Near-normal Facial Function Research Articles

Endoscopic transcanal facial nerve decompression in Bell's palsy: A pilot study

PurposeTo explore the surgical effects of endoscopic facial nerve decompression in Bell's palsy. Materials and methodsThis retrospective study included 15 patients with Bell's palsy. All had grade VI (House-Brackmann grading system) complete unilateral facial paralysis before surgery and a >95% reduction in amplitude on electroneurography testing compared to the unaffected side. Their MRI results indicated perineural edema in the geniculate ganglion area. Endoscopic decompression surgery was performed soon after they presented at our hospital. The time between onset of facial paralysis and surgery ranged from 25 to 93 days. All patients had no relevant surgical history or ear diseases. ResultsAt 1-year follow-up, 13 of the 15 (87%) patients had recovered to normal or near-normal facial function (House-Brackmann grade I-II), and all patients had reached House-Brackmann grade III or lower facial function. No obvious air-bone gap or sensorineural hearing loss occurred after surgery, and there were no severe complications or synkinesis. ConclusionsEndoscopic transcanal facial nerve decompression provides a less traumatic and improved exposure of the geniculate ganglion, and may also help prevent permanent severe facial sequela. Results of intraoperative facial nerve stimulation may be related to the length of time required for recovery. The optimal time of surgery after onset of paralysis needs to be investigated further, to identify a post-drug surgical therapy which may be more acceptable for patients. Patients' response to conservative treatments should be assessed as soon as possible so as not to delay surgery.

Clinical Study of Bell's Palsy at Tertiary Care: Our Experience

Abstract Introduction Bell's palsy (BP) is the common cause of facial palsy. This study aims to report and analyze the age, sex distribution, symptomatology, site of lesion, and prognosis in 101 patients with (BP). Materials and Methods This is a cross-sectional study conducted at tertiary referral center, JSS Hospital, Mysuru. All patients consenting to participate in this study, of all ages, of either sex, both outpatients and inpatients with a diagnosis of BP during this study period were included. Results Of the 101 patients analyzed, maximum cases (25.7%) were in third decade of age; 55.4% were males, and both right and left sides of the face were equally involved. Maximum number of patients (50.5%) had a history of postaural pain at presentation Topodiagnostic tests showed majority of BP cases involving geniculate or suprageniculate regions (67.3%) in our study. 20.8% had lesion above the nerve to stapedius, and 11.9% had lesion below the nerve to stapedius. Electrodiagnostic test—electroneuromyography (ENMG)—was abnormal in 57 (67.1%) individuals at day 4. 50.4% of patients had a House-Brackmann (HB) facial nerve grade IV at presentation. 90% of the BP group in our study recovered normal to near-normal facial nerve function by the end of 28 days’ time. Conclusion Each case of BP should be evaluated with thorough clinical examination, topodiagnostic tests, and electrodiagnostic tests. Appropriate management will help in almost full recovery of disease.

Incidence and Risk Factors of Delayed Facial Palsy After Vestibular Schwannoma Resection.

Preservation of facial nerve function following vestibular schwannoma surgery is a high priority. Even those patients with normal to near-normal function in the early postoperative period remain at risk for delayed facial palsy (DFP). To evaluate the incidence and prognosis of DFP and to identify risk factors for its occurrence. A retrospective cohort study of 489 patients who underwent vestibular schwannoma resection at our institution between 2000 and 2014. Delayed facial palsy was defined as deterioration in facial function of at least 2 House-Brackmann (HB) grades between postoperative days 5 to 30. Only patients with a HB grade of I to III by postoperative day 5 were eligible for study inclusion. One hundred twenty-one patients with HB grade IV to VI facial weakness at postoperative day 5 were excluded from analysis. Of the remaining 368, 60 (16%) patients developed DFP (mean 12 days postoperatively, range: 5-25 days). All patients recovered function to HB grade I to II by a mean of 33 days (range: 7-86 days). Patients that developed DFP had higher rates of gross total resections (83% vs 71%, P = .05) and retrosigmoid approaches (72% vs 52%, P < .01). There was no difference in recovery time between patients who received treatment with steroids, steroids with antivirals, or no treatment at all (P = .530). Patients with a gross total tumor resection or undergoing a retrosigmoid approach may be at higher risk of DFP. The prognosis is favorable, with patients likely recovering to normal or near-normal facial function within 1 month of onset.

