Facial reanimation with jump interpositional graft hypoglossal facial anastomosis and hypoglossal facial anastomosis: evolution in management of facial paralysis

Surgical results for one-stage VII/VIII schwannoma resection and hemihypoglossal-facial neurorrhaphy

BACKGROUND

This retrospective study evaluated the outcomes of patients undergoing one-stage resection of VII/VIII schwannomas and hemihypoglossal-facial neurorrhaphy via the translabyrinthine approach (TLA).

METHODS

The study encompassed ten consecutive patients with unilateral hearing loss (six women, four men, mean age: 49.5 ± 12.1 years) who underwent surgery. The cohort included two patients with vestibular schwannomas (VSs), four with facial nerve schwannomas (FNSs) (two originating from the geniculate ganglion of the facial nerve and two from the cerebellopontine angle), one with VS regrowth, and three with residual VSs. Preoperative facial nerve function, assessed using the House-Brackmann (HB) scale, was Grade V in one and Grade VI in nine patients. The mean preoperative duration of facial paralysis was 7.5 ± 6.9 months.

RESULTS

All patients underwent gross total resection. Postoperatively, one patient experienced cerebrospinal fluid leaks, which were successfully managed with lumbar drains and surgical revisions. At follow-up, facial nerve function improved in all patients: HB Grade V to III in one, HB Grade VI to III in one, HB Grade VI to IV in seven, and Grade VI to V in one. No tumor recurrence was observed during the follow-up period (mean duration: 16.6 ± 9.3 months), and no patient had hemilingual atrophy.

CONCLUSION

The TLA for one-stage resection of VII/VIII schwannomas and facial nerve reconstruction is effective in treating both regrowth and residual VSs and FNSs in the cerebellopontine angle or petrosal bone in patients with severe preoperative facial palsy. This technique facilitates simultaneous tumor removal and nerve anastomosis, thereby reducing the need for multiple surgical interventions in patients with hearing loss and compromised facial nerve function.

Facial nerve reconstruction for flaccid facial paralysis: a systematic review and meta-analysis

Objectives

To determine the functional outcome after facial nerve reconstruction surgery in patients with flaccid facial paralysis.

Methods

A systematic review and meta-analysis was performed on studies reporting outcomes after direct facial nerve suture (DFS), facial nerve interpositional graft suture (FIGS), hypoglossal-facial nerve suture (HFS), masseteric-facial nerve suture (MFS), and cross-face nerve suture (CFS). These studies were identified from PubMed/MEDLINE, Embase, and Web of Science databases. Two independent reviewers performed two-stage screening and data extraction. A favorable result was defined as a final House-Brackmann grade I-III and is presented as a ratio of all patients in percentage. Pooled proportions were calculated using random-effects models.

Results

From 4,932 screened records, 54 studies with 1,358 patients were included. A favorable result was achieved after DFS in 42.67% of the patients [confidence interval (CI): 26.05%-61.12%], after FIGS in 66.43% (CI: 55.99%-75.47%), after HFS in 63.89% (95% CI: 54.83%-72.05%), after MFS in 63.11% (CI: 38.53%-82.37%), and after CFS in 46.67% (CI: 24.09%-70.70%). There was no statistically significant difference between the techniques (Q = 6.56, degrees of freedom = 4, p = 0.1611).

Conclusions

The established facial nerve reconstruction techniques including the single nerve cross-transfer techniques produce satisfactory results in most of the patients with permanent flaccid facial paralysis. An international consensus on standardized outcome measures would improve the comparability of facial reanimation techniques.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Effectiveness of Hypoglossal-Facial Anastomosis in the Rehabilitation of Facial Paralysis Following Vestibular Schwannoma Surgery: A Systematic Review

The facial nerve plays a crucial role in facial expression and sensory functions, with irreversible injuries often demanding rehabilitation therapies, with hypoglossal-facial nerve anastomosis (HFA) being one of the treatment options. This systematic review assessed different HFA techniques for facial paralysis, particularly post vestibular schwannoma resection, focusing on effectiveness and associated morbidities. Fifteen studies, comprising a case series and a retrospective cohort, were analyzed. Techniques included end-to-end, split, side-to-side, end-to-side, and jump interpositional graft hypoglossal-facial anastomosis (JIGHFA). Positive outcomes were observed with end-to-end and side-to-side techniques, while the split technique and JIGHFA showed promise. Comparative analyses favored the 'end-to-side' approach. Shorter intervals between surgery and HFA correlated with improved outcomes. Methodological variations highlight the need for prospective studies with standardized methodologies for robust evidence and informed decision-making on optimal HFA techniques.

Hypoglossal Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-Analysis

Background: Hypoglossal-facial nerve (12-7) anastomosis can restore symmetry and voluntary movement on the face in patients with facial nerve paralysis. Traditional 12-7 transfer includes direct end-to-end nerve anastomosis, sacrificing the entire hypoglossal nerve. Contemporary, end-to-side anastomosis, or split anastomosis techniques limit tongue morbidity by preserving some hypoglossal nerve. Direct outcome comparisons between these techniques are limited. Objective: To compare reported outcomes of facial movement, tongue, speech, and swallow outcomes among the different types of hypoglossal-facial nerve anastomosis schemes. Evidence Review: For this systematic review and meta-analysis, a comprehensive strategy was designed to search PubMed, Scopus, and the Cochrane Database from inception to January 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, reporting guideline yielding 383 results. Any participant who underwent 12-7 transfer using any of the three techniques, with or without an interposition graft, and had documented preoperative and postoperative evaluation of facial nerve function with a validated instrument such as House-Brackmann (HB), was considered for inclusion. Secondary outcomes of synkinesis, tongue atrophy, and speech or swallowing dysfunction were also compared. Forty-nine studies met inclusion criteria, representing data from 961 total patients who underwent 12-7 transfer. Results: The proportion of good HB outcomes (HB I-III) did not differ by anastomosis type: End-to-side and end-to-end anastomosis (73% vs. 59%, p = 0.07), split and end-to-end anastomosis (62% vs. 59%, p = 0.88), and end-to-side anastomosis and split anastomosis (73% vs. 62%, p = 0.46). There was no difference in reported synkinesis rates between the anastomosis types. However, end-to-side anastomosis (z = 6.55, p < 0.01) and split anastomosis (z = 3.58, p < 0.01) developed less tongue atrophy than end-to-end anastomosis. End-to-side anastomosis had less speech/swallowing dysfunction than end-to-end anastomosis (z = 3.21, p < 0.01). Conclusion: End-to-side and split anastomoses result in similar HB facial nerve outcomes as the traditional end-to-end 12-7 anastomosis. End-to-side anastomosis has decreased complications of tongue atrophy and speech/swallow dysfunction compared to end-to-end anastomosis. In addition, split anastomosis has decreased rates of tongue atrophy compared to end-to-end anastomosis.

Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation: An anatomical study in cadavers and a case report

BACKGROUND

Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented.

METHODS

Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry).

RESULTS

The harvestable length of ACN was 100 ± 12 mm. A clinically significant anatomical variant ("short ansa") was present in 33% of cases (length: 37 ± 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in "short ansa" cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up.

CONCLUSIONS

Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the "short ansa" anatomical variant in clinical cases is proposed.

Sternocleidomastoid Muscle Transfer for Treatment of Longstanding Facial Paralysis: Long-term Outcomes and Complications

BACKGROUND/AIM

The use of sternocleidomastoid muscle (SCM) flap for facial reanimation was established in the 1980s by the senior author of this paper. We aimed to analyze long-term outcome and complications of this procedure.

PATIENTS AND METHODS

We conducted a retrospective chart review of all patients undergoing SCM reanimation for longstanding facial palsy between January 2009 and December 2015. Patients with follow-up longer than 12 months (range=12-96) were included in the study. Facial muscle function was evaluated before and at each follow-up after the surgery with the House-Brackmann (HB) scale-facial nerve grading system and Facegram analysis. Donor site morbidity and overall complication rates were documented and analyzed.

RESULTS

Forty-two patients aged 18-66 years (mean age=37) with a mean duration of facial palsy of 5 years (range=2-48) met the inclusion criteria. The HB score 2 years after surgery improved significantly (p<0.05) in comparison to the pre-operative condition (3.6 vs. 4.7). Twelve months after surgery, oral commissure excursion improved by mean 8.95 mm. No flap necrosis occurred, nor compromise of neck and shoulder function despite an obvious contour defect in the SCM donor site. None of the patients presented head posture or movement issues.

CONCLUSION

The SCM flap transfer is a reliable and effective procedure to achieve moderate improvement of the oral commissure excursion using a local method with moderate donor site morbidity. It can be regarded as a valuable option for dynamic facial reanimation in case of longstanding facial palsy.

End-to-Trunk Masseteric to Facial Nerve Transfer With Selective Neurectomy for Facial Reanimation

OBJECTIVE

To examine functional outcomes following end-to-trunk masseteric to facial nerve transfer in patients with chronic flaccid facial paralysis.

DESIGN

Retrospective chart review.

SETTING

Tertiary-care private practice setting.

PARTICIPANTS

Patients with complete unilateral facial paralysis of less than 24 months duration.

INTERVENTIONS

Direct end-to-trunk masseteric to facial nerve anastomosis.

OUTCOME MEASURES

Outcome measures included time to first movement, development of synkinesis, and an objective assessment of the resting tone and dynamic movement that was achieved.

RESULTS

Patient age at the time of transfer ranged from 6 to 61. Follow-up ranged from 12 to 24 months. No patients had any perioperative complications. No patient experienced significant mass movement or synkinetic facial movement with chewing. No patient had worsened chewing or swallowing. Patients have not yet recovered significant resting tone. All patients achieved smile activity when biting down with a median (interquartile range) oral commissure excursion of 7.57 mm (5.19-9.94 mm), starting 3 to 5 months after transfer.

CONCLUSIONS

End-to-trunk masseteric to facial nerve transfer is a safe and effective procedure. Patients had rapid reinnervation with good excursion and achieved a natural appearing smile. The rehabilitated smile appears better than that achieved with hypoglossal-facial nerve transfer. The procedure can be performed coincident with cross-facial nerve grafting, and in some cases may produce dynamic facial movement that obviates the need for free muscle transfer.

Facial reanimation with interposition nerve graft or masseter nerve transfer: a comparative retrospective study

Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve. However, no comparative study of these two procedures has yet been reported. In this two-site, two-arm, retrospective case review study, 32 patients were included. Of these, 17 patients (eight men and nine women, mean age 42.1 years) underwent interposition nerve graft after tumor extirpation or trauma between 2003 and 2006 in the Ear Institute, School of Medicine, Shanghai Jiao Tong University, China, and 15 patients (six men and nine women, mean age 40.6 years) underwent masseter-to-facial nerve transfer after tumor extirpation or trauma between November 2010 and February 2016 in Shanghai Ninth People's Hospital, China. More patients achieved House-Brackmann III recovery after masseter nerve repair than interposition nerve graft repair (15/15 vs. 12/17). The mean oral commissure excursion ratio was also higher in patients who underwent masseter nerve transfer than in patients subjected to an interposition nerve graft. These findings suggest that masseter nerve transfer results in strong oral commissure excursion, avoiding obvious synkinesis, while an interposition nerve graft provides better resting symmetry. This study was approved by the Institutional Ethics Committee, Shanghai Ninth People's Hospital, China (approval No. SH9H-2019-T332-1) on December 12, 2019.

Reinnervation with Selective Nerve Grafting from Multiple Donor Nerves

Nerve substitution is an important tool in facial reanimation. The goal is to reinnervate the distal facial nerve and musculature using an alternative cranial nerve in order to achieve facial movement, symmetry, and tone. Multiple donor nerves have been used for nerve transfer procedures, the most common being hypoglossal, masseteric, and cross-facial nerve graft. Each donor nerve has its advantages and disadvantages. Multiinnervation uses the use of multiple donor nerves in order to leverage the benefits while balancing the pitfalls of each nerve. The nerve transfer depends on the type of nerve injury, time since injury, and patient factors.

