlear dose of 2.7 Gy, the majority of patients with serviceable hearing retained serviceable hearing 3 years after GKS. A mean cochlear dose less than 3 Gy was associated with higher serviceable hearing preservation.

Intracapsular decompression or radical resection followed by Gamma Knife surgery for patients harboring a large vestibular schwannoma

Microsurgery is the primary treatment used for patients harboring a large vestibular schwannoma (VS). However, its outcome may lead to hearing impairment and facial nerve dysfunction particularly when resection is extended outside the tumor capsule. When surgery for a large VS consists of intracapsular resection and decompression, better preservation of facial and hearing function are obtained. In this study, the authors compared outcomes of intracapsular decompression followed by Gamma Knife surgery (GKS) with outcomes of standard microsurgery followed by radiosurgery. Between August 2003 and October 2008, 35 patients harboring large VSs (> 3 cm in diameter) were enrolled in this study. Eighteen patients underwent intracapsular decompression followed by GKS (Group I), and 17 patients underwent radical extracapsular resection followed by GKS (Group II). In all cases GKS was performed with a margin dose of 12 Gy. All patients were followed up for at least 3 years. All patients also underwent periodic audiography, electroneuronography (ENoG), MR imaging, and testing with the SF-36 form. The Student t-test and repeated ANOVA were used for statistical analysis. The mean ages of the patients (± SEM) in Groups I and II were 50 ± 3.0 and 49 ± 2.3 years, respectively. The female/male ratios were 8:10 in Group I and 7:10 in Group II. All patients had excellent facial function as measured according to the House-Brackmann Facial Grading System (Grade I or II) preoperatively. After the operation, 16 patients (89%) in Group I retained excellent facial function, whereas only 6 patients (35%) in Group II had excellent facial function (p < 0.01). In Group I, 11 patients had serviceable hearing, and all 11 (100%) retained hearing function after the operation. In Group II, 11 patients had serviceable hearing, but none retained hearing function postoperatively (p < 0.001). In Group I, the mean tumor volume (± SEM) was 17.5 ± 1.1 cm(3), and the postoperative volume was 9.35 ± 1.02 cm(3). In Group II, the mean tumor volume was 16.4 ± 0.95 cm(3), whereas the postoperative volume was 1.1 ± 0.14 cm(3) (p < 0.001). After GKS, the tumor volume was reduced to 5.12 ± 1.1 cm(3) and 0.9 ± 0.1 cm(3) in Groups I and II, respectively. No patients experienced adverse effects after GKS. The mean return-to-work times were 2.4 ± 0.16 and 33.4 ± 4.3 weeks in Groups I and II, respectively (p < 0.001). According to the results obtained using the 36-Item Short Form Health Survey (SF-36), patients in Group I enjoyed more significant improvements in quality of life than patients in Group II (p < 0.001). Intracapsular decompression followed by GKS afforded a better neurological outcome and quality of life than radical extracapsular resection followed by GKS. Further application of this approach in patients harboring large VSs seems warranted.

Postoperative Facial Nerve Function in Pediatric Parotidectomy

To analyze the incidence of postparotidectomy facial nerve dysfunction in pediatric patients and to evaluate the association between patient demographics or underlying pathology and functional outcomes. Case series with chart review. Tertiary-care pediatric hospital. We reviewed charts of patients younger than 18 years who underwent parotidectomy performed by a pediatric otolaryngologist between 1999 and 2011 at a tertiary pediatric center. Distributions of postoperative facial nerve dysfunction and timing of recovery were noted. Chi-square and t-test analyses were conducted to determine the association between demographics or pathology and functional outcomes. Forty-three patients met inclusion criteria: 41 underwent superficial parotidectomy, and 2 underwent total parotidectomy. Leading indications for surgery were atypical mycobacterial infection (16/43 [37.2%]) and first branchial cleft anomaly (8/43 [18.6]). The facial nerve was sacrificed in 1 (2%) patient with Ewing's sarcoma involving the nerve. The incidence of immediate facial nerve paresis was 21% (9/43), involving the marginal mandibular nerve (n = 7), buccal branch (n = 1), and both marginal mandibular and frontal branches (n = 1). Full recovery of nerve function in patients with paresis occurred within 1 month (n = 2), 2 months (n = 1), 6 months (n = 3), or 10 months (n = 2). Postparotidectomy paresis of distal branches of the facial nerve is a common occurrence in the pediatric population and should be discussed during preoperative evaluation. The risk is comparable to that of the adult population. Age, gender, and pathologic diagnosis were not predictive of postoperative nerve dysfunction.

