Facial Dysfunction Research Articles

Anomalous Extratemporal Facial Nerve in Oculoauriculovertebral Spectrum

Facial nerve dysfunction is common in oculoauriculovertebral spectrum (OAVS). However, the course of the nerve has rarely been described. A 23-year-old woman with OAVS underwent excision of microtic ear remnants in preparation for an osseointegrated prosthesis and suffered iatrogenic transection of the facial nerve-the pes anserinus was within the subcutaneous tissue 15 mm posterior and 15 mm cephalad to the external acoustic meatus. The patient underwent primary nerve repair and regained nearly complete preoperative function. When considering reconstruction for OAVS patients, clinicians should have a high index of suspicion for anomalous facial nerve anatomy.

Health-related quality of life in patients with major salivary gland carcinoma.

To evaluate the health-related quality of life (QOL) in patients with major salivary gland carcinoma (MSGC). 45 patients with MSGC completed the University of Washington Quality of Life (UWQOL) questionnaire. Results and factors influencing quality of life were analyzed using Mann-Whitney U test. 24 patients were male, 21 patients were female, and median age was 57years. 33 patients presented with early stage (UICC stage I or II) cancer. All patients had surgery as initial therapy. The UWQOL domains with the worst results were 'appearance', 'activity' and 'anxiety'. Factors influencing QOL were sex, tumor stage, comorbidities, follow-up time, tumor grade, postoperative radiation therapy and facial nerve dysfunction. Diagnosis and treatment of MSGC has influence on overall QOL. Postoperative radiation has the greatest impact on QOL. This is one of the largest study evaluating QOL in patients with salivary gland carcinoma using the UWQOL.

Evaluation of the prognostic value of multimodal intraoperative monitoring in posterior fossa surgery patients with cerebellopontine angle tumors.

The aim of this study was to compare the outcomes of four intraoperative monitoring approaches in order to compare their prognostic value in surgical complications of the facial nerve. This quasi-experimental study was conducted on 25 patients with Cerebellopontine Angle (CPA) tumors, who were hospitalized in the Valiasr Hospital, affiliated to the Arak University of Medical Sciences, Arak, Iran. The degree of the facial nerve paralysis was assessed based on the House-Brackmann (HB) facial nerve grading system. The Orbicularis oris and Oculi muscles were evaluated by electromyography (EMG) before and after the surgery. Monitoring the facial nerve was performed by the EMG, Facial Nerve Antidromic Potentials (FNAPs), Transcranial Electrical Stimulation (TES), and Brainstem Auditory Evoked Potentials (BAEPs) methods. The mean HB score was 0.36.6±5.83, indicating that the function of the facial muscle was abnormal in all the patients pre-surgery. The comparison of the four monitoring approaches six months after surgery showed that the predictive value of facial nerve TES was higher than the other approaches (P<0.005). Furthemroe, 4% of the patients showed normal function in the facial muscle after the surgery. In addition, 8%, 56%, and 32% of the patients had mild abnormalities, moderate to severe paralysis in the facial muscles, and severe facial nerve dysfunction, respectively. In summary, 36% of the patients showed a mild abnormalities in the follow-up period, and full recovery was observed in 28% of the cases. In conclusion, the transcranial motor evoked potential (TCMEP) is a useful method for monitoring the facial nerve during the surgery along with the continuous EMG recordings.

Parotid Quadrantectomy Is a Safe Management for Localized Pleomorphic Adenoma.