Facial Nerve Outcomes After Middle Fossa Decompression for Bell’s Palsy

Evaluate the long-term outcomes of facial nerve decompression via the middle fossa approach for Bell's palsy patients with poor prognosis based on clinical and electrodiagnostic testing. Retrospective case series. Tertiary-care, academic medical center. Fourteen patients underwent surgical decompression for Bell's palsy within 14 days of symptom onset from 2000 to 2012. Surgical criteria included greater than 90% degeneration on ENoG testing and no voluntary EMG potentials. Middle cranial fossa (MCF) bony decompression of the facial nerve, including the meatal foramen, labyrinthine segment, and geniculate ganglion. Long-term facial function, hearing results, and surgical complications. After MCF decompression, 10 patients (71.4%) regained normal or near-normal facial function (House-Brackmann [HB] I or II) within 1 year after surgery, and 5 of those patients (35.7%) improved to HB I. The remaining 4 patients (28.6%) improved to HB III. Patients older than 60 years (n = 3) had an HB III outcome and did significantly worse than the younger-than-60-years group (p = 0.002). The difference in preoperative and postoperative pure tone average and word recognition score was 2.1 dB and 0.9%, respectively. There were no major complications. Minor, transient complications occurred in 22.2% of patients. In patients with severe Bell's palsy at risk for a poor facial nerve outcome, MCF decompression of the facial nerve within 14 days of symptom onset provides good facial nerve outcomes with minimal morbidity.

Incidence and Risk Factors of Delayed Facial Palsy after Vestibular Schwannoma Resection

Introduction: Preservation of facial nerve function following vestibular schwannoma (VS) surgery is a high priority for both patients and surgeons. Even in those patients having normal or near-normal facial function in the early postoperative period, there remains the potential for delayed facial palsy (DFP). The purpose of this study was to evaluate the incidence and prognosis of DFP and to identify risk factors for its occurrence.

Hearing Preservation Surgery for Vestibular Schwannomas

Hearing preservation microsurgery for vestibular schwannomas (VSs) offers favorable hearing preservation rates for small tumors in patients with serviceable hearing. The natural history of VSs is slow growth of 1–2 mm per year; however, some tumors do not grow. Hearing loss can occur gradually or suddenly independent of tumor growth. Management options include observation, microsurgical removal, and radiosurgery. Hearing preservation rates are approximately 72 % with middle cranial fossa microsurgery for small tumors ( 70 % word discrimination). Hearing preservation is approximately 50 % with larger tumors not yet touching the brainstem. Longitudinal studies show a 5-year hearing preservation rate for observation of around 50 %. Radiosurgery should not be used as a hearing preservation modality as the 10-year serviceable hearing rates are only around 25 %. Also, observation and radiosurgery do not eradicate the tumor. Normal or near-normal facial nerve function rates are in the 90 % range for all three options. Thus, we favor microsurgical removal for small tumors in young healthy patients.

Subtotal resection of facial nerve schwannoma is not safe in the long run

Conclusions: Subtotal resection of facial nerve schwannoma (FNS) could obtain favorable facial nerve function recovery, but has a high recurrence rate in the long run. Subtotal resection with about 95% tumor resected could be considered in the elderly with good facial nerve function, but is not recommended for younger patients. Subtotal resection with about 70–80% tumor resected should be replaced by complete tumor removal and nerve grafting. Objectives: To present long-term follow-up results of subtotal resection of FNS and discuss the indications for subtotal resection. Methods: We performed subtotal resection of FNS in 15 cases and they were followed up for 7 years on average. Results: In all, 93.3% of cases finally gained normal or near-normal facial nerve function (House-Brackmann (HB) grade I or II) and one case maintained grade III. Tumor recurrence or regrowth was noted in four cases (26.7%) during follow-up. Recurrence was observed in 10% of cases who had about 95% tumor resected and in 60% of cases who had 70–80% tumor resected.

Lower Cranial Nerve Function Following Jugular Foramen Tumor Resection

Objective: Describe the presentation, tumor characteristics, and postoperative lower cranial nerve function following surgery for jugular foramen tumors. Method: Thirty jugular foramen tumor resections performed between 1989 and 2009 were reviewed. The mean age was 48.2 years (range, 18.6-77.7 years) at time of presentation. Surgical approaches included infratemporal fossa (70%), retrosigmoid (23%), transtemporal (20%), transcondylar (17%), and transcervical (17%). The mean follow-up was 4.6 years. Results: Combined surgical approaches were used in over 50% of the cases, and 60% underwent preoperative tumor embolization. Tinnitus was the most common presenting symptom, and middle ear or neck mass was the most common presenting sign. The most common diagnosis was paraganglioma. Six patients required tracheotomy, and 8 had feeding tubes at discharge. Fifty-seven percent of patients underwent speech or swallow therapy, 43% were treated with vocal cord injections, and 17% underwent medialization thyroplasty. Cerebrospinal fluid leak was uncommon (13%), and meningitis occurred in 1 patient. Normal or near-normal facial nerve function was maintained in 89% of patients. Conclusion: Resection of jugular foramen tumors carries a significant risk of lower cranial nerve dysfunction; however, long-term speech, airway, and swallowing morbidity can be minimized with contemporary ancillary surgical procedures.