Hypoglossal and Masseteric Nerve Transfer for Facial Reanimation: A Systematic Review and Meta-Analysis

Background: Hypoglossal and masseteric nerve transfer are currently the most popular cranial nerve transfer techniques for patients with facial paralysis. The authors performed a systematic review and meta-analysis to compare functional outcomes and adverse effects of these procedures. Methods: A review of online databases was performed to include studies with four or more patients undergoing hypoglossal or masseter nerve transfer without muscle transfer or other cranial nerve transposition. Facial nerve outcomes, time to reinnervation, and adverse events were pooled and studied. Results: A total of 71 studies were included: 15 studies included 220 masseteric-facial transfers, and 60 studies included 1312 hypoglossal-facial transfers. Oral commissure symmetry at rest was better for hypoglossal transfer (2.22 ± 1.6 mm vs. 3.62 ± 2.7 mm, p = 0.047). The composite Sunnybrook Facial Nerve Grading Scale was better for masseteric transfer (47.7 ± 7.4 vs. 33.0 ± 6.4, p < 0.001). Time to first movement (in months) was significantly faster in masseteric transfer (4.6 ± 2.6 vs. 6.3 ± 1.3, p < 0.001). Adverse effects were rare (<5%) for both procedures. Conclusions: Both nerve transfer techniques are effective for facial reanimation, and the surgeon should consider the nuanced differences in selecting the correct procedure for each patient.

Efficacy of surgical repair for the functional restoration of injured facial nerve

Background

Early surgical repair to restore nerve integrity has become the most commonly practiced method for managing facial nerve injury. However, the evidence for the efficacy of surgical repair for restoring the function of facial nerves remains deficient. This study evaluated the outcomes of surgical repair for facial nerve lesions.

Methods

This retrospective observational study recruited 28 patients with the diagnosis of facial nerve injury who consecutively underwent surgical repairs from September 2012 to May 2019. All related clinical data were retrospectively analyzed according to age, sex, location of the facial nerve lesion, size of the facial nerve defect, method of repair, facial electromyogram, and blink reflex. Facial function was then stratified with the House-Brackmann grading system pre-operation and 3, 9, 15, and 21 months after surgical repair.

Results

The 28 patients enrolled in this study included 17 male and 11 female patients with an average age of 34.3 ± 17.4 years. Three methods were applied for the repair of an injured facial nerve, including great auricular nerve transplantation in 15 patients, sural nerve grafting in 7 patients, and hypoglossal to facial nerve anastomosis in 6 patients. Facial nerve function was significantly improved at 21 months after surgery compared with pre-operative function (P = 0.008). Following surgical repair, a correlation was found between the amplitude of motor unit potential (MUP) and facial nerve function (r = -6.078, P = 0.02). Moreover, the extent of functional restoration of the facial nerve at 21 months after surgery depended on the location of the facial nerve lesion; lesions at either the horizontal or vertical segment showed significant improvement(P = 0.008 and 0.005), while no functional restoration was found for lesions at the labyrinthine segment (P = 0.26).

Conclusions

For surgical repair of facial nerve lesions, the sural nerve, great auricular nerve, and hypoglossal-facial nerve can be grafted effectively to store the function of a facial nerve, and MUP may provide an effective indicator for monitoring the recovery of the injured nerve.

Progress in facial reinnervation

Facial nerve injury often results in facial paralysis, which seriously affects the patients both aesthetically and functionally. Facial nerve reinnervation methods, including direct anastomosis, nerve graft, nerve transposition, cross-facial nerve graft, and combined surgeries, have recently become a hot topic with many new procedures being explored. This study summarizes the relevant literatures and discusses the scope of application, advantages, and disadvantages of the different methods. The treatment options or combined surgeries for facial nerve reinnervation should be individualized for specific patients to achieve the best reanimation outcome with good static symmetry, facial tone, and spontaneous, natural, symmetrical, and strong facial movements.

Split hypoglossal facial anastomosis for facial nerve palsy due to skull base fractures: A case report

Introduction

Traumatic brain injury (TBI) is the most prevalent causes of morbidity and mortality worldwide. The biomechanics of primary TBI involve a direct impact, practically extended to the base of the skull, and most of the skull base fractures (SBF) are identified in anterior and medial cranial fossa. Furthermore, those predicted in the medial area are related to fissures from temporal bones.

Presentation of case

We report two cases of right facial nerve palsy initiated by SBF's, which were diagnosed and treated at our institution. The 3D CT evaluation in our first case showed a longitudinal fracture of the right petrosal bone, which was longitudinal and transverse for the second case. Two cases of facial nerve palsy were managed with split hypoglossal facial anastomosis to restore functional reanimation. All patients were adequately achieved after the procedure, and the hypoglossal nerve function was preserved.

Conclusion

Split hypoglossal facial anastomosis technique was used to treat patients with facial nerve paralysis resulting from SBF's. This was to achieve good recovery outcome, in terms of facial reanimation and preservation of tongue function.

•

A skull base fracture (SBF) is about 4% of all cases Traumatic brain injury (TBI).

•

SBF which frequently occurs in the petrous part of the temporal bone, is implicated in facial nerve palsy.

•

Split hypoglossal facial anastomosis technique showed good recovery of facial reanimation with HB scale assessment.

Using the Post-Descendens Hypoglossal Nerve in Hypoglossal-Facial Anastomosis: An Anatomic and Histologic Feasibility Study

BACKGROUND

Hypoglossal-facial anastomosis (HFA) is a popular facial reanimation technique. Mobilizing the intratemporal segment of the facial nerve and using the post-descendens hypoglossal nerve (ie, the segment distal to the take-off of descendens hypoglossi) have been proposed to improve results. However, no anatomic study has verified the feasibility of this technique.

OBJECTIVE

To assess the anatomic feasibility of HFA and the structural compatibility between the 2 nerves when the intratemporal facial and post-descendens hypoglossal nerves are used.