Pleomorphic adenoma is the most common benign tumor of the parotid gland and is classically treated with superficial or total parotidectomy. Less radical surgeries have been proposed to minimize the risk of facial nerve injury. The oncological safety of these procedures remains controversial. We conducted this study to evaluate the safety of superficial hemi-lobectomy (quadrantectomy). Retrospective analysis was conducted on the paraffin sections of archived superficial parotidectomy specimens from 11 male and 6 female patients (median age 33 years). The microscopic extent of extra-capsular extension was determined on pathological revision. In addition, prospective evaluation of 12 quadrantectomy procedures (M/F = 7/5, median age = 36 years) compared to 24 radical surgeries (M = F, median age = 40 years) regarding temporary and persistent facial nerve dysfunction on routine clinical assessment and recurrence rate. On retrospective pathological revision, pleomorphic adenomata had a median microscopic spread of 3 mm beyond capsule in paraffin sections (SD = 3.6). On prospective analysis with a median follow-up of 33 months (range = 18-54 months), quadrantectomy had similar relative risk of temporary facial nerve dysfunction evaluated at the immediate postoperative period as well as persistent nerve dysfunction assessed at 3 months (P = 0.701 and P = 0.902, respectively). Of the whole study population, one case of recurrence after total parotidectomy was observed at mid-term follow-up (P = 1.000). Parotid quadrantectomy is a safe management for smaller pleomorphic adenomata localized close to one of the two divisions of the facial nerve.

Complications in translabyrinthine surgery of vestibular schwannoma

Objective: To evaluate the risk of complications associated with tumor size and patient’s age in translabyrinthine vestibular schwannoma surgery.Methods: 700 patients with vestibular schwannoma primarily underwent translabyrinthine surgery between 1988 and 2014. Pre- and postoperative data were collected in a database and incidence of the postoperative complications cerebrospinal fluid leakage, meningitis, intracranial hemorrhage (ICH), facial nerve function and mortality were assessed and related to the tumor size and patient’s age and retrospectively evaluated.Results: The tumor size significantly influenced the incidence of ICH and facial nerve dysfunction whereas age was correlated to facial nerve outcome.Conclusions: The translabyrinthine approach is a safe surgical procedure with relatively low risks of complications. The tumor size was significantly associated with a higher risk of ICH and facial nerve dysfunction whereas age only influenced the facial nerve outcome.

Thirty-day perioperative outcomes in resection of cervical lymphatic malformations

IntroductionLimited information exists regarding short-term morbidity in the resection of lymphatic malformations. In order to make informed collaborative medical decisions, clinicians and families would benefit from information on 30-day outcomes and the expected course associated with surgical excision of lymphatic malformations. MethodsA retrospective chart review was conducted to develop a case series of patients who underwent resection of lymphatic malformation at a pediatric tertiary care center between June 1, 2007 and September 30, 2016. Demographic data, disease characteristics, operative details, post-operative care, and adverse events in the 30-day post-operative period were analyzed. Primary outcomes included facial nerve dysfunction, seroma formation, re-admission, and overall rate of any complications. Secondary outcomes included operative time, duration of stay, and duration of drain placement. ResultsForty-nine excisions were performed in 46 patients (21 male, 25 female). Median age was 5 years. All but 7 cases were performed as the initial primary intervention. Median operative time was 96 min (range 22–224). Higher stage lesions (3-5) were associated with a longer operative time (p = .03). Median length of stay was 2 days (range 0–35). Higher stage lesions were associated with an increased length of stay (p = .0004). Median duration of drain placement was 2 days (range 0–14), and was longer in higher stage lesions (p = .0002). Higher stage lesions (p = .002) and cases ultimately found to have residual disease (p = .019) were associated with an increased overall rate of complications; there was no association between cyst type and rate of complications. Seroma formation (31%) and transient facial nerve weakness (26%) were the two most common complications observed. There was no association between stage or cyst type and likelihood of seroma formation. Seromas resolved after a median duration of 3 months and transient facial nerve weakness resolved after a median duration of 2 months. 3 patients required return to the OR and 1 patient was readmitted. ConclusionThe overall rate of adverse events after surgical excision of cervical lymphatic malformations is relatively low. Increased rates of complications can be expected with higher stage. Similarly, for these higher stage lesions, a longer operative time, hospital stay, and duration of drain placement can be expected.

Ophthalmic Complications Following Acoustic Neuroma Resection.

