Permanent Facial Paralysis Research Articles

Bilateral temporal bone fractures: a case report

<p>Bilateral temporal bone fractures are rare; accounting for 9% to 20% of cases of temporal bone fractures. Clinical manifestations include hearing loss, facial paralysis, CSF otorhinorrhea and dizziness. This is a case report of a patient who presented with bilateral temporal bone fractures. This is a report of a 23-yr-old male who sustained bilateral temporal bone fractures and presented 18 days later with complaints of watery discharge from left ear and nose, bilateral profound hearing loss and facial weakness on the right side. Pure tone audiometry revealed bilateral profound sensori-neural hearing loss. CT temporal bones & MRI scans of brain were done to assess the extent of injuries. The patient underwent left CSF otorrhea repair, as the CSF leak was active and not responding to conservative management. One week later, the patient underwent right facial nerve decompression. The patient could not afford a cochlear implant (CI) in the right ear at the same sitting, however, implantation was advised as soon as possible because of the risk of cochlear ossification. The transcochlear approach was used to seal the CSF leak from the oval and round windows on the left side. The facial nerve was decompressed on the right side. The House-Brackmann grade improved from Grade V to grade III at last follow-up. Patients with bilateral temporal bone fractures require prompt assessment and management to decrease the risk of complications such as meningitis, permanent facial paralysis or hearing loss. </p>

Branchial anomalies in children: A report of 105 surgical cases

BackgroundBranchial anomalies (BAs) account for 20% of all congenital masses in children. We sought to review the incidence of involvement of individual anomalies, diagnostic methods, surgical treatment, and complications of BAs in children. In addition, we also classified our study and analyzed a congenital lower neck cutaneous fistula near the sternoclavicular joint that was thought to be the skin-side remnant of the fourth BAs. MethodsWe conducted a retrospective analysis of 105 children who were referred to our hospital from June 2009 to December 2016 for the treatment of BAs. ResultsIn this series, there were 51 males and 54 females. The age at the time of operation varied from 19 days to 13 years, and the mean age was 4.5 years. A total of 33 (31.4%) cases presented with first BAs, 13 (12.4%) presented with second BAs, and 59 (56.2%) presented with third and fourth BAs, including 6 cases of congenital lower neck cutaneous fistula. Fistulectomy under general anesthesia was performed on all of them. For postoperative complications, 2 cases had temporary facial paralysis, 1 case had permanent facial paralysis, 4 cases had temporary recurrent laryngeal nerve injury. Recurrence occurred in 2 patients with first BAs after medium follow-up time of 3.6 years (6 months–8 years). ConclusionsBAs are common congenital head and neck lesions in children, and there are four distinct types (first, second, third and fourth anomalies). The incidence of third and fourth BAs in Asia maybe higher when compared with literature reports, second BAs seem rare in this population, but more research is needed to confirm this perspective. Diagnosis is not difficult with a proper knowledge of the anatomy of the BAs. The surgical procedures should be tailored depending on the various types, and complete excision of the fistula is the key to prevent recurrence.

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

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

Mandibular Condylar Fractures in Children: Morphofunctional Results After Treatment With External Fixation.

Best treatment for paediatric patients with mandibular condylar fractures is still debated, and many approaches have been proposed. Closed treatment is the most used, but there is evidence showing long-term problems in patients with dislocated fractures. On the other hand, there are concerns on surgical treatment with open reduction internal fixation, particularly on the implanted hardware during growth. The aim of this study is to evaluate the long-term outcomes of paediatric patients treated surgically with external fixation. A total of 21 paediatric patients were treated. Diagnostic procedures included clinical and radiographic examinations. Of those 21 patients, 16 presented monocondylar fractures, 5 bicondylar fractures. They were treated surgically with open reduction and external fixation. Patients showed good recovery in maximal mouth opening, maximal lateral excursion and in vertical height of ramus, and all returned to preinjury occlusion. No patient presented permanent facial nerve palsy, and none referred pain or stiffness in the operated area. Minimal scars were visible. Just 1 patient referred clicking in the operated temporo-mandibular joint. Surgical approach using external fixation could be considered an option for treatment of mandibular condylar fractures in paediatric patient. Vertical height recovery, early mobilization, and good occlusion can be achieved, minimizing the risk of facial asymmetry.

