Facial nerve preservation following gamma knife radiosurgery for vestibular schwannomas in neurofibromatosis type 2: a systematic review and meta-analysis of 552 tumors.

Abstract Facial paralysis can cause profound functional and psychological impact. Management strategies have evolved significantly, with advances in understanding facial nerve anatomy, nerve physiology, and microsurgical techniques. This review provides a comprehensive overview of surgical strategies for both acute and chronic facial paralysis, highlighting contributions from Chang Gung Memorial Hospital that have shaped contemporary practice. Indications, timing, and selection of interventions—including nerve grafting, nerve transfers, and free functioning muscle transplantations—are examined with emphasis on techniques that restore facial symmetry. Recent developments in the management of acute facial paralysis following oncologic resection and in eyelid reanimation are also discussed. By integrating evidence from published research and institutional experience, this review aims to guide the selection of surgical strategies to enhance facial movement and symmetry.

Evidence summary: facial nerve rehabilitationtraining management for patients with peripheral facial paralysis.

Synkinetic dysfunction of the Depressor Anguli Oris (DAO) and Mentalis muscle (MM) in conjunction with a weak Depressor Labii Inferiors (DLI) produces a characteristic deformity in the perioral region. Chemodenervation, myectomy and facial nerve neurectomy have been utilized to treat this imbalance with varying degrees of success. This study explores the value of highly selective Mentalis denervation combined with transfer of the hypertonic DAO to the hypotonic DLI for improving facial symmetry. A retrospective review of ten patients treated with a DAO-DLI transfer and mentalis denervation was undertaken. Still preoperative and postoperative photographs were evaluated utilizing a facial landmark detection system (Emotrics) and direct photographic measurement utilizing an iris calibrated technique. An average improvement of 3.7 mm of lower lip depression was identified (p value 0.001). Additionally, a statistically significant improvement in smile angle and dental show (p value < 0.05) was also encountered along with a positive trend in commissure height deviation. This early experience suggests that DAO-DLI muscle transfer in conjunction with highly selective denervation of the mentalis muscle can have a positive effect in the treatment of labio-mental synkinesis.

Outcomes for chemodenervation treatment of facial synkinesis are well described, and evidence for surgical interventions such as selective neurectomy and myectomy is growing. There is minimal comparative data on outcomes between selective neurectomy and/or myectomy versus chemodenervation. To compare facial synkinesis treatment with chemodenervation compared with surgery as measured by standardized outcome measures. A systematic review of three databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Included studies used validated facial nerve outcome measurements (patient-graded, physician-graded, or semiautomatic) for chemodenervation or surgical treatment for patients with facial synkinesis. Studies were excluded if free muscle transfer was performed. Meta-analysis was performed on studies using the same outcome measure, and risk of bias assessment was performed using Cochrane Review systems. In total, 36 studies (1171 total patients) were included in the review. Chemodenervation and surgery both demonstrated benefit as measured by the Facial Clinimetric Evaluation Scale and Sunnybrook scale, without a difference between treatment types (p = 0.76 and p = 0.061, respectively). Synkinesis Assessment Questionnaire scores improved more with chemodenervation than with surgical treatment (mean 15.45 vs. 5.90 improvement, p < 0.0001). For semiautomated objective measurements using Emotrics software, myectomy produced more improvement in dental show compared to neurectomy (13.28 mm vs. -4.89 mm, p < 0.0001) and more oral commissure excursion than neurectomy or chemodenervation (3.79 mm vs. 1.60 mm vs. 1.00 mm, respectively, p < 0.0001). Although most commonly used together, comparative analysis suggests that selective neurectomy and/or myectomy produce similar improvements in facial synkinesis compared to chemodenervation when assessed with patient surveys or clinician-graded tools. However, high interstudy heterogeneity and confounding covariates limit definitive conclusions, and more data from surgical treatments are needed.

