Facial Preservation Research Articles

Bilobe parotid lipoma: a rare case report of parotid involving both the superficial and deep lobe with review of literature

Lipomas are common benign soft tissue tumours, they are found in every body part where the fat is normally present but they are rarely found in the head and neck region. There are few reports of parotid lipoma and till date only one case report of bilobe lipoma has been reported earlier. They compromise 0.6%-4.4% of all parotid tumour. A 60 year old male presented with a large swelling in left parotid region extending from left pre-auricular region to submandibular region from 6 years. Examination of the facial nerve was normal. Ultrasound of the region suggested of lipoma. Fine needle aspiration cytology was done which supported the ultrasounds diagnosis. Patient underwent tumour excision with facial nerve preservation. Lipoma of size 10 x 8 cm which is the largest reported bilobe parotid lipoma reported till date. Literature review has suggested lipomas of parotid region are rare hence should be kept in one of the differential diagnosis. Surgical intervention is challenging because of the probability of injuring the facial nerve, thus knowledge of the anatomy and meticulous surgical technique is essential.

The outermost "dura-like membrane" of vestibular schwannoma.

Background:The membranous structure of vestibular schwannoma is an important factor in its surgical treatment. Herein, we report intraoperative and microscopic findings relating to an outermost dura-like membrane in cases of vestibular schwannoma and the importance of these findings.Methods:Intraoperative findings of 16 cases of vestibular schwannoma treated with an initial surgery were studied with an aim to determine if the cases had a dura-like membrane. Then we studied microscopic findings of the dura-like membrane using hematoxylin and eosin, Masson trichrome, and immunohistochemical staining in 2 cases.Results:The dura-like membrane was observed in 8 out of 16 cases. The average tumor size of the cases that had a dura-like membrane was 30 ± 8.1 mm, and Koos grading 4 was in 7 out of 8 cases, and one was grade 3. In cases without a dura-like membrane, these values were significantly smaller, with an average tumor size of 12.8 ± 5.2 mm, and Koos grading 4 was only in 1 of 8 cases, grade 3 was in 2 cases, and other 5 cases were grade 2. The outermost dura-like membrane enveloped the vestibular schwannoma around the internal acoustic meatus and was continuous with the dura mater. Reactive angiogenesis was observed in the dura mater. Microscopic findings proved its continuity with the dura mater. In one case, the facial nerve was damaged before it was identified during subcapsular dissection. In that case, the dura-like membrane negatively affected our ability to identify the facial nerve.Conclusions:A dura-like membrane sometimes envelops vestibular schwannoma around the internal acoustic meatus. Recognition of this membranous structure is important for the surgical preservation of facial and acoustic nerves.

A Neuromonitoring Approach to Facial Nerve Preservation During Image-guided Robotic Cochlear Implantation.

A multielectrode probe in combination with an optimized stimulation protocol could provide sufficient sensitivity and specificity to act as an effective safety mechanism for preservation of the facial nerve in case of an unsafe drill distance during image-guided cochlear implantation. A minimally invasive cochlear implantation is enabled by image-guided and robotic-assisted drilling of an access tunnel to the middle ear cavity. The approach requires the drill to pass at distances below 1 mm from the facial nerve and thus safety mechanisms for protecting this critical structure are required. Neuromonitoring is currently used to determine facial nerve proximity in mastoidectomy but lacks sensitivity and specificity necessaries to effectively distinguish the close distance ranges experienced in the minimally invasive approach, possibly because of current shunting of uninsulated stimulating drilling tools in the drill tunnel and because of nonoptimized stimulation parameters. To this end, we propose an advanced neuromonitoring approach using varying levels of stimulation parameters together with an integrated bipolar and monopolar stimulating probe. An in vivo study (sheep model) was conducted in which measurements at specifically planned and navigated lateral distances from the facial nerve were performed to determine if specific sets of stimulation parameters in combination with the proposed neuromonitoring system could reliably detect an imminent collision with the facial nerve. For the accurate positioning of the neuromonitoring probe, a dedicated robotic system for image-guided cochlear implantation was used and drilling accuracy was corrected on postoperative microcomputed tomographic images. From 29 trajectories analyzed in five different subjects, a correlation between stimulus threshold and drill-to-facial nerve distance was found in trajectories colliding with the facial nerve (distance <0.1 mm). The shortest pulse duration that provided the highest linear correlation between stimulation intensity and drill-to-facial nerve distance was 250 μs. Only at low stimulus intensity values (≤0.3 mA) and with the bipolar configurations of the probe did the neuromonitoring system enable sufficient lateral specificity (>95%) at distances to the facial nerve below 0.5 mm. However, reduction in stimulus threshold to 0.3 mA or lower resulted in a decrease of facial nerve distance detection range below 0.1 mm (>95% sensitivity). Subsequent histopathology follow-up of three representative cases where the neuromonitoring system could reliably detect a collision with the facial nerve (distance <0.1 mm) revealed either mild or inexistent damage to the nerve fascicles. Our findings suggest that although no general correlation between facial nerve distance and stimulation threshold existed, possibly because of variances in patient-specific anatomy, correlations at very close distances to the facial nerve and high levels of specificity would enable a binary response warning system to be developed using the proposed probe at low stimulation currents.