Facial nerve paralysis postparotidectomy: A retrospective review of the prevalence and risk factors at a tertiary center

Objective: Facial nerve paralysis is one of the most devastating complications after parotid gland surgery. We aimed to determine the prevalence and risk factors of facial palsy after parotidectomy.Methods: We performed a retrospective review of the data from 54 patients who underwent parotid surgery between 2004 and 2015 at a tertiary medical care center. The prevalence of facial nerve paralysis and possible risk factors (demographic characteristics, tumor characteristics, and operative factors) associated with postoperative paralysis were assessed. Categorical variables were evaluated using the Fisher’s exact test, and a two-tailed t-test was used to assess the associations between continuous and binary outcome variables.Results: The postparotidectomy prevalence of temporary and permanent facial nerve paralysis were 26% and 13%, respectively. Tumors involving both lobes were significantly associated with permanent facial nerve paralysis (p = .048). Long operative duration (> 164 minutes) was associated with both temporary and permanent facial nerve paralysis (p = .040).Conclusions: Operative factors such as operative duration and tumor characteristics such as bilobal involvement increased the risk of postparotidectomy facial nerve paralysis. Such factors should be considered to reduce the risk of palsy in patients undergoing parotidectomy.

219 A Clinical Analysis on Microvascular Decompression Surgery for Treatment of Hemifacial Spasm

Abstract INTRODUCTION Hemifacial spasm (HFS) is caused by vascular compression of the facial nerve at its root exit zone from the brainstem. Microvascular decompression (MVD) is the only treatment option that offers the prospect of a definitive cure for HFS. However, this surgery can be risky and the postoperative outcomes might not be good enough sometimes. In order to refine that, we investigated our result of MVDs. METHODS Among 2500 consecutive cases of MVDs have been performed in our institute between January 2000 and December 2015, 2196 patients were enrolled in the current study. They were retrospectively analyzed with emphasis on postoperative outcomes and complications. RESULTS >Postoperatively, the spasm complete cease occurred immediately in 73.4%. The symptoms improved at some degree in 22.7%. The spasm not improved at all in 3.9%. However, the symptom free rate was 88.3% at 6 months after surgery. Eventually, the successful rate was increased by 93.1% at 1 year after MVD. Major complications included permanent hearing disturbance (1.13%), permanent facial palsy (0.4%), vertebral artery injury (0.2%), subdural hemorrhage (0.2%), and epidural hemorrhage (0.1%). Minor complications included transient cerebrospinal fluid leakage (1.3%), infection (0.6%). CONCLUSION MVD is a safe and effective treatment for HFS. A precise recognition of the neurovascular conflict site lead to a successful MVD.

Extracapsular dissection versus superficial parotidectomy for treatment of parotid benign tumors: evidence based medicine analysis

Objective:The aim of this study is to systematically assess the clinical outcomes of extracapsular dissection (ECD) and superficial parotidectomy (SP), and to provide evidences for the clinical decision for treatment of parotid gland benign tumors. Method:Relevant studies that compared the outcomes of extracapsular dissection and superficial parotidectomy for the parotid benign tumors were searched in Pubmed, CNKI and Wangfang data databases, and Meta-analysis was performed using software RevMan 5.0. Result:Fifteen studies were selected for the Meta-analysis. A total of 2 929 participants were included in those studies, of which 1 796 underwent ECD and 1 133 underwent SP. The recurrence rates for ECD and SP were 1.29% (23 of 1 776 cases) and 1.48% (16 of 1 081 cases), respectively. There were no statistically significant in recurrence rate between ECD and SP. The rates of transient facial nerve paresis for ECD and SP were 5.48% (74 of 1 350) and 22.94% (139 of 606), that of permanent facial nerve paralysis were 0.66% (8 of 1 221) and 2.71% (15 of 554). The incidences of Frey's syndrome in ECD group and SP group were 1.91% (26 of 1 360) and 16.71% (111 of 664), that of fistula in were 0.53% (5 of 946) and 2.96% (10 of 338). ECD could reduce the risk for complications compared with SP. Conclusion:This systematic review with Meta-analysis suggests that ECD has a similar recurrence rate as SP with fewer postoperative complications. ECD may be considered as an alternative surgical modality for select benign parotid tumor.

First branchial cleft anomalies in children: Experience with 30 cases.