Past studies have shown high rates of ocular complications with the need for ophthalmic surgery following acoustic neuroma resection (ANR). To determine the rates of ophthalmic complications, referrals, and surgery following ANR, and the factors associated with poor outcomes. A retrospective study of ophthalmic outcomes in patients who underwent ANR was conducted, following institutional review board approval. Surgical approach, tumor size, tumor characteristics, completeness of resection, postoperative House-Brackmann grades, ocular complications, referrals to ophthalmology, and ophthalmic treatments were recorded. Between 2007 and 2012, 174 patients underwent ANR. There were 3 surgical groups: retrosigmoid (n = 97), translabyrinthine (n = 59), and combined retrosigmoid and translabyrinthine (n = 18). Median tumor size was 2.2 cm. Postoperatively, 30% of patients had facial nerve dysfunction (House-Brackmann ≥3), which recovered to 19% by 1 mo and 8.6% by 1 yr following ANR. Fifty-six (32.9%) patients experienced ocular complications postoperatively, with lagophthalmos, dry eye, and blurry vision as the most common complications. Thirty-six (67.9%) of the patients who required ophthalmic treatment were managed nonsurgically, with just 13 (7.6%) patients requiring referral to an ophthalmologist. In total, only 9 (5.3%) patients received an ophthalmic procedure. Patients with tumors >2 cm, those undergoing combined retrosigmoid and translabyrinthine resection, and those with severe facial nerve dysfunction which did not improve in the first month following surgery were more likely to have poor ophthalmic outcomes. We present lower rates of ophthalmic complications following ANR than previously reported. Improved surgical technique, better postoperative eye care, and facial nerve monitoring most likely accounted for the improved ocular outcomes.

Facial nerve injury in neurosurgery: a rehabilitation potential of botulinum therapy

Surgical treatment of posterior cranial fossa and cerebellopontine angle tumors is associated with a risk of facial nerve dysfunction. The causes for facial muscle paresis include nerve compression by the tumor, destruction of the nerve structure by the tumor growing from nerve fibers, nerve injury during surgical removal of the tumor, etc. The first 3 months after facial nerve injury are a potential therapeutic window for the use of botulinum toxin type A (BTA). During this period, the drug is introduced both in the healthy side to improve the facial symmetry at rest and during mimetic movements and in the affected side to induce drug-induced ptosis. Post-paralytic syndrome develops 4-6 months after facial nerve injury. At this stage, administration of BTA is also an effective procedure; in this case, drug injections are performed on the affected side at small doses and symmetrically on the healthy side at doses doubling those for the affected side. BTA injections are mandatory in complex treatment of facial muscle paralysis.

Delayed facial nerve decompression for severe refractory cases of Bell\u2019s palsy: a 25-year experience

BackgroundThis study aims to assess the effectiveness of delayed facial nerve decompression for Bell’s palsy (BP).MethodsWe performed a retrospective case review of all patients having undergone facial nerve decompression for severe refractory BP between 1984 and 2009 at our tertiary referral center. Demographics, timing between onset of symptoms and surgical decompression, degree of facial nerve dysfunction pre- and post-operatively, follow-up length after surgery and postoperative complications were recorded. Facial nerve dysfunction was assessed using the House-Brackmann (HB) scale. Electroneuronography, electromyography and imaging results were assessed when available.ResultsEighteen patients had surgery between 21 and 60 days after onset of BP (group I), and 18 patients had surgery more than 60 days after onset of symptoms (group II). In group II, 11 patients had surgery between 61 and 89 days and 7 patients after 90 days. Groups I and II showed similar functional gain and rates of improvement to HB 3 or better (11/18 vs. 11/18, p > 0.05). In group II, patients operated 60 to 89 days after onset of BP showed a significantly higher rate of improvement to HB 3 or better (9/11 vs. 2/6, p = 0.049) with higher functional gain compared to those operated after 90 days (p = 0.0293).ConclusionsWhen indicated, facial nerve decompression for BP is usually recommended within the first 2 weeks of onset of facial paralysis. Nonetheless, our results suggest that patients with severe BP could benefit from decompression surgery within 90 days after onset of symptoms in the absence of an opportunity to proceed earlier to surgery. Further investigation is still required to confirm our findings.Trial registrationRetrospective registered. IRB# 2016–6154, CE 15.154 – CA

