Facial Trunk Research Articles

Functional parotid surgery for removal of benign parotid tumors

Objective: To evaluate the effect of the application of functional parotid surgery for removal of benign parotid tumors and the prevention of Frey syndrome. Method: One hundred and fifty-six cases with benign tumor were underwent functional regional parotidectomy. All tumors were smaller than 4 cm in diameter. The safe surgical margin was 5 mm when the tumors were less than 2 cm in diameter, while the safety margin was 1 cm for the tumors diameter between 2-4 cm. 156 cases were assigned to two groups(A and B). The absorbable hemostatic sponge was placed between the surface of parotid gland and skin flap after tumor resection in group A，while no sponge was placed in group B. Postoperative followup was 12-24 months. Result: No compression bandage was performed. No patient had recurrence or salivary fistula. There were 3 cases of temporary facial paralysis, of which 2 cases recovered from the mandibular marginal branch injury within 1 month and 1 case recovered from the facial nerve trunk injury within 6 months. Compared with group B 15.38%(12/78)，the incidence of Frey syndrome was significantly decreased in group A 3.85%（3/78）.χ₂=5.728, P<0.05. Conclusion: The removal of benign parotid tumors by functional parotid surgery can effectively preserve the function of residual gland and reduce complication. Intraoperative implantation of absorbable hemostatic sponge between parotid gland and skin flap can reduce the incidence of Frey syndrome.

Variation of the Great Auricular Nerve and Prediction of the Facial Nerve Trunk Size.

This study aimed to reveal the anatomical variation in the great auricular nerve (GAN) and the correlation between the size of the GAN and the facial nerve trunk (FNT), so as to aid surgeons to perform safe facelift surgery and parotidectomy. Sixteen human cadavers were studied on 16 left and 15 right facial sides. The GAN's branching patterns, location, and the mean width of the GAN and FNT were measured. The average distance where the nerve emerged from under the sternocleidomastoid muscle was 87.61 ± 12.13 mm when measured perpendicular to the Frankfort horizontal plane. The branching pattern of the GAN could be classified into 5 types of which the most common was type 3 (30.77%), where the GAN divided into the anterior (superficial) and posterior branches, and then the deep branch originated from the posterior branch of the GAN. The mean width of the GAN and FNT from all the dissections was 3.26 ± 0.67 mm and 3.36 ± 0.71 mm, respectively. There was a significant correlation between the width of the nerves on both facial sides (right: r =0.740, P =0.002; left: r = 0.839, P < 0.001). This study revealed the anatomical variation and the width of the GAN, which can strongly predict the width of the FNT. This should be taken into consideration during facelift surgery and parotidectomy, especially in patients with a small GAN to prevent iatrogenic injury to the small FNT.

Value of Visualization of the Intraparotid Facial Nerve and Parotid Duct Using a Micro Surface Coil and Three-Dimensional Reversed Fast Imaging With Steady-State Precession and Diffusion-Weighted Imaging Sequence.