First branchial cleft anomalies (FBCA) are rare in the clinical setting, as they account for 1 to 8% of all branchial abnormalities. The purpose of this study is to explore the relationship between the fistula tract and facial nerve and the surgical method of FBCA. This retrospective study included 30 cases of FBCA in children managed from 2009 to 2016. All patients underwent surgery to remove the tract of the FBCA. We reviewed the clinical data of the patients to obtain their demographics and management. Thirty patients (11 male and 19 female) with anomalies of FBCA were diagnosed. The ages ranged from 1 to 13 years (median, 3 years). Twenty cases had a close relationship with the parotid gland. The facial nerve was identified in 20 of the 30 patients. The tract ran deep to the facial nerve in 3 cases, superficial to it in 21 cases, and passed between the branches of the nerve in 6 cases. The facial nerve was not identified in ten patients, as the tract was superficial to it. There were 2 cases of postoperative temporary facial paralysis (2/30, 6.7%). The symptoms gradually improved after one month, 1 case had permanent facial paralysis (1/30, 3.3%), and 1 case had postoperative recurrence. Complete excision of the tract is the only way to manage FBCA, and the course of the tracts vary and have different relationships with the facial nerve. There are 3 types: Superficial, deep to the facial nerve, and between the branches of the nerve. Therefore, surgical approaches differ among the various types, and careful preoperative planning and protecting the facial nerve during resection of the tract are essential.

Comprehensive analysis of parotid mass: A retrospective study of 369 cases

ObjectiveTo present the results of patients who underwent superficial or total parotidectomy because of parotid gland tumors in our tertiary care clinic. MethodsThe data of 362 patients who underwent parotid surgery from January 2008 to November 2015 were collected and analyzed in demographic, histopathological features, and complications. ResultsThree hundred sixty-nine cases (performed in 359 patients) were analyzed and we assessed complications of parotid surgery such as transient or permanent facial paralysis and Frey’s syndrome. Pleomorphic adenomas and Warthin’s tumors consisted 74% of all parotid gland tumors. These tumors were generally located in the superficial lobe and tail of the parotid gland (81%). Also, tumor size in the positive surgical margin group was larger than in the negative surgical margin group (p=0.012). ConclusionsMost of parotid gland tumors are benign. However, the frequency of malignancy increases in deep lobe of parotid gland. High grade malignant tumors have more tendency to have positive surgical margin during surgery, and facial paresis preoperatively.

Complications and Management of Large Intracranial Vestibular Schwannomas Via the Retrosigmoid Approach.

To investigate the common complications from the microsurgical treatment of large intracranial vestibular schwannoma (VS) via suboccipital retrosigmoid approach and to propose strategies for minimizing such complications. We selected all patients with large unilateral VS from the collected database (1999-2013) who underwent microsurgical resection as their initial treatment for histopathologically confirmed VS. Tumors larger than 30× 20 mm were defined as large. A total of 1167 patients with VS were included. Gross total tumor resection was achieved in 1006 patients (86.2%). The mortality rate is 0.77%. The facial nerve was preserved anatomically in 1083 cases (92.8%), and the functional valuation of the facial nerve according to postoperative House-Brackmann scale showed 423 patients (36.2%) in grades I-II, 534 cases (45.8%) in grade III, and 210 patients (18.0%) in grade IV-VI. The main short-term postoperative complication included new hearing loss (American Institute of Otolaryngology-Head and Neck Surgery grade D) in 634 cases (54.3%), disequilibrium in 250 cases (21.4%), labial herpes in 127 cases (10.9%), meningitis in 115 (9.85%) and lower cranial nerve deficit in 77 cases (6.59%). Follow-up data were available for 978 of the 1167 patients (83.8%). Long-term complications include hearing loss (American Institute of Otolaryngology-Head and Neck Surgery grade D) (75.8%), permanent facial paralysis (11.9%), facial numbness (10.9%), tinnitus (2.96%), chronic headache (2.25%), and taste disturbance (1.43%). The key factors for reducing surgical complications include careful assessment of the functions of acoustic and facial nerves as well as a thorough understanding of anatomy via the retrosigmoid approach before operation, skillful microsurgical technique, and monitoring of multiple cranial nerves during resection.