Особенности нервосберегающих операций при новообразованиях околоушно-жевательной области в детском и подростковом возрасте

A retrospective analysis was made in 40 patients who underwent the examination and treatment in Dmitry Rogachev National Research Center from January 2014 to July 2017. Median age at the time of surgery was 7 years (range 4 m.–18 years). All patients underwent a comprehensive examination to determine the operation type. Precision neurolysis and facial nerve preservation were carried out in all cases of the absence of macroscopic invasion of the tumor into nerve. Facial nerve monitoring during parotidectomy was used in 45% (n = 18) patients. Follow-up period varied between 3 months and 3.5 years. There was no recurrences. Frequency of immediate postoperative facial nerve paresis was 27.5% (n = 11), from which only 2,5% (n = 1) was permanent paresis. Type of surgery was the only one risk factor of postoperative facial nerve dysfunction. Thus, age, reoperation, closely spaced tumor, operating time and malignant tumors were not risk factors of intraoperative facial nerve injury. Nerve-preserving surgery showed its effectiveness, allowing the functional state of the facial nerve to be preserved without incidental injury to the radical removal of the neoplasm of the parotid chewing area especially important in childhood and adolescence.

The extent of surgery for benign parotid pathology and its influence on complications: A prospective cohort analysis

BackgroundThe surgical management of benign parotid tumors is aimed at complete extirpation of the mass with preservation of facial nerve function. There is a relative paucity of literature pertaining to complications after benign parotid surgery and related risk factors. We aim to critically review the outcomes following treatment of benign parotid pathology when surgery entailed either complete superficial parotidectomy (CSP), partial superficial parotidectomy (PSP) or extracapsular dissection (ECD). Material and methodsThis is a review of prospectively collected data of all parotidectomies performed between June 2006 to June 2016 for histologically-proven benign pathology of the parotid. Median follow-up time was 31.6weeks. ResultsA total of 101 parotidectomies were carried out on 97 patients (40 CSP, 56 PSP and 5 ECD). Pleomorphic adenoma (48.4%) and Warthin's tumors (32.7%) were the most common pathologies. Temporary facial weakness occurred after 7 operations (6.9%). Facial weakness was permanent in 4 cases (3.9%). The rates of sialocele and salivary fistula were 4.9% and 0.9%, respectively. Only one patient (0.9%) developed Frey Syndrome postoperatively. No significant associations between extent of parotid surgery and postoperative facial nerve dysfunction (p=0.674) or wound complications (p=0.433) were observed. Univariate analyses for potential contributing factors such as advanced age, smoking status, tumor location or histology did not demonstrate any increased risk with developing postoperative complications. ConclusionPartial superficial parotidectomy was associated with low rates of morbidity to the facial nerve and surgical wound. The results were comparable to complete superficial parotidectomy. We recommend offering patient partial superficial parotidectomy where appropriate and this is in line with the current trend of minimising surgical dissection, thereby potentially decreasing the risk of short-term and long-term complications.

Long-Term Facial Nerve Outcomes after Microsurgical Resection of Vestibular Schwannomas in Patients with Preoperative Facial Nerve Palsy

Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House-Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1-4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House-Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.

Congenital facial nerve dysfunction

Congenital facial nerve dysfunction

Retreatment of vestibular schwannoma with Gamma Knife radiosurgery: clinical outcome, tumor control, and review of literature.