To explore the value of micro surface coil combined with three-dimensional reversed fast imaging with steady-state precession and diffusion-weighted imaging (3D-PSIF-DWI) in displaying intraparotid facial nerves and parotid ducts. In total 24 healthy volunteers with no parotid disease underwent scanning of head and neck coil and 4-cm micro surface coil combined with 3D-PSIF-DWI prospectively. The obtained original images were processed through maximum intensity projection, multiplanar reconstruction, and curved planar reconstruction. The magnetic resonance imaging (MRI) signal characteristics of intraparotid structure, the subjective score of image quality, the signal intensity ratio (SIR) of facial nerve/parotid tissues (SIRN), and SIR of parotid duct/parotid tissues (SIRD) were calculated, and the displaying rates of the facial nerves and parotid ducts were observed. The Wilcoxon matched-sample signed rank sum test was used to compare the scores of head and neck coil and micro surface coil 3D-PSIF-DWI sequence images; paired-t test was used to compare SIRN and SIRD of the 2 groups; χ test was used to compare the displaying rate of the facial nerves and parotid ducts in the 2 groups. In total 24 volunteers successfully underwent MRI scan of parotid glands. On 3D-PSIF-DWI images, the parotid gland showed slightly low signal intensity, muscle tissues showed intermediate intensity, while the vessels showed slightly high or equal intensity; the parotid segment of facial nerves was displayed as a tortuous line-like high intensity, and the parotid duct showed curved high intensity, lymph nodes showed kidney-shaped, oval, or spindle-shaped high intensity. The subjective scores for head and neck coil and small coil images were (2.2 ± 0.7) and (1.5 ± 0.3) respectively, with significant difference (Z = -2.714, P = 0.007), and image quality of micro surface coils was better than that of head and neck coil. The SIRNs of head and neck coil and micro surface coil images were 1.6 ± 0.5 and 2.2 ± 1.1 respectively; the SIRDs were 2.0 ± 0.6 and 2.8 ± 1.4 respectively, which showed significant differences (t = 3.440, 3.639 respectively, P value was 0.001, 0.001 respectively). All facial nerve trunks could be displayed by head and neck coils and micro surface coils. On head and neck coil images, 46 sides of temporofacial division, 47 sides of cervicofacial division, 21 sides of temporal branches, 22 sides of zygomatic branches, 29 sides of buccal branches, 30 sides of marginal mandibular branches, 32 sides of cervical branches, and 28 sides of the parotid duct could be displayed. On micro coil images, 48 sides of temporofacial division, 48 sides of cervicofacial division, 37 sides of temporal branches, 39 sides of zygomatic branches, 42 sides of buccal branches, 35 sides of marginal mandibular branches, 46 sides of cervical branches, and 28 sides of the parotid duct could be displayed. The display number of first branches of the intraparotid facial nerve by these 2 methods had no significant difference, the number of the secondary branches and parotid duct had significant differences. Micro surface coil surpassed parotid MRI with 3D-PSIF-DWI sequence than neck coil, which can simultaneously clearly display the trunk and branches of the intraparotid facial nerves and parotid ducts.

Early Masseter to Facial Nerve Transfer May Improve Smile Excursion in Facial Paralysis.

Masseter-to-facial nerve transfer has been shown to be an effective and safe treatment option in patients with acute and subacute facial palsy. The present article aims to characterize whether there is a benefit in early nerve transfers while minimizing other confounding variables; we present a study that consist of only patients with complete facial nerve paralysis resulting from intratemporal facial nerve resections. Between 2012 and 2016, 7 masseter-to-facial nerve transfers were performed for complete facial nerve palsy after intratemporal proximal nerve resections. Pre- and postoperative photographic and video evaluations were performed using both the Sunnybrook facial grading scale and the MEEI FACE-gram software for more objective metric measurements. Statistical analysis was performed to determine which patient and surgical variables had significant effects on outcome. Mean 14-month follow-up revealed that patients who underwent nerve transfer prior to 6 months' denervation achieved postoperative oral commissural excursion of 11.1 mm versus 6.5 mm in patients who underwent nerve transfer after 6 months (P = 0.003). Performing masseter-to-facial nerve transfer to the main facial nerve trunk resulted in a significantly higher improvement in the modiolus-philtral ratio (31.6% versus 6.1%) than selective transfer in patients (P = 0.01) at the latest follow-up. Early masseter-to-facial nerve transfers, before 6 months of palsy duration, can potentially improve smile excursion and symmetry of open mouth smile. Additionally, truncal coaptations may provide improved tone over coapting to selective facial nerve branches. These findings necessitate larger studies regarding the importance of denervation time with fifth-to-seventh nerve transfers.

Fetal anatomy of the facial nerve trunk and its relationship with posterior auricular artery.

The aims of the study are to define anatomy of the facial nerve (FN) and its main trunks as well as their relationship with the posterior auricular artery in fetal period to evaluate the data for regional surgery in newborns and young infants. Formalin-fixed 34 fetuses from anatomy laboratory collection with a mean gestational age of 26.4 ± 4.6 (20-36) weeks were dissected. Parameters regarding the presence of major or minor trunks, width, length, branching pattern of FN were evaluated according to side, gender and trimester. The positional relationship of posterior auricular artery with the FN trunk was inspected. On all sides only the major trunk of the FN was detected. For length and width parameters, there was no statistically significant difference for side and gender except for trimester. Linear functions were found as 0.329 + 0.025×weeks for width and 5.264 + 0.185×weeks for length. There are statistically significant linear relationships between width and length of the FN trunk and week parameters as r = 0.507, p < 0.001 and r = 0.484, p < 0.001, respectively. Posterior auricular artery crossed FN trunk laterally in 42 of 53 sides, medially in 9 sides while it was puncturing it proximally in 2 sides. In all cases, it was in close contact to the FN trunk. FN trunk showed bifurcation in 82% and trifurcation in 18%. Dimensions of FN trunk, growth ratio and linear functions can be beneficial in understanding the fetal growth of FN trunk and its usage for grafts. Data about the relationship of the posterior auricular artery with FN trunk may be crucial in avoiding iatrogenic injuries during surgery in early ages.