METHODS

The facial and hypoglossal nerves were exposed bilaterally in 10 sides of 5 cadaveric heads. The feasibility of a side-to-end (ie, partial end-to-end) HFA with partial sectioning of the post-descendens hypoglossal nerve and the mobilized intratemporal facial nerve was assessed. The axonal count and cross-sectional area of the facial and hypoglossal nerves at the point of anastomosis were assessed.

RESULTS

The HFA was feasible in all specimens with a mean (standard deviation) 9.3 (5.5) mm of extra length on the facial nerve. The axonal counts and cross-sectional areas of the hypoglossal and facial nerves matched well. Considering the reduction in the facial nerve cross-sectional area after paralysis, the post-descendens hypoglossal nerve can provide adequate axonal count and area to accommodate the facial nerve stump.

CONCLUSION

Using the post-descendens hypoglossal nerve for side-to-end anastomosis with the mobilized intratemporal facial nerve is anatomically feasible and provides adequate axonal count for facial reanimation. When compared with use of the pre-descendens hypoglossal nerve, this technique preserves C1 fibers and has a potential to reduce glottic complications.

A comparative retrospective study: hypoglossofacial versus masseterofacial nerve anastomosis using Sunnybrook facial grading system

INTRODUCTION

The aim of our study is to compare the functional results between two surgical techniques for reanimation of facial paralysis: hypoglossal-to-facial versus masseteric-to-facial nerve anastomosis.

METHODS

This is a retrospective study of 13 patients treated for complete facial paralysis in two medical tertiary centers. The patients were classified into two groups. First group: masseteric-to-facial nerve anastomosis. Second group: hypoglossofacial nerve anastomosis. Sunnybrook facial grading system was used to evaluate the functional results. The mean scores were compared using Mann-Whitney test. The correlation between the age at surgery, the delay in time from the onset of the facial paralysis to the time of surgery and the results of Sunnybrook scores was studied using correlation and linear regression.

RESULTS

No significant statistical difference was found between the mean of total score of the two groups (first group = 38 ± 4.898, second group = 37.83 ± 4.956). All the patients treated by hypoglossofacial nerve anastomosis presented with hemiglossal atrophy. We found slight superiority for the masseterofacial nerve anastomosis in dynamic movements, whereas at rest the hypoglossofacial anastomosis is slightly better. All the differences were not statistically significant. No correlation was found between the age at surgery (age range included 32-73 years) and post-operative results. No correlation was found between the delays up to 24 months from the onset of the facial paralysis and post-operative results.

CONCLUSION

Our study showed that both types of anastomosis are effective with comparable results. The masseterofacial nerve anastomosis is preferred when possible to avoid the hemiglossal atrophy and its complications.

Facial Reanimation in the Seventh and Eighth Decades of Life

BACKGROUND

Treatment of facial paralysis in the older population is often relegated to static rather than dynamic reanimation for fear of poor outcomes. This pervasive approach lacks physiologic foundation and is not evidence based. Thus, the authors present an extensive literature review demonstrating weak evidence supporting this misguided concept, followed by detailed outcomes from three centers of the largest reported series to date of patients older than 60 years after reanimation performed using three techniques-lengthening temporalis myoplasty, free functional muscle, and nerve transfers.

METHODS

A PubMed search spanning over 40 years identified all reports on reanimation in patients older than 60 years. In addition, detailed demographics, surgical techniques, and outcomes of 30 patients older than 60 years were analyzed.

RESULTS

Of 629 articles, only 45 patients were identified, described in case reports or small series, lacking details or consistent long-term follow-up. In the clinical series, average age, preoperative House-Brackmann score, and comorbidities were similar among the groups. Highest excursion was observed in the free functional muscle group, followed by nerve transfer and temporalis myoplasty, averaging 10.4, 6.8, and 3.1 mm, respectively. The most notable philtral deviation correction was in the lengthening temporalis myoplasty group, followed by the free muscle and nerve transfer groups, averaging 5.6, 2.2, and 1.13 mm, respectively. Complication rates were highest in the free functional muscle group.

CONCLUSIONS

Facial palsy patients should not be denied dynamic restoration based on age alone. Although surgical technique may vary based on duration of palsy, surgeon experience, and preference, with each presenting advantages and disadvantages, dynamic restoration is feasible regardless of age.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Controversies in Contemporary Facial Reanimation

Facial palsy is a devastating condition with profound functional, aesthetic, and psychosocial implications. Although the complexity of facial expression and intricate synergy of facial mimetic muscles are difficult to restore, the goal of management is to reestablish facial symmetry and movement. Facial reanimation surgery requires an individualized treatment approach based on the cause, pattern, and duration of facial palsy while considering patient age, comorbidities, motivation, and goals. Contemporary reconstructive options include a spectrum of static and dynamic procedures. Controversies in the evaluation of patients with facial palsy, timing of intervention, and management decisions for dynamic smile reanimation are discussed.

Facial reanimation using hypoglossal-facial nerve anastomosis after schwannoma removal

CONCLUSION

In this series, the split type hypoglossal-facial nerve anastomosis resulted in more favorable outcomes in terms of both facial function and tongue atrophy.

OBJECTIVE

This study compared surgical techniques for hypoglossal-facial nerve anastomosis after schwannoma removal and evaluated which technique achieves better facial outcomes and less tongue morbidity.

METHOD

This study included 14 patients who underwent hypoglossal-facial nerve anastomosis after schwannoma removal and were followed for more than 1 year. Three surgical techniques were performed: end-to-end, end-to-side, and split anastomoses. Facial palsy and tongue atrophy after anastomosis were evaluated using the scales suggested by House-Brackmann and Martins, respectively. Tumor volume and the time to surgery were also evaluated, and the effects on facial outcomes were analyzed.