Background: Melkersson–Rosenthal syndrome (MRS) is a rare neuro-mucocutaneous disorder characterized by a classical triad of recurrent facial nerve palsy, orofacial edema, and fissured tongue. Owing to its variable and often incomplete clinical presentation, the condition poses a diagnostic challenge and is frequently underrecognized. Diagnosis is primarily clinical and relies on exclusion of other neurological, infectious, and granulomatous disorders. Case Presentation: We report the case of a 23-year-old female who presented with a three-year history of recurrent left-sided lower motor neuron facial palsy associated with intermittent, painful swelling of the upper and lower lips. The episodes occurred every few months and lasted approximately two to three weeks. Clinical examination revealed unilateral facial weakness, recurrent orofacial edema, and a fissured tongue. Extensive laboratory investigations, autoimmune screening, and magnetic resonance imaging of the brain were unremarkable, excluding alternative etiologies. Based on the characteristic clinical features and exclusion of other causes, a diagnosis of Melkersson–Rosenthal syndrome was established. Results: The patient was initially managed with oral corticosteroids during acute episodes, resulting in significant symptomatic improvement. Due to the recurrent nature of the disease, long-term immunosuppressive therapy with azathioprine was initiated. At six-week follow-up, the patient demonstrated a marked reduction in the frequency and severity of facial palsy episodes, significant resolution of orofacial swelling, and improvement in tongue-related discomfort, leading to enhanced quality of life. Conclusion: This case highlights the importance of clinical awareness and early recognition of Melkersson–Rosenthal syndrome in patients presenting with recurrent facial palsy and orofacial swelling. Prompt diagnosis and appropriate immunomodulatory therapy can effectively control symptoms, reduce recurrence, and improve long-term outcomes in affected individuals. Keywords: Fissured Tongue, Immunosuppressive Therapy, Melkersson–Rosenthal Syndrome, Orofacial Edema, Recurrent Facial Palsy.

Mandibular distraction osteogenesis (MDO) is a critical intervention for addressing severe upper airway obstruction in infants with Robin Sequence (RS). Nonetheless, this procedure carries a risk of facial nerve dysfunction (FND), particularly affecting the marginal mandibular nerve (MMN). Since 2019, our group has prospectively monitored real-time facial nerve conduction using electroneurography (ENoG) during MDO procedures. This pilot study evaluates nerve conduction changes and their potential association with postoperative clinically visible FND. Nine infants with RS undergoing MDO from 2019-2024 were randomly selected from a prospectively enrolled cohort. ENoG recorded motor responses from the orbicularis oculi and mentalis muscles. Significant changes were defined as a peak latency increase of ≥10% or an amplitude decrease of ≥60% from baseline. Twenty-five unilateral procedures [osteotomy/placement of hardware (18); hardware removal (6); revision (1)] were analyzed by a certified ENoG technician. Median age at surgery was 11.4 months (IQR 2.4-42.7). Retraction during osteotomy was the surgical step most associated with a significant amplitude decrease in 83.3% of cases, while device activation caused the most frequent peak latency increase in 44.4% of cases. Temporary MMN dysfunction was observed after four procedures (16.0%). Sensitivity/specificity were 17.6%/87.5% while NPV was 84.8%. This prospective pilot study suggests intraoperative risk of MMN injury during MDO is greatest during retraction for osteotomy and device activation. With an NPV of 84.8%, ENoG predicted the absence of postoperative FND when there were no significant conduction changes. Further research is necessary to confirm its diagnostic utility and establish standardized pediatric intraoperative ENoG thresholds.

To describe the course of the superficial temporal artery (STA) and identify the optimal location for temporal artery biopsy when a pulse cannot be reliably palpated. In this anatomical study, the arterial systems of 12 fresh adult cadaver heads were filled with red neoprene latex to highlight the STA. Coronal incisions starting at the root of the auricular helix and extended 80 mm superiorly were made bilaterally. The primary outcome was the probability of the STA being encountered at each location on a standardized, superimposed 50 × 50 mm grid. Secondary outcomes included degree of declination from the incision line, distance at which the vessel crossed the incision, presence of frontal/parietal bifurcation, presence of branches, visibility of the temporal branch of the facial nerve, and vessel caliber. Means, standard deviations, and ranges were used to describe the data. In all specimens analyzed, the STA crossed the coronal incision line within 45 mm of the helix root. The STA was found within the same 5 × 5 mm location, 10 to 15 mm cranial to the root of the helix, and 5 to 10 mm anterior to the incision in 68.4% of specimens. In the remaining specimens, a portion of the STA was found within 7 mm of this location. Especially in cases where the STA is nonpalpable, care must be taken to avoid iatrogenic injury to the facial nerve during temporal artery biopsy. Surgeons should recognize that the STA can be reliably encountered with an incision beginning 5 mm anterior and 5 mm cranial to the helix root, carried 40 mm in the posterior and cranial direction, 30 degrees declined from the coronal plane.