Perfusion maintains functional potential in denervated mimic muscles in early persistent facial paralysis which requires early microsurgical treatment - the histoanatomic basis of the extratemporal facial nerve trunk assessing axonal load in the context of possible nerve transfers.

Early persistent facial paralysis is characterized by intact muscles of facial expression through maintained perfusion but lacking nerve supply. In facial reanimation procedures aiming at restoration of facial tone and dynamics, neurotization through a donor nerve is performed. Critical for reanimating target muscles is axonal capacity of both donor and recipient nerves. In cases of complete paralysis, the proximal stump of the extratemporal facial nerve trunk may be selected as a recipient site for coaptation. To further clarify the histological basis of this facial reanimation procedure we conducted a human cadaver study examining macro and micro anatomical features of the facial nerve trunk including its axonal capacity in human cadavers. Axonal loads, morphology and morbidity of different donor nerves are discussed reviewing literature in context of nerve transfers. From 6/2015 to 9/2016 in a group of 53 fresh frozen cadavers a total of 106 facial halves were dissected. Biopsies of the extratemporal facial nerve trunk (FN) were obtained at 1 cm distal to the stylomastoid foramen. After histological processing and digitalization of 99 specimens available, 97 were selected eligible for fascicle counts and 87 fulfilled quality criteria for a semi-automated computer-based axon quantification software using ImageJ/Fiji. An average of 3.82 fascicles (range, 1 to 9) were noted (n = 97). 6684±1884 axons (range, 2655- 12457) were counted for the entire group (n = 87). Right facial halves showed 6364±1904 axons (n = 43). Left facial halves demonstrated 6996±1833 axons (n = 44) with no significant difference (p = 0.73). Female cadavers featured 6247±2230 (n = 22), male showed 6769±1809 axons (n = 40). No statistical difference was seen between genders (p = 0.59). A comparison with different studies in literature is made. The nerve diameter in 82 of our specimens could be measured at 1933±424 μm (range, 975 to 3012). No donor nerve has been described to match axonal load or fascicle number of the extratemporal facial nerve main trunk. However, the masseteric nerve may be coapted for neurotization of facial muscles with a low complication rate and good clinical outcomes. Nerve transfer is indicated from 6 months after onset of facial paralysis if no recovery of facial nerve function is seen.

Borle's triangle: A reliable anatomical landmark for ease of identification of facial nerve trunk during parotidectomy

PurposeAn accurate understanding of the anatomy, identification and preservation of facial nerve is critical in performing successful functional parotidectomies. The current literature is replete with inconsistencies of various landmarks when used alone for identification of facial nerve trunk (FNT). The purpose of the paper is to introduce a new anatomical triangle, Borle's triangle (BT) for safer and reliable operative identification of FNT during parotodectomies. Patients and methodsBetween Aug 2014 and Dec 2017, twelve patients who reported with unilateral disease of the parotid gland with intact facial nerve function who underwent superficial or complete parotidecomies were included in the study. BT was conceptualized by intersection of three imaginary lines drawn along anatomical structures and forming a triangle comprising of angles a, b and c. ResultsIntroperatively, BT helped reliably identify the FNT and its branches successfully in all the cases. The mean distance of FNT from angle b was found to be 12.18 ± 1.7 mm. Transient neurological deficits with one or more branches were seen in four cases whilst, one case had transient deficit with all the five peripheral branches. All of them spontaneously resolved completely by the end of three months post operatively. ConclusionsWhen used in isolation, substantial variations exist in distances measured from anatomic landmarks to the main FNT in the literature. The BT utilizes three commonly used anatomical landmarks. It predictably helps in proper anatomic orientation, identification and preservation of FNT and branches with ease in parotidectomies.