Avoiding the complications of parotidectomy for benign disease: Intraoperative techniques

Parotidectomy for benign disease is the most common indication for parotidectomy. Surgical treatment of benign parotid disease remains a challenging undertaking that is associated with significant postoperative morbidity. The aim of this study is to present our experience with a series of 29 cases of superficial parotidectomies, regarding the incidence of the common complications and the techniques we used to reduce the incidence of these complications. We encountered 2 cases (6.9%) of facial nerve dysfunction; both were of a mild degree. We used Ligasure, loupes, nerve monitoring and certain intra operative techniques to achieve such a low incidence of facial nerve dysfunction. No case of Frey syndrome was encountered, due to the use of expanded poly tetrajluoroethylene sheets. Only 3 cases suffered partial anaesthesia of the ear pinna, as we preserved the trunk or the posterior branch of the great auricular nerve. Salivary fzstula occued in 17.2% of cases, and was mild and was treated conservatively. We recommend sticking to our techniques to decrease the postoperative complications of parotidectomy.

Rehabilitation of Central Facial Paralysis With Hypoglossal-Facial Anastomosis

To evaluate the ability of hypoglossal-facial nerve anastomosis to reanimate the face in patients with complete nuclear (central) facial nerve palsy. Retrospective case series. Tertiary academic medical center. Four patients with complete facial nerve paralysis due to lesions of the facial nucleus in the pons caused by hemorrhage due to arteriovenous or cavernous venous malformations, stroke, or injury after tumor resection. All patients underwent end-to-end hypoglossal-facial nerve anastomosis. Facial nerve function using the House-Brackmann (HB) scale and physical and social/well-being function using the facial disability index. The mean age of the patients was 53.3 years (range, 32-73). There were 3 female and 1 male patients. All patients had preoperative facial function HB VI/VI. With a minimum of 12 months' follow-up after end-to-end hypoglossal-facial anastomosis, 75% of patients regained function to HB grade III/VI, and 25% had HB grade IV/VI. Average facial disability index scores were 61.25 for physical function and 78 for social/well-being, comparable to results from complete hypoglossal-facial anastomosis after peripheral facial nerve palsy after acoustic neuroma resection. Patients with nuclear facial paralysis who undergo end-to-end hypoglossal-facial nerve anastomosis achieve similar degrees of reanimation compared with those with peripheral facial nerve palsies. This raises the intriguing possibility that reinnervation may also be of benefit in patients with the vastly more common facial dysfunction because of cortical stroke or injury.

Correlation between facial nerve functional evaluation and efficacy evaluation of acupuncture treatment for Bell’s palsy