Prognostic factors for the incidence and recovery of delayed facial nerve palsy after vestibular schwannoma resection

Preservation of facial nerve function in vestibular schwannoma (VS) resections remains a significant operative challenge. Delayed facial palsy (DFP) is one specific challenge yet to be fully elucidated. The aim of this study was to evaluate DFP among VS resection cases to identify significant prognostic factors associated with its incidence and clinical recovery. This investigation involves a retrospective review of 104 cases of VS resection that occurred between December 2005 and May 2007. Patients who developed DFP were compared with patients exhibiting no facial palsy postoperatively with regard to surgical approach, severity and day of palsy onset, tumor size, intraoperative facial nerve monitoring, and postoperative recovery and treatment. Patients who demonstrated immediate facial palsy (IFP) following VS resection were also analyzed. Furthermore, specific analyses were performed in 2 distinct DFP patient groups: those who developed DFP after postoperative Day 3 ("late onset DFP"), and those whose palsy worsened after initial DFP identification ("deteriorators"). Of the 104 patients who underwent VS resection, 25.0% developed DFP and 8.6% demonstrated IFP postoperatively. The DFP group did not differ significantly in any measure when compared with patients with no postoperative facial palsy. However, patients with DFP presented with significantly smaller tumor sizes than patients with IFP. This IFP group averaged significantly smaller intraoperative facial nerve responses than patients without facial palsy, and larger tumor sizes than both the DFP and no facial palsy groups. Within the DFP group, patients with late onset DFP showed diminished intraoperative facial nerve responses when compared with the total DFP patient population. In total, 25 (96.2%) of 26 patients with DFP and 7 (77.8%) of 9 patients with IFP recovered to normal or near-normal facial function (House-Brackmann Grade I or II) at longest clinical follow-up. Although patients with DFP did not exhibit any distinguishable characteristics when compared with patients without postoperative facial palsy, our analysis identified significant differences in patients with palsy presenting immediately postoperatively. Further study of patients with DFP should be undertaken to predict its incidence following VS resection.

Vestibular schwannoma microsurgery with special reference to facial nerve preservation

Objective To retrospectively study the outcomes of vestibular schwannoma (VS) resection. Methods Between January 2003 and December 2006, 103 consecutive patients who had undergone VS resection were included in this study. Medical records, operation summaries, follow-up data, and neuroradiological findings were analyzed. The relationship between tumor size, location, and topography relative to the facial nerve bundles was studied for a mean duration of 16 months (range: 3–39 months). Results Complete tumor resection in combination with anatomic preservation of the facial nerve was achieved in 101 (98.1%) cases. The facial nerve was fully preserved in 100% of cases with small or medium tumors and in 37/39 patients with large tumors. Overall, 83.5% of patients had normal or near-normal facial nerve function 3–12 months post-surgically. The mortality rate was 0%. Conclusions Even in large VS, preservation of facial nerve function (H-B Grade I or II) should be prioritized over total resection. For tumors >3 cm, the goal of low morbidity and maintenance of normal facial nerve function can be attained with the retrosigmoid transmeatal approach, refined microsurgical technique, and intraoperative facial nerve monitoring.

Resection of large vestibular schwannomas: facial nerve preservation in the context of surgical approach and patient-assessed outcome

Vestibular schwannoma surgery has evolved as new therapeutic options have emerged, patients' expectations have risen, and the psychological effect of facial nerve paralysis has been studied. For large vestibular schwannomas for which extirpation is the primary therapy, the goals remain complete tumor resection and maintenance of normal neurological function. Improved microsurgical techniques and intraoperative facial nerve monitoring have decreased the complication rate and increased the likelihood of normal to near-normal postoperative facial function. Nevertheless, the impairment most frequently reported by patients as an adverse effect of surgery continues to be facial nerve paralysis. In addition, patient assessment has provided a different, less optimistic view of outcome. The authors evaluated the extent of facial function, timing of facial nerve recovery, patients' perceptions of this recovery and function, and the prognostic value of intraoperative facial nerve monitoring following resection of large vestibular schwannomas; they then analyzed these results with respect to different surgical approaches. The authors retrospectively reviewed a database of 67 patients with 71 vestibular schwannomas measuring 3 cm or larger in diameter. The patients had undergone surgery via translabyrinthine, retrosigmoid, or combined approaches. Clinical outcomes were analyzed with respect to intraoperative facial nerve activity, responses to intraoperative stimulation, and time course of recovery. Eighty percent of patients obtained normal to near-normal facial function (House-Brackmann Grades I and II). Patients' perceptions of facial nerve function and recovery correlated well with the clinical observations. Trends in the data lead the authors to suggest that a retrosigmoid exposure, alone or in combination with a translabyrinthine approach, offers the best chance of facial nerve preservation in patients with large vestibular schwannomas.

Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery: etiology and prevention

Facial nerve injury associated with acoustic neuroma surgery has declined in incidence but remains a clinical concern. A retrospective analysis of 611 patients surgically treated for acoustic neuroma between 1973 and 1994 was undertaken to understand patterns of facial nerve injury more clearly and to identify factors that influence facial nerve outcome. Anatomical preservation of the facial nerve was achieved in 596 patients (97.5%). In the immediate postoperative period, 62.1% of patients displayed normal or near-normal facial nerve function (House-Brackmann Grade 1 or 2). This number rose to 85.3% of patients at 6 months after surgery and by 1 year, 89.7% of patients who had undergone acoustic neuroma surgery demonstrated normal or near-normal facial nerve function. The surgical approach appeared to have no effect on the incidence of facial nerve injury. Poor facial nerve outcome (House-Brackmann Grade 5 or 6) was seen in 1.58% of patients treated via the suboccipital approach and in 2.6% of patients treated via the translabyrinthine approach. When facial nerve outcome was examined with respect to tumor size, there clearly was an increased incidence of facial nerve palsy seen in the immediate postoperative period in cases of larger tumors: 60.8% of patients with tumors smaller than 2.5 cm had normal facial nerve function, whereas only 37.5% of patients with tumors larger than 4 cm had normal function. This difference was less pronounced, however, 6 months after surgery, when 92.1% of patients with tumors smaller than 2.5 cm had normal or near normal facial function, versus 75% of patients with tumors larger than 4 cm. The etiology of facial nerve injury is discussed with emphasis on the pathophysiology of facial nerve palsy. In addition, on the basis of the authors' experience with these complex tumors, techniques of preventing facial nerve injury are discussed.

Late-onset facial nerve degeneration after vestibular schwannoma surgery: incidence, putative mechanisms, and prevention

Delayed facial nerve dysfunction after vestibular schwannoma surgery is a poorly understood phenomenon that has been reported to occur in 15 to 29% of patients undergoing microsurgery. It is a condition characterized by spontaneous deterioration of facial nerve function in a patient who has otherwise normal or near-normal facial function in the immediate postoperative period. This delayed paralysis is generally reported to occur in the first few days postsurgery, with the majority of patients eventually recovering their immediate postoperative facial function. However, infrequently, it can also occur more than 1 week after surgery (so-called late-onset facial nerve palsy). The authors reviewed facial nerve outcome in 611 patients who underwent microsurgery between 1973 and 1994. The facial nerve was anatomically preserved in 596 patients (97.5%), and 90% of patients had House-Brackmann[6] Grade 1 or 2 function 1 year after surgery. Late-onset facial dysfunction was seen in 13 patients (2.1%). All of these had significant deterioration in facial nerve function between 1 and 4 weeks postoperatively, and all showed improvement by 1 year. In this study, the focus on these patients who developed late-onset facial palsy. The incidence, treatment strategies, and outcomes will be discussed with emphasis on possible pathophysiological mechanisms that contribute to this relatively rare condition.

Decompression of the labyrinthine segment of the facial nerve in acoustic neuroma surgery: a consideration for minimizing postoperative delayed facial nerve dysfunction

Delayed facial nerve palsy, a condition characterized by spontaneous deterioration of facial nerve function in patients who had otherwise normal or near-normal facial function in the immediate postoperative period, has been reported in 15 to 29% of patients undergoing microsurgical resection of vestibular schwannomas. One putative mechanism for its occurrence suggests that edematous entrapment of the facial nerve in the meatal foramen (the narrowest segment of the internal auditory canal) may lead to nerve ischemia or necrosis and subsequent facial nerve dysfunction. To assess whether meatal decompression may help reduce the incidence of delayed facial nerve palsy during microsurgical resection of acoustic tumors, we compared 25 patients undergoing translabyrinthine removal of acoustic neuromas who received prophylactic decompression of the labyrinthine segment of the facial nerve (Group 1) with 40 patients who did not receive facial nerve decompression (Group 2). No patients in Group 1 had a delayed progressive facial paralysis with degeneration. In contrast, when Group 2 patients with larger, average-sized tumors were reviewed, eight patients (20%) developed delayed degeneration. These findings suggest that decompression of the labyrinthine segment may be of value in acoustic tumor surgery in reducing delayed facial nerve dysfunction. Further study is indicated in this important area.

Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery: etiology and prevention.

Facial nerve injury associated with acoustic neuroma surgery has declined in incidence but remains a clinical concern. A retrospective analysis of 611 patients surgically treated for acoustic neuroma between 1973 and 1994 was undertaken to understand patterns of facial nerve injury more clearly and to identify factors that influence facial nerve outcome. Anatomical preservation of the facial nerve was achieved in 596 patients (97.5%). In the immediate postoperative period, 62.1% of patients displayed normal or near-normal facial nerve function (House-Brackmann Grade 1 or 2). This number rose to 85.3% of patients at 6 months after surgery and by 1 year, 89.7% of patients who had undergone acoustic neuroma surgery demonstrated normal or near-normal facial nerve function. The surgical approach appeared to have no effect on the incidence of facial nerve injury. Poor facial nerve outcome (House-Brackmann Grade 5 or 6) was seen in 1.58% of patients treated via the suboccipital approach and in 2.6% of patients treated via the translabyrinthine approach. When facial nerve outcome was examined with respect to tumor size, there clearly was an increased incidence of facial nerve palsy seen in the immediate postoperative period in cases of larger tumors: 60.8% of patients with tumors smaller than 2.5 cm had normal facial nerve function, whereas only 37.5% of patients with tumors larger than 4 cm had normal function. This difference was less pronounced, however, 6 months after surgery, when 92.1% of patients with tumors smaller than 2.5 cm had normal or near normal facial function, versus 75% of patients with tumors larger than 4 cm. The etiology of facial nerve injury is discussed with emphasis on the pathophysiology of facial nerve palsy. In addition, on the basis of the authors' experience with these complex tumors, techniques of preventing facial nerve injury are discussed.

Surgical Management of Iatrogenic Facial Nerve Injuries

Surgical management of an iatrogenic facial nerve injury represents a significant challenge for the otologic surgeon. The decision to perform facial nerve grafting is a difficult one and is based on the extent of injury to the nerve. We conducted a review of 22 patients who had sustained iatrogenic facial nerve injuries during otologic surgery that required surgical exploration. The facial nerve was transected more than half its diameter in 13 of the patients. All of these patients' nerves were repaired either with direct reanastomosis of the facial nerve or with a cable nerve graft. The transection was less than 50% in nine of the patients in the study group. Eight of these patients underwent only decompression of the facial nerve. No patient with a neural repair (direct anastomosis or cable graft) had better than a House grade III result. All of the patients undergoing direct anastomosis of the nerve obtained a House grade III result. The most common result in patients undergoing cable nerve grafting was a House grade IV. The only patients with normal or near-normal facial nerve function (House grade I or II) had only decompression of the facial nerve. Five of the eight patients undergoing decompression had results similar to those undergoing cable nerve grafts. We conclude that acceptable results can be obtained when the facial nerve is repaired by direct anastomosis or a cable nerve graft. These results are comparable with those of patients treated with decompression only. When in doubt as to the extent of injury, it is preferable to repair the facial nerve, because the extent of injury may be underestimated.

Intraoperative facial nerve monitoring in posterior fossa acoustic neuroma surgery.

Intraoperative facial nerve monitoring has become an indispensable tool during cerebellopontine angle surgery. Ninety-seven patients underwent surgical removal of an acoustic neurinoma with the use of a pneumatic sensor monitoring between January 1, 1986, and December 31, 1990. In the early postoperative period, a normal or near-normal facial function (grades I and II) was achieved in 86% of the patients, a moderate dysfunction (grade III) was present in 7%, and a total or severe dysfunction (grades V or VI) was present in 6%. Normal function at 1 year was achieved in 90.5% of the patients, 4% were grade II, a moderate dysfunction (grade III) was present in 2%, and 3% showed a total or severe dysfunction (grade V and VI). The incidence of normal function decreased with tumor size, with an occurrence rate of 100%, 94%, and 91% in small, medium, and large tumors, respectively. In eight consecutive patients, all responses detected by the monitoring during the operation were collected and analyzed according to intraoperative events. Analysis of the results indicate that 95% of the 316 mechanically induced stimulations were of small or extremely small amplitude, and only 5% were of moderate amplitude. A medial-to-lateral strategy of dissection, preservation of the arachnoid veil over the facial nerve, a control by the monitoring of the amount of traction, and a more widespread use of sharp dissection were the major approaches to reduce surgical trauma during dissection.