In vivo visualization of the facial nerve in patients with acoustic neuroma using diffusion tensor imaging-based fiber tracking.

OBJECTIVE Preoperative determination of the facial nerve (FN) course is essential to preserving its function. Neither regular preoperative imaging examination nor intraoperative electrophysiological monitoring is able to determine the exact position of the FN. The diffusion tensor imaging-based fiber tracking (DTI-FT) technique has been widely used for the preoperative noninvasive visualization of the neural fasciculus in the white matter of brain. However, further studies are required to establish its role in the preoperative visualization of the FN in acoustic neuroma surgery. The object of this study is to evaluate the feasibility of using DTI-FT to visualize the FN. METHODS Data from 15 patients with acoustic neuromas were collected using 3-T MRI. The visualized FN course and its position relative to the tumors were determined using DTI-FT with 3D Slicer software. The preoperative visualization results of FN tracking were verified using microscopic observation and electrophysiological monitoring during microsurgery. RESULTS Preoperative visualization of the FN using DTI-FT was observed in 93.3% of the patients. However, in 92.9% of the patients, the FN visualization results were consistent with the actual surgery. CONCLUSIONS DTI-FT, in combination with intraoperative FN electrophysiological monitoring, demonstrated improved FN preservation in patients with acoustic neuroma. FN visualization mainly included the facial-vestibular nerve complex of the FN and vestibular nerve.

Tratamiento quirúrgico del schwannoma vestibular. Revisión de 420 casos

Introduction and objectivesVestibular schwannoma is the most frequent cerebellopontine angle tumor. The aim of our study is to reflect our experience in the surgical treatment of this tumor Material and methodsRetrospective study of 420 vestibular schwannomas operated in our hospital between 1994-2014. We include tumor size, preoperative hearing, surgical approaches, definitive facial and hearing functional results, and complications due to surgery. ResultsA total of 417 patients with 420 tumors were analyzed, 209 female (50.1%) and 208 male (49.9%). Mean age at diagnosis was 49.8±13.2 years. The majority of the tumors were resected through a translabyrinthine approach (80.2%). Total tumor removal was achieved in 411 tumors (98.3%), and anatomic preservation of facial nerve in 404 (96.2%). Definitive facial nerve outcome was House-Brackmann grade I and II in 69.9%, and was significantly better in tumors under 20mm. Surgical complications included cerebrospinal fluid leakage in 3 patients (0.7%) and retroauricular subcutaneous collection in 16 (3.8%), 5 cases of meningitis (1.2%), 4 patients with intracraneal bleeding (0.9%), and death in 3 patients (0.7%). ConclusionsSurgery is the treatment of choice for vestibular schwannoma in the majority of patients. In our experience, the complication rate is very low and tumor size is the main factor influencing postoperative facial nerve function.

Management of Geniculate Ganglion Hemangiomas: Case Series and Systematic Review of the Literature.