Retrograde approach for parotid benign tumours: A review

IntroductionParotidectomy for benign tumours is usually performed after facial nerve trunk discovery through an anterograde approach (AA) of the nerve. More recently, a retrograde approach (RA) toward the facial nerve, which begins on the facial nerve branches and ends on the nerve trunk, has been described. A literature review of the RA was conducted to evaluate the RA and to compare it with AA. MethodsA literature review was conducted for the years 1980 through 2016. Nine studies out of 216 were included, including 558 parotidectomies and 370 RA. We studied the operative time (OT), the postoperative complications including facial paralysis (FP), tumour recurrences, and possibilities for reoperation. ResultsOperative time was shorter in RA than in AA. Transitory FP significantly less frequent in RA than in AA in only one studies and not significantly in four studies. Incidence of Frey syndrome was similar in RA and AA. Tumour relapses were reported in 1.8% of cases with RA, comparable to AA. ConclusionRetrograde parotidectomy is recommendable. OT was significantly shorter for the RA. The FP rate was lower for RA than for AA, but the difference was not significant. The recurrence rate appeared to be similar between RA and AA. Possibilities of reoperation were better after RA.

P128. Can the extratemporal facial nerve been visualized by ultrasound?

Introduction Many peripheral nerves can be visualized by ultrasound for diagnostic and therapeutic interventions. The possibility of visualizing the facial nerve (FN) has been considered, but not jet proven scientifically. This study describes the first systematic evaluation of sonografic facial nerve vizualisation of the whole extratemporal facial nerv. Methods Eight cadaveric hemifaces were evaluated by means of high frequency ultrasound with two linear (13 MHz and 22 MHz) and a convex transducer (6.6 MHz), in order to detect the extratemporal course of the FN starting from its exit at the stylomastoid foramen: the main trunk, the parotid plexus between the two parts of the parotid gland (Image1), the distal branches terminating into the orbicularis oculi and the zygomatic major muscle. Ultrasound-guided color injections and FN dissection were performed to confirm the results (Image2). Results The main trunk of the FN, as it exits the stylomastoid foramen, was correctly stained in 75%, the parotid plexus in 100%. The branches innervating the orbicularis oculi muscle were stained in 100% and the branches innervating the zygomatic major muscle in 86% hemifaces, after 1 was withdrawn due to insufficient image quality. Conclusions Through our novel approach of high-resolution ultrasonography we could identify the various portions of the extratemporal FN, including its main trunk leaving the stylomastoid foramen, in an accurate and reproducible way. This might be a way to visualize and locate nerve damage.

Electroacupuncture at facial acupoints combined with electrical stimulation on the auricular vagus nerve points for 60 cases of chloasma

ObjectiveTo observe the clinical efficacy of electroacupuncture at facial acupoints combined with electrical stimulation on the auricular vagus nerve points for treatment of chloasma. MethodsSixty patients with chloasma were selected. According to acupoint selection along facial nerve trunk initially created by professor Gao Wei-bin, Yìfēng (翳风 TE 17), Shàngguān (上关 GB 3) Sīzhúkōng (丝竹空 TE 23), temporal branches, Xiàguān (下关 ST 7) Sìbái (四白 ST 2), zygomatic branches, Qiānzhèng (牵正) Quánliáo (颧髎 SI 18), zygomatic branches, Jiáchē (颊车 ST 6) Chéngjiāng (承浆 CV 24), buccal branches, and Hégŭ (合谷 LI 4). The auricular vagus nerve acupoints was added additionally (two distribution points in each cavity of auricular concha were selected). Electroacupuncture was conducted for 30 min/time, once a day, and 6 times/week. One day was free from treatment between 2 weeks. Treatment for 4 weeks was 1 course of treatment, and the effect was observed after 1 course. ResultsCured: 39 cases, markedly effective: 13 cases, effective: 6 cases, ineffective: 3 cases. The cure rate was 65%, and the total effective rate was up to 95.0%. ConclusionThe curative effect of electroacupuncture at facial acupoints combined with electrical stimulation on the auricular vagus nerve points for treatment of chloasma was satisfactory.

Evaluation of the Possible Neurotoxic Effect of the Bone Cement on the Facial Nerve: An Experimental Study.

