Habilitation of facial nerve dysfunction after resection of a vestibular schwannoma

Impact of Vestibular and Balance Rehabilitation Therapy Along With Conventional Physiotherapy in a Case of Vestibular Schwannoma With CP Angle Tumor: A Case Report

Vestibular Schwannoma forms in Schwann cells which cover the vestibular nerve, often in the internal auditory canal. Symptoms were likely present before the excision of the tumor. After the excision of the tumor, symptoms may include, hearing defects, tinnitus, facial muscle abnormalities, headache, and balance impairments. This case report is of a female patient with vestibular schwannoma, who had a few above-mentioned symptoms after the surgery. Her physiotherapy protocol included Vestibular and Balance Rehabilitation Therapy along with Conventional Physiotherapy. Also, facial proprioceptive neuromuscular facilitation (PNF) was a part of her treatment. The outcome measures used to rule out the results were the motion sensitivity quotient (MSQ) and the Berg balance scale (BBS). Improvement of symptoms is likely related to the excision of the tumor and the therapy program. The person's balance and coordination improved as a result of the rehabilitation protocol, and she was able to do her regular tasks with minimal assistance. Her standard of living was also enhanced.

Dosimetric predictive factors for facial nerve paralysis after cyberknife® stereotactic radiotherapy for vestibular schwannomas: A single institution experience of 88 patients

PURPOSE

To identify dosimetric predictive factors of facial nerve paralysis for patients with vestibular schwannomas (VS) treated in a single institution with Cyberknife® (CK) hypofractionated stereotactic radiotherapy (SRT).

METHODS AND MATERIALS

Eighty-eight patients were treated from 2010 to 2020. Different treatment schedules were used over that period, some prescribed to the 80% isodose line (4 × 5 Gy, 3 × 7 Gy, 3 × 8 Gy and 5 × 5 Gy) and one to the 70% isodose line (3 × 7.7 Gy). Local control tumor and facial nerve toxicity were recorded, as well as various dosimetric indicators.

RESULTS

Median follow-up 37 months (range, 7-96). Of the 88 stereotactic treatments, 20 patients (23%) developed objectively diagnosed radiation-induced facial nerve paralysis. The 2-year and 5-year local tumor control were respectively 95% and 88%, and the overall 2-year facial nerve preservation was 76%. Prescriptions with a maximum dose point (Dmax) of 33 Gy were at a substantially higher risk of facial paralysis than prescriptions with a Dmax less than or equal to 30 Gy (HR = 4.51, 95% CI = [1.04;19.6], p = 0.045). The 2-years cumulative incidences of facial paralysis were 32% [20%;44%] in the case of a 33 Gy Dmax, against 7% [1%;21%] otherwise. We identified four significative dosimetric predictive factors for radiation-induced facial nerve dysfunction: a GTV minimal dose over 22 Gy (EQD2 = 45.5 Gy, p = 0.019), a GTV mean dose over 29 Gy (EQD2 = 73.5 Gy, HR = 2.84, 95% CI = [1.10;7.36], p = 0.024), a PTV mean dose over 27 Gy (EQD2 = 64.8 Gy, HR = 10.52, 95% CI = [1.39;79.76], p = 0.002) and a PTV maximal dose of 32 Gy (EQD2 = 87.5 Gy,HR = 5.09, 95% CI = [1.17;22.15], p = 0.013).

CONCLUSION

We identified four dosimetric predictive factors for post-treatment facial paralysis. Increasing the doses of hypofractionated stereotactic radiotherapy for vestibular schwannomas leads to higher facial nerve toxicity and may lead to lower local control rates than other published series. Our three-hypofractionated regimens may have also played a role in these results.

Acupuncture as Part of Iatrogenic Facial Nerve Palsy Rehabilitation-First Report

BACKGROUND

Facial paresis is one of the complications after treatment for vestibular schwannoma (VS). Acupuncture has been used for Bell palsy but not in iatrogenic facial paresis. The objective of this study is to measure the efficacy of using acupuncture for iatrogenic facial nerve palsy and patients' satisfaction.

METHODS

This is a single-center retrospective study with patients from 2007-2019 received treatment for newly diagnosed or recurrent VS. Some patients who suffered facial paresis after surgery had self-initiated acupuncture. All patients who had facial paresis were included. Their facial nerve status before and immediately after surgery, postoperative 6 months and 12 months, were recorded. Those who received acupuncture also answered 6- and 12-month patient satisfaction surveys over the phone. Adverse effects were also assessed.

RESULTS

There were 123 patients in this period. Of these, 29 patients had iatrogenic facial paresis and 23 of them received acupuncture. There was significant improvement of facial paresis for the acupuncture group compared with the nonacupuncture group at 6 and 12 months. More than 80% of patients who received acupuncture were satisfied. They had motor improvement and experienced less pain and tightness. No adverse effects were reported.

CONCLUSIONS

Acupuncture for postresection VS facial paresis seemed to speed up its recovery. Both patients' recovery and satisfaction were good after acupuncture, and it seemed to be a safe procedure in trained hands.

[Surgical indications and complications management in vestibular schwannoma]

BACKGROUND

Recent surgical treatment concepts for patients with vestibular schwannoma (VS) require an interdisciplinary approach as well as recognition and mastering of complications.

OBJECTIVE

This paper provides an overview of indications, as well as possible options for function preservation and management of complications in the surgical resection of these tumors.