To analyze facial nerve (FN) outcomes based on duration of FN palsy and surgical strategy in patients with geniculate ganglion hemangiomas (GGH). Case series and systematic review of the literature. Tertiary care center. All patients undergoing surgical resection of GGH from 1992 to 2014 were studied and a review of the English literature was performed. One hundred twenty unique patients (mean age 41.4 yrs, 44% female) were identified with GGH: 8 in the current series and 112 from the literature review. Of these patients, 94% presented with FN weakness, 18% reported hemifacial spasm, and 16% had hearing loss at presentation. Eleven patients underwent an initial period of observation, 6 of which experienced either growth or progression of FN dysfunction. One hundred fourteen subjects ultimately underwent surgical intervention. The average preoperative House-Brackmann (HB) score was 4.6 and the mean duration of preoperative FN palsy was 27 months (range, 1-132). The average postoperative HB score was 3.5 at the last follow-up. Anatomical FN preservation was reported in 44% of patients. Duration of FN palsy ≤12 months was associated with better pre- and postoperative FN outcome (HB 4.1 vs 5.1, p = 0.01 and 2.9 vs 4.0, p < 0.001, respectively). FN preservation was also associated with better postoperative FN outcome compared with interposition grafting (HB 2.6 vs 3.9, p < 0.001). GGHs are rare benign vascular malformations that present with progressive FN palsy. In most patients, early surgical intervention should be considered since shorter duration of FN paralysis and anatomical preservation of the FN are significant predictors of final FN outcome.

Dorsal displacement of the facial nerve in acoustic neuroma surgery: clinical features and surgical outcomes of 21 consecutive dorsal pattern cases.

In acoustic neuroma surgery, the facial nerve (FN) course varies among patients, but a dorsal pattern is rarely observed. We retrospectively reviewed and classified 556 acoustic neuromas operated on via a lateral suboccipital retrosigmoid (LSO) approach into two groups: dorsal (group D) and non-dorsal (group ND). The clinical features and outcomes including functional preservation of the FN, the extent of tumor resection, and the retreatment rate were compared. Among 556 cases, 21 (3.8%) patients with dorsal patterns were identified. No significant differences in clinical features or preoperative status were noted between groups D and ND. No significant differences in functional FN preservation were found between groups D and ND in the immediate postoperative period (90.5 and 83.0%, respectively) or 1-year postoperatively (95.2 and 97.0%, respectively). Compared with group ND, the extent of tumor resection was significantly less (p < 0.0001) and the retreatment rate was significantly higher in group D (hazard ratio, 33.6; 95% confidence interval [CI], 11.7-96.1; p < 0.0001). In one dorsal pattern case, surgical resection was abandoned based on the intraoperative findings. Dorsal displacement of the FN was accurately predicted with preoperative imaging evaluations in just two cases. Functional preservation of the FN during acoustic neuroma surgery is achievable if the FN runs along the dorsal side of the tumor. However, a dorsal pattern, especially when the FN is broadened, is clearly associated with less complete tumor removal and a higher rate of retreatment than typical pattern cases.

Safety and Efficacy of Gamma Knife Radiosurgery for the Management of Koos Grade 4 Vestibular Schwannomas.

Gamma Knife radiosurgery (GKRS) is commonly used in treating small vestibular schwannomas; however, its use for larger vestibular schwannomas is still controversial. To assess the long-term safety and efficacy of treating eligible Koos grade 4 vestibular schwannomas with GKRS. We conducted a single-center, retrospective evaluation of patient undergoing GKRS for Koos grade 4 vestibular schwannomas. We evaluated clinical, imaging, and treatment characteristics and assessed treatment outcome. Inclusion criteria were tumor size of ≥4 cm and follow-up of at least 6 months. Patients with neurofibromatosis type 2 were excluded. Primary outcomes measured were tumor control rate, hearing and facial function preservation rate, and complications. All possible factors were analyzed to assess clinical significance. Sixty-eight patients met inclusion criteria. Median follow-up was 47 months (range, 6-125 months). Baseline hearing was serviceable in 60%. Median tumor volume at radiosurgery was 7.4 cm (range, 4-19 cm). The median marginal dose used was 12 Gy at the 50% isodose line. Actuarial tumor control rates were 95% and 92% at 2 and 10 years, respectively. Actuarial serviceable hearing preservation rates were 89% and 49% at 2 and 5 years, respectively. Facial nerve preservation was 100%. Clinical complications included balance disturbance (11%), facial pain (10%), facial numbness (5%), and tinnitus (10%). Most complications were mild and transient. Hydrocephalus occurred in 3 patients, requiring ventriculoperitoneal shunt insertion. Larger tumor size was significantly associated with persisting symptoms post-treatment. Patients with Koos grade 4 vestibular schwannomas and minimal symptoms can be treated safely and effectively with GKRS.