To assess and grade facial nerve dysfunction according to the extent of facial paralysis in the clinical course of acupuncture treatment for Bell's palsy, and to observe the interrelationship between the grade, the efficacy and the period of treatment, as well as the effect on prognosis. The authors employed the House-Brackmann scale, a commonly used evaluation scale for facial paralysis motor function, and set standards for eye fissure and lips. According to the improved scale, the authors assessed and graded the degree of facial paralysis in terms of facial nerve dysfunction both before and after treatment. The grade was divided into five levels: mild, moderate, moderately severe, severe dysfunction and complete paralysis. The authors gave acupuncture treatment according to the state of the disease without artificially setting the treatment period. The observation was focused on the efficacy and the efficacy was evaluated throughout the entire treatment process. Fifty-three cases out of 68 patients with Bell's palsy were cured and the overall rate of efficacy was 97%. Statistically significant differences (P<0.01) were perceived among the efficacy of five levels of facial nerve dysfunction. Efficacy was correlated with the damage level of the disease (correlation coefficient r=0.423, P<0.01). The course of treatment also extended with the severity of facial nerve dysfunction (P<0.01). Differences exist in patients with Bell's palsy in terms of severity of facial nerve dysfunction. Efficacy is reduced in correlation with an increase in facial nerve dysfunction, and the period of treatment varies in need of different levels of facial nerve dysfunction. It is highly necessary to assess and grade patients before observation and treatment in clinical study, and choose corresponding treatment according to severity of damage of the disease.

Brow Ptosis after Temporal Artery Biopsy: Incidence and Associations

Temporal artery biopsy (TAB), performed for the diagnosis of giant cell arteritis, has a low reported rate of complications. One complication is damage to the facial nerve branches, which can result in brow ptosis and/or orbicularis oculi weakness. However, the incidence of facial nerve damage after TAB is unknown. Prospective, institutional review board-approved study of all TABs performed by 2 surgeons over a 17-month period. Seventy patients undergoing 77 TABs. Demographic data, including age, gender, and race/ethnicity, were collected for all patients. Frontalis and orbicularis oculi muscle function were evaluated pre- and postoperatively in all patients. The use of blood thinners, location of the incision, length of incision and biopsy, biopsy results, and procedure difficulty were recorded. Incidence of postoperative facial nerve damage, other complications, and rates of facial nerve recovery were evaluated. Analysis of variables was performed for any potential correlation with facial nerve damage. Incidence of facial nerve damage. Analysis included 75 biopsies performed in 68 patients. The majority of the patients were white (75.0%) and female (67.6%). The mean age was 72.6 years (range, 51-96). Postoperative facial nerve damage was found in 12 patients (16.0%) and 58.3% of these fully resolved at an average of 4.43 months (range, 1-6). Two patients (2.7%) had postoperative infections. There was no correlation with facial nerve damage and use of blood thinners, biopsy result, surgeon, procedure difficulty, incision length, or specimen length. The distance from the incision to both the orbital rim and the brow was significant: Incisions farther from the orbital rim and brow were less likely to have postoperative facial nerve damage. There is a 16.0% incidence of postoperative facial nerve damage with TABs, which recovers fully in over half of patients. Incisions closer to the orbital rim and brow were more likely to have postoperative facial nerve dysfunction. Incisions >35 mm from both the orbital rim and brow or above the brow were less likely to have postoperative brow ptosis. The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Surgery for vestibular schwannomas: a systematic review of complications by approach

Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications. MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery. The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5-3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5-3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches. The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.

Skull base meningiomas: Long-term results and patient self-reported outcome in 507 patients treated with fractionated stereotactic radiotherapy (FSRT) or intensity modulated radiotherapy (IMRT)