A Longitudinal Cohort Study of Children with Peripheral Facial Nerve Palsy in Lyme Disease Endemic Areas.

CXCL12-mimetic peptide-conjugated hydrogel orchestrates the neural microenvironment to accelerate facial nerve repair

The Inferior Alveolar Nerve Block (IANB) is the most utilized regional anesthetic technique in dentistry, but it carries a rare risk of transient Facial Nerve (CN VII) palsy, reported at approximately 0.3\%.This motor complication manifests as unilateral facial weakness, drooping of the corner of the mouth, and critical inability to close the ipsilateral eye (lagophthalmos). The primary etiology is a technical error: the inadvertent deposition of local anesthetic directly into the parotid gland capsule, a consequence of overly deep or posterior needle placement . While immediate palsy is a chemical conduction block, delayed presentation is hypothesized to stem from localized ischemic neuritis and secondary edema. Management is focused on immediate patient reassurance, mandatory ocular protection (lubricants and patching) to prevent corneal damage , and the use of systemic corticosteroids to mitigate inflammation . The prognosis is excellent, with complete functional recovery commonly observed within eight weeks. Prevention relies on rigorous adherence to injection protocol, including aspiration, slow injection, and strict depth control to prevent posterior needle penetration .

Facial nerve decompression is a surgical procedure performed for severe facial nerve paralysis associated with conditions such as Bell’s palsy and Ramsay Hunt syndrome. Classical Western studies by Fisch first established the surgical principles of facial nerve decompression, providing the foundation for subsequent work on decompression extent and outcomes. However, the optimal extent of bony decompression of the facial nerve canal remains unclear, and a 180° removal of the surrounding bone has traditionally been performed based on empirical judgment. Nevertheless, more extensive bone removal may increase the risk of surgical complications. This study aimed to evaluate the relationship between the angle of bony decompression around the facial nerve canal and pressure reduction, in order to determine the optimal decompression angle. To achieve this, a simplified experimental model was employed to quantitatively evaluate the relationship between decompression angle and internal pressure reduction, providing mechanical insight into facial nerve decompression rather than clinical data. To evaluate this relationship, a decompression model was created, and pressure changes were measured at opening angles ranging from 30° to 180°. The results revealed that a 150° decompression provided a comparable reduction in pressure to that of a 180° decompression. These findings suggest that the extent of bone removal can be minimized while still achieving sufficient pressure reduction, potentially lowering the risk of nerve injury. We also observed significant pressure reduction at 30°, suggesting utility in regions where extensive bone removal is difficult. The finding that a 150° decompression produced an effect comparable to that of 180° is an important contribution toward improving surgical safety. Moving forward, we aim to refine the decompression model and conduct further investigations using more detailed angle settings, with the goal of establishing a practical surgical technique.

Subcutaneous anesthetic technique to the auriculotemporal nerve for minimally invasive procedures in the temporomandibular joint.

To analyze the efficacy of tympanoplasty for severe tympanosclerosis under the continuous irrigation mode. Retrospective. First Affiliated Hospital of Wenzhou Medical University. Patients with severe tympanosclerosis involving critical anatomic structures (eg, stapes footplate, facial nerve canal, vestibular window niche). Tympanoplasty with continuous irrigation mode. Saline irrigation to reduce bleeding, improve surgical continuity, and shorten operative time. Removal of calcified lesions and ossicular chain reconstruction. Surgical efficacy (assessed by completeness of lesion removal and hearing improvement), operative time, frequency of endoscope withdrawal for cleaning, complication rates (including facial paralysis, vertigo, sensorineural hearing loss, and taste disturbances), tympanic membrane healing status, chorda tympani preservation rate, and feasibility in overcoming traditional limitations (eg, single-handed operation, bone drilling difficulties). Reduced intraoperative bleeding. Improved procedural continuity. Shortened operative time. Enhanced feasibility for complex lesions (eg, near facial nerve). Postoperative outcomes improved with reduced complication rates. The continuous irrigation mode represents a safer and more effective advancement in tympanosclerosis surgery, addressing limitations of conventional endoscopy by improving efficiency and reducing complications. Further clinical validation is needed.