RESULTS

Overall, nine of 14 (64.3%) patients had favorable facial outcomes, and eight of 14 (57.1%) had favorable tongue outcomes. Regarding facial palsy, five of seven (71.4%) end-to-end, three of four (75%) split, and only one of three (33.3%) end-to-side patients had favorable facial function. Regarding tongue atrophy, all three (100%) end-to-side, three of four (75%) split, and two of seven (28.6%) end-to-end patients had favorable tongue outcomes. The effects of tumor volume and time to surgery on facial outcome were not significant.

Hypoglossal-Facial Nerve Anastomosis: A Meta-Analytic Study

Objectives:

A meta-analysis was conducted on the outcome of facial nerve function after hypoglossal-facial nerve anastomosis in humans. The roles of the timing of and the underlying cause for surgery, the type of the repair, and previous facial nerve function in the final result were analyzed.

Methods:

Articles were identified by means of a PubMed search using the key words “facial-hypoglossal anastomosis,” which yielded 109 articles. The data were pooled from existing literature written in English or French. Twenty-three articles were included in the study after we excluded those that were technical reports, those describing anastomosis to cranial nerves other than the hypoglossal, and those that were experimental animal studies. Articles that reported facial nerve function after surgery and timing of repair were included. Facial nerve function had to be reported according to the House-Brackmann scale. If there was more than 1 article by the same author(s), only the most recent article and those that did not overlap and that matched the above criteria were accepted. The main parameter of interest was the rate of functional recovery of the facial nerve after anastomosis. This parameter was compared among all groups with Pearson's X2 test in the SPSS program for Windows. Statistical significance was set at a p level of less than .05.

Results:

Analysis of the reports indicates that early repair, before 12 months, provides a better outcome. The severity of facial nerve paralysis does not have a negative effect on prognosis. Gunshot wounds and facial neuroma are the worst conditions for favorable facial nerve recovery after anastomosis. Transection of the hypoglossal nerve inevitably results in ipsilateral tongue paralysis and atrophy. Modification of the anastomosis technique seems to resolve this problem. Nevertheless, the effect of modified techniques on facial reanimation is still unclear, because the facial nerve function results were lacking in these reports.

Conclusions:

Hypoglossal-facial nerve anastomosis is an effective and reliable technique that gives consistent and satisfying results.

Treatment of complete facial palsy in adults: comparative study between direct hemihypoglossal-facial neurorrhaphy, hemihipoglossal-facial neurorrhaphy with grafts, and masseter to facial nerve transfer

BACKGROUND

The hypoglossal (with or without grafts) and masseter nerves are frequently used as axon donors for facial reinnervation when no proximal stump of the facial nerve is available. We report our experience treating facial nerve palsies via hemihypoglossal-to-facial nerve transfers either with (HFG) or without grafts (HFD), comparing these outcomes against those of masseteric-to-facial nerve transfers (MF).

METHOD

A total of 77 patients were analyzed retrospectively, including 51 HFD, 11 HFG, and 15 MF nerve transfer patients. Both the House-Brackmann (HB) scale and our own, newly-designed scale to rate facial reanimation post nerve transfer (quantifying symmetry at rest and when smiling, eye occlusion, and eye and mouth synkinesis when speaking) were used to enumerate the extent of recovery.

RESULTS

With both the HB and our own facial reanimation scale, the HFD and MF procedures yielded better outcome scores than HFG, though only the HGD was statistically superior. HGD produced slightly better scores than MF for everything but eye synkinesis, but these differences were generally not statistically significant. Delaying surgery beyond 2 years since injury was associated with appreciably worse outcomes when measured with our own but not the HB scale. The only predictors of outcome were the surgical technique employed and the duration of time between the initial injury and surgery.

CONCLUSIONS

HFD appears to produce the most satisfactory facial reanimation results, with MF providing lesser but still satisfactory outcomes. Using interposed grafts while performing hemihypoglossal-to-facial nerve transfers should likely be avoided, whenever possible.

[Rehabilitation of facial palsy and vertigo in patients with vestibular schwannoma]

BACKGROUND

Facial palsy and vertigo, as symptoms of vestibular schwannoma (VS) or consequences of its therapy, have a significant impact on patients' quality of life.

OBJECTIVE

This review analyzed current literature on the topic and deduced recommendations for rehabilitation of facial palsy and vertigo.

METHODS

The present review describes a PubMed-based search of the literature of the past 10 years.

RESULTS

There is no evidence-based drug therapy for the treatment of acute facial palsy after VS surgery. Several surgical procedures for facial nerve reconstruction, muscle transfer, and static techniques have been established. Physiotherapeutic movement therapy, optimally with biofeedback, seems to improve facial function in patients with post-paralytic syndrome. Botulinum toxin injections are the method of choice for synkinesis treatment. For treatment of acute and chronic vertigo in patients with VS, the same antivertiginous drugs as for other vertigo patients are used. If the patient shows retained vestibular stimulation function, preoperative intratympanic gentamycin therapy followed by compensation training is a promising approach to decreasing postoperative vertigo. Good vestibular rehabilitation comprises intensive and regular movement training, preferably with real-time feedback and therapy control.

CONCLUSION

There are several conservative, surgical, or combined conservative-surgical treatment options for individualized facial nerve rehabilitation of VS patients, as confirmed by clinical studies. In cases of acute vertigo, standard antivertiginous pharmacotherapy is indicated. In cases of acute and also of chronic vertigo, intensive balance and movement training relieves complaints.

Hypoglossal-facial nerve 'side'-to-side neurorrhaphy using a predegenerated nerve autograft for facial palsy after removal of acoustic tumours at the cerebellopontine angle

TRIAL DESIGN

Hypoglossal-facial nerve (HN-FN) neurorrhaphy is a method commonly used to treat facial palsy when the proximal stump of the injured FN is unavailable. Since the classic HN-FN neurorrhaphy method that needs to section the injured FN is not suitable for incomplete facial palsy, we investigated a modified method that consists of HN-FN 'side'-to-side neurorrhaphy, retaining the remaining or spontaneously regenerated FN axons while preserving hemihypoglossal function.