A Case of Primary Aggressive Non Hodgkin’s Lymphoma of Parotid Gland

Introduction: Primary parotid Non Hodgkin lymphoma is rare and is generally overlooked in differential diagnosis. A high index of suspicion is therefore warranted for the diagnosis. In the present case report, we describe a case of high grade diffuse large B cell Non-Hodgkin’s lymphoma of the parotid gland. Case presentation: A 24 Years old Male presented with a painless mass over the Left parotid region. Imaging studies were suggestive of an infiltrative mass lesion in left parotid along with lytic lesions in vertebral bodies of dorsolumbar spine. The patient underwent total parotidectomy of left Parotid gland with facial nerve preservation. Histopathology of the resected specimen was consistent with primary diffuse large B cell lymphoma of the parotid gland. Conclusion: Lymphomas arising from the parotid gland are an uncommon entity, said to account for only 0.6–5% of tumors or tumor-like lesions of the parotid, and are therefore commonly overlooked. This misdiagnosis often leads to unnecessary diagnostic procedures, delaying the initiation of proper treatment

Diagnosis and treatment of cavernous hemangioma of the internal auditory canal.

Cavernous hemangioma of the internal auditory canal (IAC) is an extremely rare type of tumor, and only 50 cases have been reported in the literature prior to this study. The aim in this study was to describe the symptomatology, radiological features, and surgical outcomes for patients with cavernous hemangioma of the IAC and to discuss the diagnostic criteria and treatment strategy for the disease. The study included 6 patients with cavernous hemangioma of the IAC. All patients presented with sensorineural hearing loss and tinnitus, and 2 also suffered from vertigo. Five patients reported a history of facial symptoms with hemispasm or palsy: 3 had progressive facial weakness, 1 had a hemispasm, and 1 had a history of recovery from sudden facial paresis. All patients underwent CT and MRI to rule out intracanalicular vestibular schwannomas and facial nerve neuromas. Five patients had their tumors surgically removed, while 1 patient, who did not have facial problems, was followed up with a wait-and-scan approach. All patients had a presurgical diagnosis of cavernous hemangioma of the IAC, which was confirmed pathologically in the 5 patients who underwent surgical removal of the tumor. The translabyrinthine approach was used to remove the tumor in 4 patients, while the middle cranial fossa approach was used in the 1 patient who still had functional hearing. Tumors adhered to cranial nerves VII and/or VIII and were difficult to dissect from nerve sheaths during surgeries. Complete hearing loss occurred in all 5 patients. In 3 patients, the facial nerve could not be separated from the tumor, and primary end-to-end anastomosis was performed. Intact facial nerve preservation was achieved in 2 patients. Patients were followed up for at least 1 year after treatment, and MRI showed no evidence of tumor regrowth. All patients experienced some level of recovery in facial nerve function. Cavernous hemangioma of the IAC can be diagnosed preoperatively through analysis of clinical features and neuroimaging. Early surgical intervention may preserve the functional integrity of the facial nerve and provide a better outcome after nerve reconstruction. However, preservation of functional hearing may not be achieved, even with the retrosigmoid or middle cranial fossa approaches. The translabyrinthine approach seems to be the most appropriate approach overall, as the facial nerve can be easily located and reconstructed.

Novel mouse model for simulating microsurgical tumor excision with facial nerve preservation.