The role of continuous intraoperative neuromonitoring followed by facial nerve stimulation during parotidectomy

Abstract BACKGROUND. Intraoperative neural monitoring (IONM) has begun to be studied in detail by surgeons around the world since several decades ago from the need to verify functional integrity of the neural elements. Parotid gland surgery requires a thorough knowledge of the anatomy of this region by ENT surgeons. Also, the surgeons performing parotid surgery need to have important strategies of management which include: handiness to identify facial nerve, dissection nerve branches and application of neuromonitoring in order to preserve nerve functions. OBJECTIVE. This study has analysed the usefulness of intraoperative continuous monitoring in superficial or in total parotidectomy. It identifies the facial nerve and reduces the risk of postoperative facial palsy. We have been using intraoperative continuous monitoring - evoked facial nerve electromyograms (EMG). MATERIAL AND METHODS. Continuous intraoperative facial nerve monitoring was prospectively achieved in the case of three patients diagnosed with benign tumors, on which parotidectomy with the preservation of the nerve was carried out in order to highlight the value and efficacy of this method. RESULTS. In our country, continuous intraoperative facial nerve monitoring performance is still not a common practice in ENT Departments. It revealed postoperatively that the incidence of temporary or permanent facial palsy was 0% and the minimal stimulation was obtained at levels equal to 0,5 mA, which implies integral functioning of the facial nerve. CONCLUSION. In parotid surgery, facial nerve IONM represents the gold standard in recognition of real-time electrophysiological signals, electromyography waves and auditory signals to enable the correct approach wherever possible, avoiding extensive nerve damage. It is known the importance of continuous IONM in postoperative prognosis of the neural function and intraoperative decision making regarding the technical surgery.

Traumatic arteriovenous fistula of the left parotid region: A case report.

The formation of arteriovenous fistula beneath the parotid is relatively rare. To the best of our knowledge, the present study reports the first case of a 48-year-old man with a pulsatile mass on the left parotid region, which had been present for >3 years following penetrating wounds. Computed tomography angiography and digital subtraction angiography revealed a fistula between the left external carotid artery and the left jugular vein. The patient was successfully managed through surgical excision without embolization. Intraoperative facial nerve monitoring was employed to prevent postoperative facial paralysis. The present study briefly reviewed the current literature, illustrating the pathophysiology, symptoms, imaging studies and treatment for arteriovenous fistula in the head and neck region. To conclude, arteriovenous fistula located near the facial nerve may be successfully managed by surgical treatment, without permanent facial paralysis.

Parotid gland tumours in the ENT Department in Międzyleski Hospital in Warsaw between 2007 and 2014.

Parotid gland tumours comprise 3% of all head and neck tumours. Although uncommon they are a histologically diverse group of tumors. The WHO classification of salivary gland tumours from 2005 recognizes 24 different malignant subtypes. They present different clinical courses and varying prognoses. Nearly 80% of salivary gland tumours are located in the parotid gland. Our study evaluated retrospectively 445 patients with parotid gland tumours treated in our hospital in the period between 2007 and 2014. We analyzed surgical treatment and histological diagnosis. There were 253 (56.9%) women and 192 (43.1%) men. The incidence of benign neoplasms was 90%. The most frequent benign tumour was pleomorphic adenoma (46%) and Whartin's tumour (35%). The most commonly found malignant tumour was acinic cell carcinoma (23%) and adenocarcinoma (13%). Non-Hodgin lymphoma in the parotid gland constituted nearly 17% of all malignant lesions. Hybrid tumours were diagnosed in 5 cases. Each patient underwent surgical procedure. Temporary facial nerve paralysis after surgery was diagnosed among 10 patients. Additionally, among 4 patients permanent facial nerve paralysis was diagnosed, which appeared before surgery or during surgical resection of the infiltrated facial nerve. In this study the frequency of benign neoplasms was higher and its histopathology was different than in the literature. The most common malignant parotid gland neoplasm was acinic cell carcinoma. The study presents 5 cases of hybrid neoplasms which are very uncommon and cause difficulties with prognostic evaluation and treatment selection.

Facial and vestibular neuropathy of unknown origin in 16 dogs.

The aim of this study was to describe the signalment, clinical presentation, diagnostic findings and long-term follow-up in dogs with concomitant facial and vestibular neuropathy of unknown origin. Appropriate cases were located through medical record searches. Inclusion criteria comprised dogs that had: clinical signs of facial paralysis with concomitant peripheral vestibular syndrome, thyroid function tests, no abnormalities on magnetic resonance imaging of the brain and tympanic bullae, and cerebrospinal fluid analysis. Sixteen dogs met the inclusion criteria. Facial paralysis had acute onset (<24 hours) in all dogs, thyroid function was within normal limits. There was albuminocytologic dissociation in cerebrospinal fluid of 69% of the dogs. There was complete resolution of clinical signs in 31% of the dogs but 38% showed long-term vestibular deficits, 46% developed hemifacial contracture, 15% had permanent facial paralysis and 15% relapsed. Facial and vestibular neuropathy of unknown origin shares similarities with idiopathic facial paralysis. The prognosis for return of normal facial and vestibular function is guarded and there may be relapse after recovery.