METHODS

Up-to-date treatment concepts and surgical indications were differentiated according to size and extent of tumors. The frequency of important complications was extracted from the literature. Technical options to avoid and correct complications were compiled from personal experience and review of the literature.

RESULTS

Complications unrelated to cranial nerves are not infrequent, particularly in older patients. Small and medium-sized tumors that do not reach the fundus and cochlear fossa can be completely removed with good chances of hearing preservation. As long as these tumors do not grow, patients benefit from observation. Large tumors are overrepresented in surgical series compared to their prevalence. Postoperative facial nerve function correlates to tumor volume. Hearing preservation in these tumors is rare. Intraoperative electrophysiological techniques are valuable for attempted preservation of cranial nerve function. Persistent facial palsies can be remedied by dynamic and static interventions for facial rehabilitation.

CONCLUSION

Mortality and morbidity associated with surgical treatment of VS are very acceptable. Surgical concepts should be custom-tailored to the individual patient in order to ensure high quality of life.

Long-Term Facial Nerve Outcomes after Microsurgical Resection of Vestibular Schwannomas in Patients with Preoperative Facial Nerve Palsy

Objectives  This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design  A retrospective review. Setting  Single-institution cohort. Participants  Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures  Incidence, House-Brackmann grade. Results  Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1-4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House-Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions  Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.

Fluorescently labeled peptide increases identification of degenerated facial nerve branches during surgery and improves functional outcome

Nerve degeneration after transection injury decreases intraoperative visibility under white light (WL), complicating surgical repair. We show here that the use of fluorescently labeled nerve binding probe (F-NP41) can improve intraoperative visualization of chronically (up to 9 months) denervated nerves. In a mouse model for the repair of chronically denervated facial nerves, the intraoperative use of fluorescent labeling decreased time to nerve identification by 40% compared to surgeries performed under WL alone. Cumulative functional post-operative recovery was also significantly improved in the fluorescence guided group as determined by quantitatively tracking of the recovery of whisker movement at time intervals for 6 weeks post-repair. To our knowledge, this is the first description of an injectable probe that increases visibility of chronically denervated nerves during surgical repair in live animals. Future translation of this probe may improve functional outcome for patients with chronic denervation undergoing surgical repair.

Intraoperative neurophysiological monitoring in peripheral nerve surgery: Technical description and experience in a centre

INTRODUCTION

Intraoperative neurophysiological monitoring has experienced a spectacular development in the past 20 years, particularly in the fields of neurosurgery and spine surgery. it has become a useful, almost indispensable, tool in preventing nerve damage during surgery. The aim of this article is to describe the intraoperative technique and analyze its results in the field of peripheral nerve surgery.

OBJECTIVE

To describe the usefulness of a technique in peripheral nerve surgery, the technique used and the experience in a centre.

PATIENTS AND METHODS

A retrospective study was conducted on 30 cases of peripheral nerve surgery performed in this centre from 2009 to 2013, using the intraoperative monitoring technique.

RESULTS

Of the total of 13 peripheral nerve tumors recorded, there were 11 excellent results and 2 good results, one temporary hypoesthesia and one with almost complete sensory, except for motor, recovery. Traumatic injury was recorded in 17 cases, of which 6 required performing a graft, and the remaining 11 cases only neurolysis was performed, with complete motor and sensory recovery.

CONCLUSIONS

Intraoperative neurophysiological monitoring is a useful tool in the secondary surgery of peripheral nerve injury and the intraneural tumor pathology.

Neuro-ophthalmological approach to facial nerve palsy

Facial nerve palsy is associated with significant morbidity and can have different etiologies. The most common causes are Bell's palsy, Ramsay-Hunt syndrome and trauma, including surgical trauma. Incidence varies between 17 and 35 cases per 100,000. Initial evaluation should include accurate clinical history, followed by a comprehensive investigation of the head and neck, including ophthalmological, otological, oral and neurological examination, to exclude secondary causes. Routine laboratory testing and diagnostic imaging is not indicated in patients with new-onset Bell's palsy, but should be performed in patients with risk factors, atypical cases or in any case without resolution within 4 months. Many factors are involved in determining the appropriate treatment of these patients: the underlying cause, expected duration of nerve dysfunction, anatomical manifestations, severity of symptoms and objective clinical findings. Systemic steroids should be offered to patients with new-onset Bell's palsy to increase the chance of facial nerve recovery and reduce synkinesis. Ophthalmologists play a pivotal role in the multidisciplinary team involved in the evaluation and rehabilitation of these patients. In the acute phase, the main priority should be to ensure adequate corneal protection. Treatment depends on the degree of nerve lesion and on the risk of the corneal damage based on the amount of lagophthalmos, the quality of Bell's phenomenon, the presence or absence of corneal sensitivity and the degree of lid retraction. The main therapy is intensive lubrication. Other treatments include: taping the eyelid overnight, botulinum toxin injection, tarsorrhaphy, eyelid weight implants, scleral contact lenses and palpebral spring. Once the cornea is protected, longer term planning for eyelid and facial rehabilitation may take place. Spontaneous complete recovery of Bell's palsy occurs in up to 70% of cases. Long-term complications include aberrant regeneration with synkinesis. FNP after acoustic neuroma surgery remains the most common indication for FN rehabilitation.