ObjectivesTo investigate neurotoxic effect of bone cement (BC) on facial nerve by using electrophysiological and histopathological methods.MethodsThis study included 20 male albino Wistar rats, divided into four equal groups. Group A was designed as the control group, while group B was sham group. In the group C, BC solution was dropped onto the facial nerve trunks of rats and washed with physiological saline after 5 seconds. In the group D, BC solution was dropped onto the facial nerve trunks of rats and after allowing 5 minutes to dry, wounds were closed. Pre- and postoperative (on 4th week) evoked electromyography (EMG) measurements were done. For histopathological assessments, the rats were euthanized and tissue samples of facial nerve and surrounding areas were collected.ResultsAccording to the wave amplitude levels of evoked EMG, postoperative amplitude levels of group D were significantly decreased, compared to preoperative amplitude levels (P=0.043). We found no statistically significant difference in inflammation among the groups. In none of the groups, foreign body reaction and granulation tissue were not detected in any of the groups. In addition, degeneration in axon, myelin, or perineural nets was not detected in any of the groups.ConclusionThis study results suggest that BC has no direct toxicity on facial nerve, while it has indirect effects, by decreasing amplitude. Therefore, we conclude that direct contact of BC with nerve should be avoided, and the area should be cleaned by aspiration or washing with physiological saline in case of contact.

Posterior auricular artery as a novel anatomic landmark for identification of the facial nerve: A cadaveric study.

Despite preservation techniques, performing a parotidectomy carries a transient facial nerve dysfunction rate in up to 65% of cases and a permanent facial nerve weakness rate of 4%-7%. The lateral aspect of the face and neck was exposed in 5 cadaveric heads (10 sides). The relationship of the posterior auricular artery (PAA) and the facial nerve was studied and recorded and descriptive measurements were taken. In all specimens, the facial nerve trunk crossed the PAA inferior to the stylomastoid foramen and could be identified precisely by tracing the PAA proximally. The distance from the cross point of the PAA and the facial nerve to the external meatal cartilage was 5.2 ± 0.2 mm. The PAA represents a potential new anatomic landmark for facial nerve identification at the main trunk.

Valproic Acid Promotes Survival of Facial Motor Neurons in Adult Rats After Facial Nerve Transection: a Pilot Study.

Valproic acid (VPA), a medication primarily used to treat epilepsy and bipolar disorder, has been applied to the repair of central and peripheral nervous system injury. The present study investigated the effect of VPA on functional recovery, survival of facial motor neurons (FMNs), and expression of proteins in rats after facial nerve trunk transection by functional measurement, Nissl staining, TUNEL, immunofluorescence, and Western blot. Following facial nerve injury, all rats in group VPA showed a better functional recovery, which was significant at the given time, compared with group NS. The Nissl staining results demonstrated that the number of FMNs survival in group VPA was higher than that in group normal saline (NS). TUNEL staining showed that axonal injury of facial nerve could lead to neuronal apoptosis of FMNs. But treatment of VPA significantly reduced cell apoptosis by decreasing the expression of Bax protein and increased neuronal survival by upregulating the level of brain-derived neurotrophic factor (BDNF) and growth associated protein-43 (GAP-43) expression in injured FMNs compared with group NS. Overall, our findings suggest that VPA may advance functional recovery, reduce lesion-induced apoptosis, and promote neuron survival after facial nerve transection in rats. This study provides an experimental evidence for better understanding the mechanism of injury and repair of peripheral facial paralysis.

Electrical stimulation promotes regeneration and re-myelination of axons of injured facial nerve in rats

ObjectiveTo investigate the effects of electrical stimulation (ES) on the nerve regeneration and functional recovery of facial expression muscles in facial nerve defect rats.MethodsSixty rats were surgically introduced with a 1-cm defect on the right facial nerves and evenly divided into the Surgery group (Group A, the main trunk of the right facial nerve was surgically cut-off with a 1.0 cm at the foramina stylomastoideum) and the Surgery + ES group (Group B). Twenty normal rats were as normal control group (without receiving surgery or ES). For rats in group B, the orbicularis oris muscle of the right paralyzed face was stimulated with an electrical pulse of 3 V, 20 Hz and 0.3 mA for 1 h each day. The effects of ES on the facial muscle movement, compound muscle action potentials (CMAPs), histological structure, and the expression levels of S100B and NF200 proteins were comparatively studied.ResultsIn group A, facial paralysis scores were slightly improved from day 1 to 28; the facial nerve trunks had swelled and malformed till day 14; and CMAPs could be induced in fewer animals and were abnormal, resulting in a slow recovery of the facial muscle movement. In group B, facial paralysis scores were improved from 4 to 2.6 during the 4 weeks; more rats showed a higher amplitude and shorter latency of CMAPs from day 14 to 28 after surgery; and increased axons and the expression of S100B and NF200 proteins and gradually decreased swelling in the injured facial nerve.ConclusionES promotes outgrowth and myelination of axons and a partial functional recovery of facial muscles in injured facial nerve rats.