To determine the feasibility of using a mouse tumor model as a microsurgical training tool for otolaryngology-head and neck surgery (OHNS) trainees. Animal study. We injected athymic nude mice with human cutaneous squamous cell carcinoma (A431 cell line) deep to the parotid region overlying the masseter muscle. We sacrificed the animals 1 to 3 weeks postinjection, once a visible tumor growth was confirmed. We then asked 10 OHNS trainees to excise the tumor with preservation of the facial nerves under a high-magnification dissecting microscope. The trainees graded the tasks in several areas of specific measures using a visual analogue scale (VAS) including 1) tumor texture, 2) surgical realism, 3) usefulness, and 4) difficulty of the task. Noticeable tumor growth occurred within 5 days following A431 cell injection and reached measureable size (0.5-1.5 cm) within 1 to 3 weeks. The tumor displaced the facial nerve laterally and medially, with few demonstrating infiltration of the nerve. VAS scores (± standard deviation) were 8.1 (± 1.7), 7.7 (± 2.5), 9.0 (± 0.9) and 6.6 (± 1.9) for tumor texture, surgical realism, usefulness, and the difficulty of the task, respectively. We demonstrate a novel, reliable and cost-effective mouse model for simulating tumor extirpation microsurgery with preservation of important neural structures. OHNS trainees have found this simulation model to be realistic, useful, and appropriately challenging.

Fully Endoscopic Resection of Cerebellopontine Angle Meningiomas.

To describe our operative technique and results from patients who underwent fully endoscopic resection of cerebellopontine angle (CPA) meningiomas. Prospective observational study. A single academic institution that includes both neurosurgery and neuro-otology. Eleven consecutive patients who underwent fully endoscopic resection of a CPA meningioma. Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons score as well as facial nerve preservation base on the House-Brackmann (HB) score. In addition, the extent of resection and complication rates was studied. All 11 patients underwent successful gross total resection, Simpson grade 2, of their meningioma, seen both intraoperatively and on postoperative imaging. Overall, 100% of patients maintained normal facial nerve function (HB 1/6). Audiometric testing revealed that 10 of 11 patients maintained either stable or improved hearing postoperatively based on Committee on Hearing and Equilibrium Guidelines for the Evaluation of Hearing Preservation in Acoustic Neuroma grade with the remaining patient retaining serviceable hearing. Tumor size ranged from 0.5 to 2.5 cm (mean: 1.54 cm). Mean operative time was 166 minutes (range: 122-207 minutes); estimated blood loss averaged 54.5 mL. Hospital length of stay ranged from 2 to 6 days (mean: 3.1 days), and a superficial wound infection was the only complication seen in one patient. Fully endoscopic techniques can be used in CPA meningioma resection with excellent clinical results as an alternative to the traditional open microscopic approach.

Strategy for the surgical treatment of vestibular schwannomas in patients with neurofibromatosis type 2

ObjectiveGuidelines for appropriate management of vestibular schwannomas in NF2 patients are controversial. In this paper we reviewed our experience with patients with NF2 for the results of surgical treatment with particular reference to hearing and facial nerve preservation. MethodsWe included in the study 30 patients (16 women and 14 men) with the diagnosis of NF2 treated in our department between 1998 and 2014 who underwent surgery for vestibular schwannoma removal with a follow-up for at least 1 year. In 3 cases, the vestibular schwannomas were unilateral. Six patients with bilateral vestibular schwannomas underwent unilateral procedure. Therefore, 51 acoustic tumors were studied in 30 patients. ResultsNo operative death we noted. Significant deterioration to the non-functional level occurred in 19 out of 22 cases with well-preserved preoperative hearing. Only three ears maintained their preoperative good hearing. Hearing was preserved in cases of small schwannoma not exceeding 2cm. Among 21 patients who underwent bilateral operations hearing was preserved in 3 out of 7 cases when smaller tumor or better hearing level side was attempted at first surgery. In contrary none of the 14 patients retained hearing when the first operation concerned the worse-hearing ear. Among 14 tumors up to 2cm there was only one case of moderately severe facial nerve dysfunction (House–Brackmann Grade IV) in the long follow-up. ConclusionEarly surgical intervention for vestibular schwannoma in NF2 patient is a viable management strategy to maintain hearing function and preserve facial nerve function.

Role of Radiotherapy in Parotid Pleomorphic Adenoma: Two Case Reports and a Review of the Literature

Pleomorphic adenoma is the most common benign salivary gland neoplasm (%75-80). It is found mostly in the parotid gland in middle-aged women. The optimal treatment is superficial or total parotidectomy with facial nerve preservation, which results in local control rates of 95% or higher. Radiotherapy (RT) is indicated for ositive margins, unresectable tumours, and multifocal recurrences after prior resection. Local control rates after RT for microscopic and gross residual tumour are approximately 80% to 85% and 40% to 60%, respectively. In this article, we share our experience of 2 cases of recurrent pleomorphic adenoma. Key Words: Pleomorphic Adenoma; Radiotherapy; Treatment.