METHODS

To improve axonal regeneration, we used for the first time a predegenerated sural autograft for performing HN-FN 'side'-to-side neurorrhaphy followed by postoperative facial exercise. We treated 12 patients who had experienced FN injury for 1-18 months as a result of acoustic tumour removal. All patients experienced facial grade V-VI paralysis according to the House-Brackmann scale, but their FN was anatomically preserved. No spontaneous facial reinnervation was detected before repair.

RESULTS

Although we did not perform fresh nerve grafts and HN-FN 'side'-to-end neurorrhaphy as controls for ethical reasons, the reparative outcomes after nerve reconstruction were remarkable: functional improvements were detected as soon as 3 months after repair, House-Brackmann grade II or III FN functions were achieved in five and four patients, respectively, and there were no apparent signs of synkinesis. The three patients who experienced less satisfactory outcomes had exhibited facial palsy for more than 1 year accompanied by muscle atrophy, consistent with a need for rapid surgical intervention.

CONCLUSIONS

Based on fundamental concepts and our experimental results, this new surgical method represents a major advance in the rehabilitation of FN injury.

TRIAL REGISTRATION NUMBER

JS2013-001-02.

Neural circuit analysis of axons regenerated by facial-hypoglossal nerve cross-link surgery

Introduction

Several methods of nerve reconstruction for facial nerve palsy are known. Although the recently introduced method of “cross-linking” of the facial and hypoglossal nerves with a grafted nerve has proved efficacious, the underlying mechanism is unclear.

Methods

In this study, we created an animal model with Wistar rats and analyzed the newly reconstructed neural circuit by anterograde and retrograde neural tracer methods. The saphenous nerve was harvested as a graft, and its double end-to-side neurorrhaphy with the facial and hypoglossal nerves with epineural windows was carried out under the microscope. After an appropriate interval, small amounts of fluoro-ruby or fluoro-emerald were injected into the animals and analyzed 5 days later by fluorescent microscopy (Anterograde experiment: fluoro-ruby into the hypoglossal nucleus at 5 weeks; retrograde experiment: fluoro-ruby into the distal facial nerve sheath and fluoro-emerald into the distal hypoglossal nerve sheath, both at two months.).

Results

The labeled axons derived from the hypoglossal nucleus were observed passing through the grafted nerve to the facial nerve. On the other hand, retrogradely labeled neurons were observed at both the hypoglossal and facial nuclei with some double-labeled neurons, suggesting that collateral sprouting had occurred.

Conclusions

We suggest that the newly constructed neural circuits we observed are conducive to the treatment of facial nerve palsy.

•

We studied the mechanism of nerve crosslinking for ameliorating facial nerve palsy.

•

In a rat model, retrograde tracers demonstrated the crosslink connections.

•

Axon collateralization into the crosslink was found.

•

This may be therapeutic by increasing nerve supply to the damaged side.

Literature study on clinical treatment of facial paralysis in the last 20 years using Web of Science: Comparison between rehabilitation, physiotherapy and acupuncture

BACKGROUND:

Facial paralysis is defined as severe or complete loss of facial muscle motor function.

OBJECTIVE:

The study was undertaken to explore a bibliometric approach to quantitatively assess the research on clinical treatment of facial paralysis using rehabilitation, physiotherapy and acupuncture using Web of Science from 1992 to 2011.

DESIGN:

Bibliometric approach.

DATA RETRIEVAL:

A bibliometric analysis based on the publications on Web of Science was performed using key words such as “facial paralysis”, “rehabilitation”, “physiotherapy” and “acupuncture”.

INCLUSIVE CRITERIA:

(1) Research articles on the clinical treatment of facial paralysis using acupuncture or physiotherapy (e.g. exercise, electro-stimulation) and other rehabilitation methods; (2) researches on human and animal fundamentals, clinical trials and case reports; (3) Article types: article, review, proceedings paper, note, letter, editorial material, discussion, book chapter. (4) Publication year: 1992–2011 inclusive. Exclusion criteria: (1) Articles on the causes and diagnosis on facial paralysis; (2) Type of articles: correction; (3) Articles from following databases: all databases related to social science and chemical databases in Web of Science.

MAIN OUTCOME MEASURES:

(1) Overall number of publications; (2) number of publications annually; (3) number of citations received annually; (4) top cited paper; (5) subject categories of publication; (6) the number of countries in which the article is published; (7) distribution of output in journals.

RESULTS:

Overall population stands at 3 543 research articles addressing the clinical treatment of facial paralysis in Web of Science during the study period. There is also a markedly increase in the number of publications on the subject “facial paralysis treatments using rehabilitation” during the first decade of the 21^st century, except in 2004 and 2006 when there are perceptible drops in the number of articles published. The only other year during the study period saw such a drop is 1993. Specifically, there are 192 published articles on facial paralysis treated by rehabilitation in the past two decades, far more than the output of physiotherapy treatment. Physiotherapy treatment scored only 25 articles including acupuncture treatment, with over 80% of these written by Chinese researchers and clinicians. Ranked by regions, USA is by far the most productive country in terms of the number of publications on facial paralysis rehabilitation and physiotherapy research. Seeing from another angle, the journals that focus on otolaryngology published the most number of articles in rehabilitation and physiotherapy studies, whereas most acupuncture studies on facial paralysis were published in the alternative and complementary medicine journals.

CONCLUSION:

Study of facial paralysis remains an area of active investigation and innovation. Further clinical studies in humans addressing the use of growth factors or stem cells continue to successful facial nerve regeneration.

Current thoughts and developments in facial nerve reanimation

PURPOSE OF REVIEW

To present the most current literature regarding the management of acute and chronic facial paralysis. This review will focus primarily on smile reanimation in the setting of acute and chronic facial paralysis. The management of the flaccid and the hypertonic face will be discussed.

RECENT FINDINGS

Recent developments include advances in neural repair with fibrin glue and the use of cadaveric nerve grafts as interposition grafts. Advances in nerve substitutes have been shown to limit donor-site morbidity and provide similar outcomes to autografts. Techniques for muscle transfer continue to evolve to improve smile outcomes.