ABSTRACTObjectiveMalignant otitis externa (MOE) is a potentially life‐threatening infection of the external auditory canal (EAC), often with skull base extension. Vascular complications are exceptionally rare, with only six reports of petrous internal carotid artery (ICA) pseudoaneurysm following MOE.MethodsWe present the first reported case of a nasopharyngeal hematoma as a complication of MOE.ResultsAn 82‐year‐old male with poorly controlled diabetes presented with 2 months of recurrent left ear otalgia, purulent otorrhea, and facial nerve palsy. He was commenced on 6 weeks of antimicrobial therapy following diagnosis of MOE on imaging. One month post‐treatment, an interval scan found a new collection in the left pharyngeal submucosal region expanding into the torus tubarius. Endoscopic examination revealed a left torus tubarius mass effacing the eustachian tube orifice with some blood‐stained mucous. The patient was otherwise afebrile and reported only mild trismus with rust‐colored sputum. Subsequent computed tomography (CT) imaging revealed that the mass was likely a subacute or evolving nasopharyngeal hematoma, in close proximity to the left petrous and caudal lacerum ICA, with mild luminal irregularities. An angiogram showed no active contrast extravasation or pseudoaneurysm. He was managed conservatively given the absence of active bleeding and a stable airway. A repeat nasoendoscopy 2 weeks later revealed interval decrease in size of the mass, with resolution of symptoms.ConclusionThe pathophysiology of nasopharyngeal hematoma as a complication of MOE may involve direct infection‐mediated and inflammatory‐induced erosion of arterial walls. Though rare, nasopharyngeal hematomas should be considered in MOE patients with unexplained nasopharyngeal masses. These hematomas, especially when associated with luminal ICA irregularities, may represent a sentinel finding preceding the eventual formation of a carotid pseudoaneurysm. Thus, the presence of nasopharyngeal hematomas warrants vigilant surveillance, with escalation to urgent endovascular intervention in the event of vascular instability.

High-risk morphology in cystic vestibular schwannomas: an imaging-based scoring system for facial nerve outcomes.

Background: Cochlear implant surgery became worldwide operation used to manage patients with severe to profound sensory neural hearing loss that were not benefit from hearing aids. Facial nerve (FN) injury during the surgery still the most complication that the surgeons think about it during doing posterior tympanotomy. Methods: A retrospective study including 76 patients complaining of severe to profound SNHL, get implanted in Misrata Medical Center, Misrata city, Libya, in the period between January 2018 and April 2020, using our new technique: Fossa incudis approach (FIA), in which and after cortical mastoidectomy performed, exposure of tip of short process of incus which situated in fossa incudis was done to become guide and help us to enter middle ear safe. Results: After 76 operations performed on 76 patients with different anatomical situations, we report 0% FN injury. The time of surgery was relatively shorter (90 minutes±10). Conclusions: Our technique (FIA) is safe and easy to learn; it helps us to minimize the incidence of FN injury and decrease the time of operation.

Background: Primary squamous cell carcinoma (SCC) of the parotid gland is a rare, aggressive malignancy often requiring radical parotidectomy with facial nerve sacrifice, particularly in T4b stage disease. The utility of neoadjuvant chemotherapy (NACT) in downstaging these tumors to facilitate functional nerve preservation remains controversial and under-reported in the literature. Case presentation: A 58-year-old male presented with a fixed, rapidly enlarging left preauricular mass classified as cT4bN2M0 (Stage IVA). The tumor involved the sternocleidomastoid muscle and encased the external carotid artery. Following a multidisciplinary tumor board decision, the patient underwent an extended course of six cycles of Paclitaxel and Carboplatin. The tumor exhibited a partial clinical response and significant central necrosis on imaging. Subsequently, a total parotidectomy was performed. Despite intraoperative fragility and adherence to deep vascular structures, the main trunk and primary divisions of the facial nerve were anatomically and functionally preserved. Histopathology confirmed high-grade SCC with perineural invasion limited to the distal excised branches, achieving clear margins. The patient received 66 Gy of adjuvant radiotherapy. At the 18-month follow-up, the patient remains disease-free with House-Brackmann Grade I facial function. Conclusion: Long-term facial nerve preservation is feasible in selected cases of locally advanced parotid SCC using a multimodal approach. Extended NACT may induce tumor necrosis and facilitate dissection along the neuro-vascular interface, provided that perineural invasion does not involve the main nerve trunk.