Intraoperative neuromonitoring for removal of large vestibular schwannoma: Facial nerve outcome and predictive factors

BackgroundPreservation of facial nerve (FN) function is one of the major goals for resection of large vestibular schwannoma (VS) (≥30mm). Little is known about the FN outcome and its predictive factors due to limited data. ObjectiveTo explore the predictive factors affecting FN outcome following resection of large VS. Methods106 Large VS patients underwent surgical resection from 2010 to 2012 via intraoperative neuromonitoring for FN preservation approach. Postoperative FN function evaluation was conducted at the time points of 3–7th day, 3rd month and at the end of the 2nd year. Correlation between tumor size, intraoperative parameters and FN function were examined. ResultsThe ratios of total and subtotal resection were 82.1% and 14.2%, respectively. Acceptable FN function was achieved in 78% patients. Patients with good FN function showed much smaller (P<0.01) VS size than those of poor-FN function patients at 3–7th day, 3rd month and 2nd year. There was a significant correlation between facial motor evoked potential (FMEP) ratios and postoperative FN function at 3–7th day (r=−0.709, P<0.001) 3rd month (r=−0.709, P<0.001) and 2nd year (r=−0.750, P<0.001). Maximal response amplitude (MRA) ratio was a supplementary indicator for train time in predicting both immediate and long-term FN function in patients with large VS. ConclusionIndicative factors of both immediate and long-term postoperative FN function in large VSs include tumor size, intraoperative train time, start to final FMEP ratios and proximal to distal MRA ratios.

Functional Preservation After Planned Partial Resection Followed by Gamma Knife Radiosurgery for Large Vestibular Schwannomas

The treatment goal for vestibular schwannomas (VS) has been changed from total removal of the tumor to functional preservation with long-term tumor growth control. The small- to medium-sized VS can be treated by stereotactic radiosurgery, but large VS require surgical decompression for the relief of cerebellar dysfunction and increased intracranial pressure. We have been performing planned partial surgical resections followed by gamma knife radiosurgery (GKS) for large VS. Here, we evaluate a recent series of such cases from the standpoint of functional outcomes. From January 2000 to May 2013, we treated 40 patients with large unilateral VS (maximum tumor diameter at least 25 mm) with planned partial tumor removal followed by GKS for functional preservation. The median maximum diameter of the tumors was 32.5 mm (range 25-52 mm). All patients underwent surgery via the retrosigmoid approach, and tumors situated on the ventral and in the internal auditory canal intentionally were not removed, thus preserving cranial nerve functions. GKS was performed 1-12 months after surgical resection (median interval 3 months). The median tumor volume at GKS was 3.3 cm(3) (range 0.4-10.4 cm(3)) and the median prescribed dose was 12 Gy (range 10-12 Gy). The median follow-up period after GKS was 65 months (18-156 months). At the final follow-up, facial nerve preservation (House-Brackmann grade I-II) was achieved in 38 patients (95%; House-Brackmann grade I: 92.5%, II: 2.5%). Among the 14 patients with preoperative pure tone average (PTA) less than 50 dB, 6 of them (42.9%) maintained PTA less than 50 dB at the last follow-up. Two patients improved from severe hearing loss to PTA less than 50 dB (1 patient after surgery and 1 patient one and half years after GKS). Five- and 10-year tumor growth control occurred in 86% of patients. Four patients (10%) required salvage surgery; the predictive factor was tumor volume greater than 6 cm(3) at GKS (P= 0.01). Planned partial removal of large VS followed by GKS achieved a high rate of facial nerve and hearing preservation. To achieve long-term tumor growth control, the tumor volume at GKS after planned partial surgical resection should be smaller than 6 cm(3). Our results revealed that patients with hearing preservation postoperatively have a chance of maintaining hearing function, even though the possibility exists of deterioration by long-term follow-up after surgical intervention and GKS. Furthermore, some patients with severe hearing loss before treatment have the chance of hearing improvement, even those with large VS.