OBJECTIVE Gamma Knife radiosurgery (GKRS) has become an accepted treatment for vestibular schwannoma, with a high rate of tumor control and good clinical outcome. In a small number of cases, additional treatment is needed. This retrospective study examines the clinical outcome, reproducibility of volumetric response patterns, and tumor control rate after administering a second GKRS to treat vestibular schwannomas. METHODS A total of 38 patients were included: 28 patients underwent a radiosurgical procedure as the initial treatment (Group 1), and 10 patients underwent microsurgical resection with adjuvant radiosurgery on the tumor remnant as the initial treatment (Group 2). The indication for a second GKRS treatment was growth observed on follow-up imaging. The median margin dose was 11.0 Gy for the first procedure and 11.5 Gy for the second procedure. Tumor control after retreatment was assessed through volumetric analysis. Clinical outcome was assessed through medical chart review. RESULTS Median tumor volume at retreatment was 3.6 cm3, with a median treatment interval of 49 months. All patients showed tumor control in a median follow-up period of 75 months after the second radiosurgical procedure. Volumetric tumor response after the second procedure did not correspond to response after the first procedure. After retreatment, persisting House-Brackmann Grade II facial nerve dysfunction was observed in 3 patients (7.9%), facial spasms in 5 patients (13%), and trigeminal nerve hypesthesia in 3 patients (7.9%). Hearing preservation was not evaluated because of the small number of patients with serviceable hearing at the second procedure. CONCLUSIONS Repeat GKRS after a failed first treatment appears to be an effective strategy in terms of tumor control. The volumetric response after a repeat procedure could not be predicted by the volumetric response observed after first treatment. This justifies considering repeat GKRS even for tumors that do not show any volumetric response and show continuous growth after first treatment. An increased risk of mild facial and trigeminal nerve dysfunction was observed after the second treatment compared with the first treatment.

Surgical management of primary parapharyngeal space tumors in 103 patients at a single institution

Purpose: To evaluate clinical features, diagnosis, surgical management, and treatment of parapharyngeal space tumors in a single-center setting due to limited knowledge of diagnosis and treatment of parapharyngeal space.Methods: Clinical records of 103 patients were included for the analysis of such clinical characteristics.Results: A total of 29 different types of tumors were diagnosed after operation: 20 benign and 9 malignant. With a follow-up of 31–84 months for 90 benign cases, 84 cases had no recurrence and 6 cases were lost to follow-up. In contrast, with an 8- to 51-month follow-up for 13 malignant cases, 11 patients died and 2 were lost to follow-up. Furthermore, for postoperative complications, 3 cases had Horner syndrome, 2 had hoarseness, 2 had facial nerve dysfunction, and each for other types.Conclusions: Surgery remains the first choice for the treatment of parapharyngeal space tumors, with the transcervical approach used for most tumors. Moreover, CT or MRI may assist in making decisions about operation schemes.

Parotid tumours: clinical and oncologic outcomes after microscope-assisted parotidectomy with intraoperative nerve monitoring.

SUMMARYTemporary and permanent facial nerve dysfunctions can be observed after parotidectomy for benign and malignant lesions. Intraoperative nerve monitoring is a recognised tool for the preservation of the nerve, while the efficacy of the operative microscope has been rarely stated. The authors report their experience on 198 consecutive parotidectomies performed on 196 patients with the aid of the operative microscope and intraoperative nerve monitoring. 145 parotidectomies were performed for benign lesions and 53 for malignancies. Thirteen patients treated for benign tumours experienced temporary (11 cases) or permanent facial palsy (2 cases, both of House-Brackmann grade II). Ten patients with malignant tumour presented with preoperative facial nerve weakness that did not improve after treatment. Five and 6 patients with malignant lesion without preoperative facial nerve deficit experienced postoperative temporary and permanent weakness respectively (the sacrifice of a branch of the nerve was decided intraoperatively in 2 cases). Long-term facial nerve weakness after parotidectomy for lesions not directly involving or originating from the facial nerve (n = 185) was 2.7%. Patients treated for benign tumours of the extra facial portion of the gland without inflammatory behaviour (n = 91) had 4.4% facial nerve temporary weakness rate and no permanent palsy. The combined use of the operative microscope and intraoperative nerve monitoring seems to guarantee facial nerve preservation during parotidectomy.