PurposeTo evaluate long-term outcome of high-precision photon radiotherapy in 507 patients with skull base meningiomas. Methods and materialsAt the time of radiation therapy, most patients presented with clinical symptoms including double vision, headache, nausea, trigeminal or facial nerve dysfunction or exophthalmus. In general tumors extended into several regions of the skull base. In 54%, prior neurosurgical intervention was performed, which was a partial resection or biopsy in 266 patients.Treatment was delivered using a 6MV linear accelerator or the tomotherapy system. Fractionated stereotactic radiotherapy (FSRT) was applied in 376 patients (74%) and intensity modulated radiotherapy (IMRT) in 131 patients (26%). A median total dose of 57.6Gy (range 25–68Gy) was prescribed in median (range 1.6–5Gy).To evaluate long-term toxicity as well as quality of life (QOL), we sent out a detailed questionnaire put together with special questions regarding the skull base location of the tumors. Special focus was long-term sequelae including visual deficits, cranial nerve deficits, headaches, fatigue or any other symptoms impairing overall QOL.The median follow-up time was 107months (range 1–270months). ResultsOverall treatment was well tolerated.Local control for the whole cohort was 95% at 5years and 88% at 10years. Patients with benign histology had significant higher local control than high-grade meningiomas. For benign meningiomas, local control was 91% at 10years. For high-risk meningiomas, local control was 81% at 5years and 53% at 10years. QOL was unchanged in 47.7% of the patients, and 37.5% showed improvement. Most patients reported an improvement of symptoms or steady state; in only few patients disorders worsened over time or side effects developed. ConclusionPrecision photon radiotherapy leads to long-term tumor control with minimal side effects, but also with preservation of QOL in patients with skull base meningiomas.

Facial Nerve Palsy following Parotidectomy

Objective: To determine the incidence of temporary and permanent facial nerve dysfunction in patients following parotidectomy in a UK teaching hospital. Method: All parotidectomies performed between January 1, 2009, and January 1, 2012, were analyzed using patients’ clinical and operative records. The grade of the surgeon, the operation, and the presence of a facial nerve monitor were recorded. House-Brackmann scores were recorded preoperatively and postoperatively. The length of time until recovery of facial nerve function was recorded. Results: Sixty-five parotidectomies were performed. The indications for surgery included pleomorphic adenoma 31%, warthin 23%, malignant disease 34%, and other 15%. Overall postoperative palsy rate was 43% (28/65). The most commonly affected branch was the marginal mandibular, 25% (16/65 %). Six were permanent and 22 temporary. The rate of facial nerve palsy was 44% for benign disease and 41% for malignant. Of the 6 permanent facial nerve palsies, 4 (67%) facial nerves were sacrificed because of preoperative disease involvement. MM was the branch commonly involved in these cases often due to Level 1 nodal clearance. In patients with temporary facial nerve palsy, mean recovery time was 4.3 months (range, 24 hours-12 months). Conclusion: Facial nerve palsy is a distressing and debilitating complication of parotidectomy, not only functionally but also emotionally and socially. Informed consent is an important part of preoperative assessment and accurate facial nerve palsies incidence rates should be discussed with patients.

Pediatric Parotidectomy: Postoperative Facial Nerve Function

Objective: The purpose of this study was to analyze the incidence of postparotidectomy facial nerve dysfunction in pediatric patients and to evaluate the association between patient demographics or underlying pathology and functional outcomes. Method: We retrospectively reviewed charts of patients under 18 years who underwent parotidectomy between 1999 and 2011 at a tertiary pediatric center by a pediatric otolaryngologist. Distribution of dysfunction and timing of recovery were noted. Chi-square and t-test analyses were conducted to determine association between demographics or pathology and functional outcomes. Results: Forty-three patients met inclusion criteria. Forty-one underwent superficial parotidectomy, and 2 underwent total parotidectomy. Leading indications for surgery were atypical mycobacterium (16/4 [37.2%]) and branchial cleft anomaly (8/43 [18.6%]). The incidence of immediate facial nerve paralysis was 2% (1/43).The incidence of facial nerve paresis was 21% (9/43), distributed in the marginal mandibular nerve (n = 7), buccal branch (n = 1), and marginal mandibular nerve and frontal branch (n = 1). Full recovery of nerve function in patients with paresis occurred by 1 month (n = 2), 2 months (n = 1), 6 months (n = 3), or 10 months (n = 2). No association was revealed between age, gender, or pathology and postoperative facial nerve function. Conclusion: Transient postparotidectomy paresis of distal branches of the facial nerve is common in the pediatric population and should be discussed in the preoperative evaluation. The risk is comparable to that of the adult population. Although malignant disease would seem to portend greater risk of dysfunction, underlying pathology was not predictive.