The depressor-labii-inferioris (DLI), depressor-anguli-oris (DAO), mentalis, and platysma muscles control lower lip position-essential for smiling and oral function-and are at risk during facial reconstructive and aesthetic procedures. Prior anatomical studies, lacking functional analysis, suggested the marginal mandibular nerve (MMn) significantly contributes to mid-lower lip depression through DLI innervation. This study systematically assessed the functional anatomy and innervation of these muscles and evaluated whether MMn injury worsens lower lip position. A retrospective cohort study of prospectively collected data included adult synkinesis patients undergoing selective neurectomies and myectomies with unilateral facial nerve mapping. Intraoperatively, facial nerve branches were stimulated and categorized by muscle activation patterns. Additional sub-analysis evaluated lower lip position changes using pre- and postoperative photographs in patients who underwent MMn neurectomy without platysma myectomy. Of 82 patients, 45 met inclusion (mean age: 51.5; 87% female). An average of 11.3 nerve branches were mapped per patient: zygomatic (2.80), buccal (4.36), MMn (1.16), and cervical (3.02). DAO and mentalis demonstrated mixed innervation patterns. DLI and platysma were predominantly cervical; 95.5% of DLI branches were cervical with 68.8% being pure DLI branches. In the sub-analysis (n=24), MMn neurectomy did not worsen lower lip position. The DAO, mentalis, and platysma muscles are poly-innervated by buccal, MM, and cervical branches, while the DLI is mostly mono-innervated by cervical branches. Isolated MMn injury rarely worsens lower lip position, while injury to cervical branches to the DLI causes abnormal lower lip elevation and can be avoided by more caudal platysma myotomy.

Background/Objectives: Subcondylar mandibular fractures represent a challenging subset of maxillofacial trauma due to their proximity to the temporomandibular joint and the facial nerve. The retromandibular approach can be performed through either an anteroparotid or a transparotid route, but comparative clinical data remain limited. This study aimed to evaluate clinical outcomes, complication profiles, and operative parameters associated with the retromandibular anteroparotid versus transparotid approach for open reduction and internal fixation (ORIF) of subcondylar fractures. Methods: A retrospective analysis was conducted on 80 consecutive patients treated for subcondylar mandibular fractures at the Department of Maxillofacial Surgery, Umberto I General Hospital, Sapienza University of Rome, between 2018 and 2025. All patients underwent ORIF via a retromandibular approach (anteroparotid or transparotid) with a minimum follow-up of 6 months. Demographic data, trauma etiology, fracture morphology (classified as simple or complex), associated fractures, surgical approach, fixation details, operative time, hospital stay, and postoperative complications were collected. Facial nerve function was clinically assessed and graded using the House–Brackmann scale. Associations between fracture type, surgical approach, number of plates, and complications were evaluated using Chi-square or Fisher’s exact tests, while operative time was compared using one-way ANOVA and Kruskal–Wallis tests (p < 0.05). Results: The cohort had a mean age of 41.9 years and was predominantly male (67.5%). The anteroparotid route was used in 54 patients (67.5%) and the transparotid route in 26 (32.5%). Overall, 10 patients (12.5%) developed postoperative complications, including transient facial nerve weakness, malocclusion, visible scarring, and sialocele. All cases of sialocele occurred in the transparotid subgroup, whereas no salivary complications were observed after the anteroparotid approach. No permanent facial nerve deficits, temporomandibular joint ankylosis, or long-term facial asymmetry were recorded at 6 months. No significant association was found between surgical approach and overall complication rate, but complex fracture patterns were significantly associated with increased operative time. Conclusions: The retromandibular approach is a safe and effective option for ORIF of subcondylar mandibular fractures. Both anteroparotid and transparotid routes provided reliable exposure and stable fixation with low complication rates. The anteroparotid route appears to minimize parotid-related complications, such as sialocele, while maintaining comparable functional outcomes. These findings support the retromandibular anteroparotid approach as a valuable alternative in the surgical management of subcondylar fractures.