SUMMARY

The goal of facial reanimation surgery is to restore meaningful facial movement. The goal should be to have quality-driven clinical practice guidelines to better facilitate patient care. This process must be initiated by facial reanimation surgeons deciding to use consistent outcome measures to report their results. Currently, it is impossible to make a direct comparison between different surgical techniques because of inconsistent methods of evaluation. Despite the lack of consistent quantitative evaluation, there have been many exciting advances in the field.

Hypoglossal-facial nerve “side”-to-side neurorrhaphy for persistent incomplete facial palsy

Object

Hypoglossal-facial nerve neurorrhaphy is a widely used method for treating complete facial palsy. However, the classic surgical procedure using a “side”-to-end neurorrhaphy is not suitable for incomplete facial palsy (IFP), because sectioning of the facial nerve for neurorrhaphy compromises remnant axons and potential spontaneous reinnervation. For the treatment of persistent IFP, the authors investigated in rats a modified method using hypoglossal-facial nerve “side”-to-side neurorrhaphy.

Methods

An IFP model was created by crushing the facial nerve and then ligating the injury site to limit axonal regeneration. After 9 weeks, rats with IFP were submitted to hypoglossal-facial nerve “side”-to-side neurorrhaphy: The gap between the 2 nerves was bridged with a predegenerated peroneal nerve graft, which was sutured to only one-half of the hypoglossal nerve and to the remnant facial nerve through a small window created by removing the epineurium, thus preserving regenerating facial axons.

Results

Four months after repair surgery, double innervation of the target whisker pad by hypoglossal and facial motor neurons was supported by the recording of muscle action potentials and their retrograde labeling. Regenerated hypoglossal and facial motor neurons effectively participated in the reinnervation of the whisker pad, significantly improving facial symmetry without evident synkinesis, compared with rats that underwent IFP without hypoglossal-facial nerve neurorrhaphy.

Conclusions

This study demonstrates that hypoglossal-facial nerve “side”-to-side neurorrhaphy with a predegenerated nerve graft can lead to rapid functional benefits for persistent IFP without compromising the remnants of facial axons, thus providing a proof-of-feasibility for further studies in humans.

Combination of hypoglossal-facial nerve surgical reconstruction and neurotrophin-3 gene therapy for facial palsy

Object

Facial nerve injury results in facial palsy that has great impact on the psychosocial conditions of affected patients. Reconstruction of the facial nerve to restore facial symmetry and expression is still a significant surgical challenge. In this study, the authors assessed a hypoglossal-facial nerve anastomosis method combined with neurotrophic factor gene therapy to treat facial palsy in adult rats after facial nerve injury.

Methods

Surgery consisted of the interposition of a predegenerated nerve graft (PNG) that was anastomosed with the hypoglossal and facial nerves at each of its extremities. The hypoglossal nerve was cut approximately 50% for this anastomosis to conserve partial hypoglossal function. Before their transplantation, the PNGs were genetically engineered using lentiviral vectors to induce overexpression of the neurotrophic factor neurotrophin-3 (NT-3) to improve axonal regrowth in the reconstructed nerve pathway. Reconstruction was performed after facial nerve injury, either immediately or after a delay of 9 weeks. The rats were followed up for 4 months postoperatively, and treatment outcomes were then assessed.

Results

Compared with the functional innervation in control rats that underwent facial nerve injury without subsequent treatment, functional innervation of the paralyzed whisker pad by hypoglossal motoneurons in rats treated 4 months after nerve reconstruction was evidenced by the retrograde transport of neuronal tracers, the recording of muscle action potentials conducted by the PNG, and the recovery of facial symmetry. Although a better outcome was observed when reconstruction was performed immediately after facial nerve injury, reconstruction with NT3-treated PNGs significantly improved functional reinnervation of the paralyzed whisker pad even when implantation occurred 9 weeks posttrauma.

Conclusions

Results demonstrated that hypoglossal-facial nerve anastomosis facilitates innervation of paralyzed facial muscle via hypoglossal motoneurons without sacrificing ipsilateral hemitongue function. Neurotrophin-3 treatment through gene therapy could effectively improve such innervation, even after delayed reconstruction. These findings suggest that the combination of surgical reconstruction and NT-3 gene therapy is promising for its potential application in treating facial palsy in humans.

Hemihypoglossal nerve transfer for acute facial paralysis

Object

The authors have developed a technique for the treatment of facial paralysis that utilizes anastomosis of the split hypoglossal and facial nerve. Here, they document improvements in the procedure and experimental evidence supporting the approach.

Methods

They analyzed outcomes in 36 patients who underwent the procedure, all of whom had suffered from facial paralysis following the removal of large vestibular schwannomas. The average period of paralysis was 6.2 months. The authors used 5 different variations of a procedure for selecting the split nerve, including evaluation of the split nerve using recordings of evoked potentials in the tongue.

Results

Successful facial reanimation was achieved in 16 of 17 patients using the cephalad side of the split hypoglossal nerve and in 15 of 15 patients using the caudal side. The single unsuccessful case using the cephalad side of the split nerve resulted from severe infection of the cheek. Procedures using the ansa cervicalis branch yielded poor success rates (2 of 4 cases).

Some tongue atrophy was observed in all variants of the procedure, with 17 cases of minimal atrophy and 14 cases of moderate atrophy. No procedure led to severe atrophy causing functional deficits of the tongue.

Conclusions

The split hypoglossal-facial nerve anastomosis procedure consistently leads to good facial reanimation, and the use of either half of the split hypoglossal nerve results in facial reanimation and moderate tongue atrophy.

Habilitation of facial nerve dysfunction after resection of a vestibular schwannoma

Facial nerve dysfunction after resection of a vestibular schwannoma is one of the most common indications for facial nerve habilitation. This article presents an overview of common and emerging management options for facial habilitation following resection of a vestibular schwannoma. Immediate and delayed nerve repair options, as well as adjunctive surgical, medical, and physical therapies for facial nerve dysfunction, are discussed. Two algorithms are provided as guides for the assessment and treatment of facial nerve paralysis after resection of vestibular schwannoma.