Fractionated Stereotactic Radiation Therapy for Large Vestibular Schwannomas

Fractionated stereotactic radiotherapy (FSRT) is a well-established and effective treatment for vestibular schwannomas (VS). For larger VSs with brainstem compression, debulking surgery is often performed prior to radiation to reduce treatment volume and to decrease potential radiation damage to the brainstem and cranial nerves V and VII. The goal of this study was to retrospectively evaluate the clinical outcomes of patients with large VSs treated with FSRT at our institution. 60 patients were identified who had VSs treated with FSRT between 2009 and 2016. All patients were treated on a Novalis TX linear accelerator platform with a dose of 25 Gy in 5 fractions. Patients were categorized by Koos stage into small VS group (Koos stage 1 or 2) and large VS group (Koos stage 3 or 4). Outcomes of tumor control (freedom from radiographic progression), degree of trigeminal nerve dysfunction, degree of facial nerve dysfunction (using the House-Brackmann scale), and brainstem toxicity (radiographic necrosis) were assessed prior to treatment and at the most recent follow-up. The dose of radiation to the VS, cranial nerves, and brainstem (Dmax, D0.5cc, and V23) were evaluated in order to identify correlated late toxicity. The number of patients experiencing symptomatic pseudoprogression at any point post treatment was also recorded for each group. Clinical and radiographic data was available for 59 of the patients, and median follow-up was 33.5 months for the small VS group (range 5 – 76 months) and 15 months for the large VS group (range 2 – 49 months). The median treated volume for the small VS group was 0.9 cc (range 0.1 – 3.4 cc) and 5.2 cc for the large VS group (range 1.4 – 22.6 cc). The median brainstem Dmax was 16.5 Gy for the small VS group (range 1.1 – 28.4 Gy) and 26.1 Gy for the large VS group (range 21.7 – 30.4 Gy). The median D0.5cc was 4.75 Gy for the small VS group (range 0 – 21.7 Gy) and 20.5 Gy for the large VS group (range 9 – 23.8 Gy). The median V23 was 0.18 cc for the small VS group (range 0 – 0.33 cc) and 0.18 cc for the large group (0 – 0.62 cc). Tumor control was 100% in both groups, and there was no evidence of brainstem necrosis in either group. No patients experienced progression of trigeminal symptoms. Freedom from new facial neuropathy was 97.6% in the small VS group vs. 100% in the large VS group (p=0.99). Rates of pseudoprogression were 4.8% in the small VS group vs. 11.8% in the large group (p=0.13). Debulking surgery was performed in 2 of 42 patients in the small VS group and in 10 of 18 patients in the large VS group and was not found to affect any of these clinical outcomes. Patients with large VSs or with brainstem compression did not experience worse rates of tumor control, brainstem necrosis, pseudoprogression, or neuropathy compared to those with small VSs. Outcomes were similar for those treated with or without surgery, suggesting that FSR alone is a reasonable treatment option for patients with large VSs compressing the brainstem.

Population-Based Study of Stereotactic Radiosurgery or Fractionated Stereotactic Radiation Therapy for Vestibular Schwannoma: Long-Term Outcomes and Toxicities

To examine long-term local control of vestibular schwannoma and side effects in patients treated with stereotactic radiosurgery (SRS) and fractionated stereotactic radiation therapy (SRT) in British Columbia. From August 1998 to May 2009, 207 patients were treated with radiation therapy (RT) at British Columbia Cancer Agency. 136 (66%) received SRS, and 71 (34%) received SRT. Dose prescriptions were 50Gy/25 fractions for SRT and 12Gy/1 fraction for SRS. Our multidisciplinary provincial neuro-stereotactic conference recommended SRT for tumors >3cm and for patients with serviceable hearing (Gardner-Robertson classes I and II). Median follow-up was 7.7years to the last MRI and 6.4years to the last clinical assessment. Local control for SRS versus SRT was 94% versus 87% at 5years and 90% versus 85% at 10years (P=.2). Five- and 10-year actuarial rates of RT-induced trigeminal nerve dysfunction were 25% and 25% after SRS, compared with 7% and 12% after SRT (P=.01). Five- and 10-year actuarial rates of RT-induced facial nerve dysfunction were 15% and 15% after SRS, versus 13% and 15% after SRT (P=.93). In the 49 patients with serviceable hearing at baseline who were treated with SRT, hearing preservation was 55% at 3years, 37% at 5years, and 29% at 7years. In multivariable analysis, better pretreatment ipsilateral pure tone average was significantly associated with hearing preservation (hazard ratio 1.03; 95% confidence interval 1.00-1.07; P=.04). Both SRS and SRT provided excellent long-term local control of vestibular schwannoma. Stereotactic radiosurgery was associated with higher rates of trigeminal nerve dysfunction. Even with a fractionated course, hearing preservation declined steadily with long-term audiometric follow-up.