A collagen-coated PGA conduit for interpositional-jump graft with end-to-side neurorrhaphy for treating facial nerve paralysis in rat.

This study investigated the potential of collagen-coated polyglycolic acid (PGA) tube with interpositional jump graft (IPJG) in rat. A total of 16 Lewis rats were used in this study. Facial nerve paralysis was created by ligating facial nerve trunk with a ligature clip. The rats were divided into 3 groups. Nerve conduit group (n = 6) were treated by IPJG with collagen-coated PGA tubes between the facial nerve trunks and the hypoglossal nerves. Autograft group (n = 6) were treated by IPJG with the greater auricular nerves. As the control group (n = 4), non-treated-model rats with facial nerve paralysis were used. The number of myelinated fibers, fiber diameter, axon diameter, myelin thickness, and g-ratio, were analyzed histologically at 13 weeks after surgery. Compound muscle action potential (CMAP) and retrograde tracing were measured. Although the number of myelinated fibers in autograft group (1957 ± 775) had significantly higher than that of nerve conduit group (90 ± 41, P < .05), the nerve conduit group showed the regeneration of myelinated nerve axons. CMAP amplitude values of the autograft (4706 ± 1154 µV) and the nerve conduit groups (4119 ± 1397 µV) were significantly higher than that of the control group (915 ± 789 µV, P < .05). Retrograde tracing confirmed the double innervation of mimetic muscles by the facial and hypoglossal nucleus in both groups. This study showed histologically and physiologically the superior effectiveness of performing IPJG with a collagen-coated PGA conduit in a rat model.

An Anatomic Study of the Facial Nerve Trunk and Branching Pattern in an African Population

There are known racial variations in the branching and furcation pattern and the length of the facial nerve (FN) trunk and hardly any studies from the black African population. Surgeries around the FN predispose it to trauma and warrant a detailed anatomy of its branching pattern. Using a descriptive cross-sectional study, a total of 40 FN (20 fresh cadavers) were dissected to record the pattern and length of the FN. The frequency of various patterns of FN using the Davis et al classification was as follows: type I: 10 (25%), type II: 9 (22.5%), type III: 7 (17.5%), type IV: 6 (15%), type V: 2 (5%), and type VI: 6 (15%). The nerve bifurcated in 32(80%) and trifurcated in 8(20%) of the cadavers. There was no statistical difference in the branching patterns ( p = 0.509) and furcation types ( p = 0.414) between the sides and gender. The length of the trunk of the FN measured from the stylomastoid foramen to the bifurcation point was 16.14(−/+ 3.28 mm). The results from this data established a variation in the anatomical branching pattern of the FN in a black Kenyan population.

Masseteric Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-analysis.

A review of the role of masseteric nerve transfer is needed to guide its use in facial reanimation. To systematically review the available literature, and, when applicable, analyze the combined outcomes of masseteric nerve transfer to better define its role in reanimation and to guide further research. Two independent researchers conducted the review using PubMed-NCBI and Scopus literature databases for studies on masseteric nerve transfer for facial nerve paralysis. Studies that examined masseter nerve transfer with additional cranial nerve transposition/coaptation or muscle flap were excluded. Literature review and data extraction followed established PRISMA guidelines. Two researchers extracted data independently. The main planned outcomes for the study were quantitative results of facial nerve movement after nerve transfer including oral commissure movement and time to nerve recovery. A total of 13 articles met inclusion criteria with a total of 183 patients undergoing masseteric nerve transfer. From those studies, there were a total of 183 patients who underwent masseteric nerve transfer. There were 85 men and 98 women with a mean (SD) age of 43 (12.2) years and mean (SD) follow up examination after surgery of 22 (7.6) months. Mean (SD) duration of nerve paralysis was 14 (6) months. Most common cause of paralysis was cerebellopontine angle tumors (81%). Six studies coapted the masseteric nerve to the main facial nerve trunk, whereas 7 used distal branches (buccal or zygomatic). Four studies used interposition nerve grafts with great auricular nerve. Two measures, improvement in oral commissure excursion and length from reanimation to facial movement, were measured consistently across the studies. Pooled analysis showed time from surgery to first facial movement, described in 10 studies, to be 4.95 months (95% CI, 3.66 to 6.24). Distal branch coaptation improved time to recovery vs main branch coaptation, 3.76 vs 5.76 months (95% CI, -0.33 to 4.32), but mean difference was not significant. The use of interposition graft significantly delayed time of nerve recovery, 6.24 vs 4.06 months (95% CI, 0.20 to 4.16). When controlled for main trunk coaptation only, interposition nerve graft delayed recovery but difference was no longer statistically significant, 6.24 vs 4.75 months (95% CI, -0.94 to 3.92). Reported complications were minor and rare occurring in only 6.5% (12 of 183) of patients. The masseteric nerve was found to be a good option for nerve transfer in this patient population, and showed favorable results in both time to nerve recovery and improvement in oral commissure excursion. NA.