Outcomes After Cochlear Implantation in the Very Elderly.

To evaluate the outcomes after cochlear implantation (CI) in the elderly population, with a particular emphasis on perioperative complications, dizziness, and speech perception outcomes. A retrospective cohort study of elderly cochlear implant patients. Tertiary referral center (Cochlear Implant Clinic, Royal Victorian Eye and Ear Hospital, Melbourne). All patients aged 75 and above at the time of first cochlear implant (N = 150). Comparison was made between groups aged 85+ to 80-84, and 75-79. All patients received Nucleus devices (either CI512 or CI24RE(CA)). Speech recognition scores both pre- and postimplantation, symptomatic dizziness and effects upon independent living after surgery, and the incidence of perioperative medical and surgical complications. Complications were classified as major (intrinsic device failure, device migration, extracochlear insertion, meningitis, surgical site infection requiring reoperation, wound breakdown, permanent facial nerve paralysis) and minor (tinnitus, transient facial nerve palsy, facial nerve stimulation, taste disturbance, delayed wound healing). All three cohorts had poor preoperative speech perception. There was significant improvement in postoperative word scores at 3 and 12 months across all groups. There was no statistically significant difference between the three cohorts in terms of speech recognition outcomes at 3 and 12 months. After surgery, more than 20% of patients at all ages experienced transient imbalance, although the incidence did not differ significantly between age groups (p = 0.71). In total, there were 13 major complications in 7 patients (4.7%), and 28 minor complications in 25 patients (16.7%). Postoperative disequilibrium was commonly observed in this elderly population, yet patients still benefited with improved speech perception after cochlear implantation. Elderly patients can benefit from cochlear implantation, and age should not be a limitation for CI surgery. Cochlear implantation can be done safely and provides significant patient benefits.

Retroauricular hairline incision を用いた耳下腺良性腫瘍手術

An S-shaped incision is most frequently used for surgeries on benign parotid gland tumors. Surgical procedures using a retroauricular hairline incision (RAHI) for parotid gland tumors was first reported in 2009, but no such case has been reported from Japan. Because RAHI leaves no trace of visible scarring in the face and neck, it is more favorable in terms of cosmetics than an S-shaped incision. We operated on 25 cases of benign parotid gland tumors using RAHI between February 2012 and June 2014. In this report, we give a detailed description of the RAHI procedure, and quantify and compare operative time, bleeding, and complication rate between RAHI procedure and conventional methods. The mean operative time was 150.2 min. Permanent facial paralysis was observed any RAHI case. However, transient facial paralysis was seen in 20.0% RAHI cases, and this value is similar to data reported previously. Because RAHI does not require a preauricular skin incision, unlike S-shaped and facelift incisions, it is difficult to gain an anterosuperior view of the parotid gland. In other words, tumors in the lower pole of the superficial lobe of the parotid gland are the best indication for RAHI. RAHI is a useful approach when performed by surgeons with sufficient experience with standard methods and when surgical indications are accurately determined.

Complications of Parotid Surgery – A Study of 30 Cases

Objectives: To find out the complication of parotid surgery and association of nerve injury with the type of disease pathology and type of parotid surgery.Methods: This cross-sectional study on 30 cases was carried out in the Department of Otolaryngology-Head &amp; Neck Surgery, Bangabandhu Sheikh Mujib Medical University &amp; Dhaka Medical College Hospital, Dhaka from September 2011 to September 2012. After taking history, clinical examination and investigation (FNAC, CT-scan) diagnosis was confirmed by histopathological examination.Results: In this study, lowest age was 14 years and highest age 65 years, male to female ration was 1.1:1. 83.33% cases were benign and 16.67% cases were malignant. Most of benign tumors was pleomorphic adenoma (80%). 88% cases involved in superficial lobe. Temporary facial nerve paresis was the most common postoperative complication (29.97%); 6.6% cases develoved permanent facial palsy and hypoesthesia of ear was 26.04%. Most patient regained normal facial nerve function within 6 months from the onset.Conclusion: Marginal mandibular nerve is the most common branch of facial nerve injury.Bangladesh J Otorhinolaryngol; April 2015; 21(1): 23-27

Tumor recurrence and complications of parotidectomy using the marginal mandibular branch as a landmark during the retrograde technique.