Incidence of facial nerve sacrifice in parotidectomy for primary and metastatic malignancies

IntroductionThe parotid gland may become involved by primary parotid malignancies and secondarily by metastases from other primary sites. Surgical resection of these tumors can be technically challenging due to the intimate relationship of the parotid gland and the facial nerve. The primary aim of this project was to determine the incidence of facial nerve sacrifice in parotidectomy for primary and secondary malignancies of the parotid. MethodsA retrospective chart review of was performed. Patients who received parotidectomy with final pathology consistent with a malignant neoplasm were included. The primary outcome studied was necessity for facial nerve sacrifice. Co-variates included preoperative facial nerve function, preoperative pain, superficial versus total parotidectomy and pathologic diagnosis. Univariate analysis was performed using student t-test to determine odds ratios. ResultsWe identified 75 patients who had a parotidectomy for a malignant process in our review. 30 patients had facial nerve sacrifice: 14 total and 16 partial sacrifices. Patients were more likely to require facial nerve sacrifice when they presented with preoperative facial nerve dysfunction [100% vs 19.6%, p=0.0006, OR 154.3, CI (8.66–2750.9)], pre-op pain [76.5% vs. 29.3%, p=0.001, OR 7.84, CI (2.23–27.50)], and required excision of both superficial and deep lobes of the parotid gland [64.9% vs 15.8%, p=0.0001, OR 9.85, CI (3.27–29.66)]. ConclusionOur data illustrates that many patients with normal facial nerve function, even in the setting of malignancy, can have their facial nerve preserved. Pain, deep lobe involvement and preoperative facial nerve dysfunction are associated with an increased risk of needing at least partial facial nerve sacrifice in the setting of parotid gland malignancies.

Clinicopathologic and Surgical Study of Pleomorphic Adenoma of the Parotid Gland: Analysis of Risk Factors for Recurrence and Facial Nerve Dysfunction

To determine whether clinicopathologic or surgical features are risk factors for recurrence and facial nerve dysfunction in pleomorphic adenoma (PA) of the parotid gland. The records of 198 patients surgically treated for a PA of the parotid gland from 1999 through 2013 were retrospectively reviewed to identify patients who developed a tumor recurrence. The Fisher exact test and Mann-Whitney U test were used to analyze patient characteristics between recurrent and non-recurrent PAs. Logistic regression was used to determine the risks of recurrence and facial nerve dysfunction. Twenty-three patients (11.6%) developed a recurrence. Patients with tumor recurrence were notably younger than patients without recurrence. Of the 14 patients who underwent enucleation, 11 (78.6%) developed residual disease, as did 10 of 165 patients (6%) managed by a superficial parotidectomy (P<.0005). Furthermore, the risk of residual disease was 9.3 to 21.6 times higher in patients who underwent enucleation than in those who underwent a total or superficial parotidectomy. For tumor histology, recurrence was observed in 3 (15.8%) of the 19 cellular types, 18 (11.5%) of 157 classic cases, and 1 (4.8%) of 21 myxoid cases (P=.5). The risk of recurrence with positive resection margins was 49 times higher than with negative margins (P=.001). Young age, enucleation, and positive margins are risk factors for residual pleomorphic adenoma, and surgical technique and histomorphologic features are associated with increased facial nerve dysfunction.