Variable relationship of retro-mandibular vein to the facial nerve, a finding during parotid surgery: a rare case report

Studies describing the anatomical relation and variability of facial nerve and retro-mandibular vein were mostly on cadavers. Intraoperative encounter of variable anatomy in parotid surgery is rarely reported in literature. The usual location of retro-mandibular vein is medial to facial nerve as described in many classical text books is around 88%. Here we present a case with variable anatomy of retromandibular vein. A 55-year-old Indian gentleman presented with history of painless swelling in left parotid region for 5 months. On clinical examination, a 3×3 cm swelling probably arising from left parotid gland was felt. Preoperative ultrasonography described it as parotid cyst arising from inferior pole. Fine needle aspiration cytology described it as benign parotid cyst. A superficial parotidectomy was planned and executed. During surgery, the retro-mandibular vein was found crossing the two trunks of the facial nerve laterally (superficial to facial nerve) in between the division of facial nerve trunk and origin of ramifications. Usually retro-mandibular vein runs medial (deep) to the facial nerve trunks. Anatomical variations between facial nerve and retro-mandibular vein are underreported and not given due importance during training. With this article, we want to emphasize the importance of having awareness regarding anatomical variations related to facial nerve and retro-mandibular vein and be prepared to encounter during surgery there by preventing complications. We are reporting the first case from India.

Bleeding after tonsillectomy

Oropharyngeal hemorrhage after tonsillectomy is one of the most common postprocedural ENT emergencies that require immediate attention. Management choices depend on the severity of bleeding, underlying platelet or coagulation disorders, and the patient’s maturity and age. Treatment range from simple observation to an emergent need to both secure the airway and stop the hemorrhage. The workup of the hemorrhagic patient will be discussed from the preoperative to postoperative time period. Surgical techniques in response to various acuity will be discussed to fully elucidate options to control the hemorrhage.

Immediate reconstruction of facial nerve defect using cable grafting of the greater auricualr nerve after parotid cancer resection

Objective:To evaluate the feasibility of immediate reconstruction of facial nerve defect by using cable grafting of the greater auricular nerve after parotid cancer resection.Method:Clinical data of 11 patients suffering from parotid cancer was reviewed.9 cases were diagnosed as mucoepidermoid carcinoma and 2 cases were adenoid cystic carcinoma. Total parotidectomy and elective neck dissection were performed before cable grafting of the greater auricular nerve was interposed between stumps of facial nerve trunk and its branches. The facial nerve electromyogram and symmetry of mimetic musculature were evaluated. The House Brackmann (HB) grading system was used to assess the functional outcome of facial nerve rehabilitation. 8 patients received 50-65 Gy postoperative radiotherapy. The follow-up time ranged from 8 months to 36 months with the mean time of 12 months.Result:At all function oriented facial nerve reconstructed region, satisfactory orbicularis oculi muscle function in 7 patients was achieved (7/7); 5 patients obtained seeable and almost symmetric frowning (5/7); 9 patients obtained obvious nasolabial groove and satisfactory rest symmetry of the mouth corners (9/9); 4 patients got better facial nerve function restoration when it was 3 months after radiotherapy. Nine patients got HB grade Ⅱ, and 2 patients got HB grade Ⅲ facial nerve function restoration. Facial nerve electromyogram revealed weaker amplitude nerve conduction in 9 patients of HB grade Ⅱ than the conduction at its corresponding normal side.Conclusion:Cable grafting of the greater auricular nerve is a feasible candidate for the immediate reconstruction of facial nerve defect. Free nerve transplantation is probably not a contraindication for postoperative radiotherapy in the parotid region.