To investigate the recurrence of tumors and morbidity rates of postoperative complications associated with primary parotid pleomorphic adenomas treated with a parotidectomy using the marginal mandibular branch of the facial nerve as a landmark during the retrograde approach. Our study retrospectively analyzed the clinical data from 71 patients with a primary parotid pleomorphic adenoma who underwent a parotidectomy using the marginal mandibular branch of the facial nerve as a guide during the retrograde approach between November 2003 and August 2012. Three surgical modalities were involved in the study: a partial superficial parotidectomy was performed in 8 cases, a superficial parotidectomy was performed in 54 cases, and a total parotidectomy was performed in 9 cases. The recurrence of tumors and the morbidity rates of postoperative complications, such as transient facial nerve paralysis, permanent facial nerve paralysis, sensory deficiency, Frey syndrome, salivary fistulas, and xerostomia, were investigated. Tumor recurrence occurred in only 1 case. Overall, the morbidity rates for transient facial nerve paralysis, permanent facial nerve paralysis, sensory deficiency, Frey syndrome, and xerostomia were 22.5%, 1.4%, 39.4%, 59.2%, and 8.5%, respectively. No cases developed a salivary fistula. The use of the marginal mandibular branch of the facial nerve as a guide during the retrograde approach is a reliable and safe method for dissecting the facial nerve.

Experience and anatomical study of modified lengthening temporalis myoplasty for established facial paralysis

Lengthening temporalis myoplasty, reported by Daniel Labbé in 1997, is a unique and definite facial reanimation procedure that involves moving the whole temporal muscle anteroinferiorly and inserting its tendon directly into the nasolabial fold. In the present article, we report our experience in the use of his modified method of the procedure, which preserves the zygomatic arch by transecting the coronoid process through the nasolabial fold incision. We also describe our cadaveric study that aimed to elucidate a secure approach for coronoid process transection. We performed this procedure in five patients with permanent facial paralysis. To improve facial symmetry, we also performed several additional static reconstructions such as T-shaped double-sleeve fascia grafts for lower lip deformities. We were successful in achieving considerable static improvement at rest, immediately after the surgery, and the recovery of facial movement was apparent approximately 3 months after the surgery. With regard to the cadaveric study, we noted that the entry to the buccal fat region, which is also the pathway of the temporal fascia, was a narrow space, and a short transection of the medial upper edge of the masseter fascia would make it easy to locate the coronoid process. Therefore, for a safe and secure access to the coronoid process from the nasolabial fold, we believe that we should first expose the cranial side and continue to dissect along the side and lower edge of the maxilla to locate the medial upper edge of the masseter fascia. By transecting along its edge, we could easily access the coronoid process, located immediately behind it, and widen the pathway of the temporal fascia. This modified method is less invasive and simpler compared to the original procedure, and understanding the detailed anatomy for dissection would help surgeons perform this procedure more confidently.

Evolution and changing trends in surgery for benign Parotid tumors

The ideal extent of surgical intervention for benign parotid tumors remains a matter of controversy. The aim of the study was to trace the development of surgical therapy in a large cohort, explore its changes in a single institution specializing in salivary gland pathologies over the last 12 years, and determine the extent to which a possible shift in the surgical therapy of parotid benign tumors toward less radical methods was correlated with a change in the incidence of facial palsy and Frey's syndrome. Retrospective clinical study. A retrospective evaluation of the records for all patients treated for benign parotid tumors between 2000 and 2012 at a tertiary referral center was carried out. Surgical methods were classified into four groups: extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy, and complete parotidectomy. A total of 1,624 patients were included in the study. Our analysis demonstrated an increase in the total number of parotidectomies for benign lesions from 71 (2000) to 184 (2012), mostly due to the increase in extracapsular dissections (from 9 to 123). Increased performance of less radical surgery was associated with a significantly decreased incidence of temporary and permanent facial palsies (from 22.8% to 9% and 9.8% to 5.9%, respectively) and Frey's syndrome (from 11.3% to 1.6%). One of the most controversial issues in the treatment of benign parotid tumors is the best therapeutic approach to be taken in such patients. Our study showed that increased performance of less radical surgery was associated with better functional outcomes.