Comparison of outcomes following complex posterior fossa surgery performed in the sitting versus lateral position

The sitting position during surgery is thought to provide important advantages, yet it remains controversial. We compared surgical and neurological outcomes for patients operated on in the sitting versus lateral position. Technically difficult procedures performed from the years 2001–2008 for complex lesions in the posterior fossa (vestibular schwannomas, other cerebellopontine angle tumors, foramen magnum meningiomas, brainstem cavernomas, pineal region tumors) were included. Outcomes in the two surgical positions were compared for all 243 patients (93 sitting, 38.3%; 150 lateral, 61.7%) and for 130/243 patients with vestibular schwannomas (50 sitting, 38.5%; 80 lateral, 61.5%). Sitting and lateral patient subgroups were clinically comparable. There were no surgical mortalities. The extent of removal and surgical and neurological outcomes were comparable. We found no advantage in surgical or neurological outcomes for use of the sitting or lateral surgical positions in technically difficult posterior fossa procedures. In vestibular schwannoma surgeries facial nerve preservation (House–Brackmann score 1–2) was related to extent of resection but not to surgical position. The choice of operative position should be based on lesion characteristics and the patient’s preoperative medical status as well as the experience and preferences of the surgeons performing the procedure.

Ossifying pilomatrixoma with marrow formation of the left cheek region – Case report with review of literature

Pilomatrixoma is a rare, benign, circumscribed, calcifying epithelial neoplasm that arises from the hair follicle on any part of the body. It may present to the otorhinolaryngologist as a palpable mass in the head and neck region. They are usually found in girls during the first two decades of life. These tumors may contain calcification, which, when present, is helpful in suggesting the diagnosis. We present a rare case of ossifying pilomatrixoma in a 15year old female who presented with a painless hard slow growing swelling over the left cheek region. FNAC could not provide any clue whereas USG and CT scan showed the swelling to be in subcutaneous plane, superficial to the parotid gland. Complete excision of the mass along with the overlying adherent skin in toto with preservation of facial nerve was done. The diagnosis was confirmed after histopathological examination of the excised specimen which revealed pilomatrixoma with extensive ossification and marrow formation.

Surgical outcomes of facial nerve hemangiomas in temporal bones

ObjectiveTo report surgical outcomes of 15 cases who had facial nerve hemangiomas. MethodsAll cases underwent complete removal of hemangiomas, and preservation of nerve integrity was attempted. The postoperative outcomes of facial nerve was assessed. ResultsNerve integrity was successfully preserved in 10 cases, all of which maintained or recovered to Grade I or Grade II, and facial nerve was sacrificed in 5 cases, who recovered to Grade III or Grade IV. ConclusionsWhen possible, facial nerve preservation should be attempted, which was critical to yield better outcomes of facial nerve.

Potential use of acupuncture in the treatment of first bite syndrome

ObjectivesFirst bite syndrome (FBS) is an early postoperative pain syndrome characterized by the sudden onset of pain in the parotid region at the first bite of each meal. The etiology is not certain, hence a standardized therapy does not exist. MethodsA 50-year old woman referred to us complaining of a swelling in the right parotid region. Fine-needle aspiration biopsy (FNAB) was diagnostic for pleomorphus adenoma of the deep lobe of the parotid gland. A 50-year old man presented with a mass in the right side of the neck, FNAB was diagnostic for parapharyngeal space neurinoma. The first patient was submitted to total parotidectomy with facial nerve preservation, the second to extracapsular dissection of the tumor. A week after surgery both patients developed FBS. A qualitative/quantitative description of pain was obtained by means of a self-coded questionnaire. The score ranges from 8 to 44, corresponding to the lowest and the highest discomfort possible, respectively. Acupuncture was used to treat these 2 patients. The treatment protocol comprised 6 sessions, one per week, lasting 30 minutes each. ResultsOur questionnaire was administered before and after treatment and the score dropped from 33 to 25 in the female, from 30 to 15 in the male patient. ConclusionFBS is a complication of upper cervical surgery with a high morbidity rate. We describe the first two cases of FBS that were successfully treated with acupuncture in our ENT department. We believe that this procedure may represent a valid therapeutic alternative in the future.