Outcomes of Direct Facial-to-Hypoglossal Neurorrhaphy with Parotid Release

Lesions of the temporal bone and cerebellopontine angle and their management can result in facial nerve paralysis. When the nerve deficit is not amenable to primary end-to-end repair or interpositional grafting, nerve transposition can be used to accomplish the goals of restoring facial tone, symmetry, and voluntary movement. The most widely used nerve transposition is the hypoglossal-facial nerve anastamosis, of which there are several technical variations. Previously we described a technique of single end-to-side anastamosis using intratemporal facial nerve mobilization and parotid release. This study further characterizes the results of this technique with a larger patient cohort and longer-term follow-up. The design of this study is a retrospective chart review and the setting is an academic tertiary care referral center. Twenty-one patients with facial nerve paralysis from proximal nerve injury at the cerebellopontine angle underwent facial-hypoglossal neurorraphy with parotid release. Outcomes were assessed using the Repaired Facial Nerve Recovery Scale, questionnaires, and patient photographs. Of the 21 patients, 18 were successfully reinnervated to a score of a B or C on the recovery scale, which equates to good oral and ocular sphincter closure with minimal mass movement. The mean duration of paralysis between injury and repair was 12.1 months (range 0 to 36 months) with a mean follow-up of 55 months. There were no cases of hemiglossal atrophy, paralysis, or subjective dysfunction. Direct facial-hypoglossal neurorrhaphy with parotid release achieved a functional reinnervation and good clinical outcome in the majority of patients, with minimal lingual morbidity. This technique is a viable option for facial reanimation and should be strongly considered as a surgical option for the paralyzed face.

Hemihypoglossal-facial nerve anastomosis for facial nerve palsy

BACKGROUND AND PURPOSE

Commonly used classic hypoglossal (CN XII) to facial nerve (CN VII) anastomosis has the disadvantage of tongue hemiatrophy. Thus, various attempts have been made to modify this method to reduce the tongue damage. The aim of this report was to present the results of hemihypoglossal-facial nerve anastomosis (HHFA) technique in relation to facial muscles reanimation and hemitongue atrophy.

MATERIAL AND METHODS

The first 7 consecutive patients who underwent CN VII anastomosis with half of the CNXII, for which the follow-up period exceeded 12 months, were analysed. During the procedure, CN VII was transected as proximally as possible after drilling the mastoid process. CN XII was separated longitudinally into two parts at a short distance to allow suture of the stumps without any tension. One half of CN XII was transected and sutured to the distal stump of CN VII. Recovery from facial palsy was quantified with the House-Brackmann grading system (HB). Tongue function was assessed according to the scale proposed by Martins.

RESULTS

Features of initial reinnervation of facial muscles were visible after 6 months in all 7 patients. All patients achieved satisfactory outcome of CN VII regeneration (HB grade III) until the last control examination (12-27 months after surgery, mean 16). No or minimal tongue atrophy without deviation (grades I-II according to the Martins scale) was found in 4 patients. Mild hemiatrophy with tongue deviation < 30 degrees (grade III) was visible in 3 patients.

CONCLUSIONS

In our experience, HHFA is effective treatment of facial palsy and gives a chance to reduce damage of the tongue.

Facial reanimation after facial nerve injury using hypoglossal to facial nerve anastomosis: the gruppo otologico experience

To evaluate the results of facial nerve reanimation after facial nerve injury by means of hypoglossal to facial nerve anastomosis. Retrospective case review. Private neuro-otologic and cranial base quaternary referral center. Sixty patients underwent hypoglossal to facial nerve anastomosis for facial nerve reanimation between April 1987 and December 2010. Only forty patients completed a minimal follow up of 24 months at the time of evaluation and were included in the study population. Facial nerve paralysis was present for a mean duration of 11.3 months (range 2-42 months) and all the patients had a HB grade VI prior their surgery. Final facial nerve motor function. The most common cause of facial paralysis was vestibular Schwannoma surgery. All the patients achieved a postoperative HB grade III or IV after a mean follow-up time of 20 months. The facial movements were detected after a period that ranged from ranged from 5 to 9 months. Only 4 patients suffered from difficulties during eating and drinking and three of them had associated lower cranial nerve deficit. Despite the various techniques in facial reanimation following total facial nerve paralysis, the end to end of hypoglossal to facial nerve anastomosis remains one of the best treatments in cases of viable distal facial stump and nonatrophic musculature.

Nerve-muscle-endplate band grafting: a new technique for muscle reinnervation

BACKGROUND

Because currently existing reinnervation methods result in poor functional recovery, there is a great need to develop new treatment strategies.

OBJECTIVE

To investigate the efficacy of our recently developed nerve-muscle-endplate band grafting (NMEG) technique for muscle reinnervation.

METHODS

Twenty-five adult rats were used. Sternohyoid (SH) and sternomastoid (SM) muscles served as donor and recipient muscle, respectively. Neural organization of the SH and SM muscles and surgical feasibility of the NMEG technique were determined. An NMEG contained a muscle block, a nerve branch with nerve terminals, and a motor endplate band with numerous neuromuscular junctions. After a 3-month recovery period, the degree of functional recovery was evaluated with a maximal tetanic force measurement. Retrograde horseradish peroxidase tracing was used to track the origin of the motor innervation of the reinnervated muscles. The reinnervated muscles were examined morphohistologically and immunohistochemically to assess the extent of axonal regeneration.

RESULTS

Nerve supply patterns and locations of the motor endplate bands in the SH and SM muscles were documented. The results demonstrated that the reinnervated SM muscles gained motor control from the SH motoneurons. The NMEG technique yielded extensive axonal regeneration and significant recovery of SM muscle force-generating capacity (67% of control). The mean wet weight of the NMEG-reinnervated muscles (87% of control) was greater than that of the denervated SM muscles (36% of control).

CONCLUSION

The NMEG technique resulted in successful muscle reinnervation and functional recovery. This technique holds promise in the treatment of muscle paralysis.

Direct Facial-to-Hypoglossal Neurorrhaphy with Parotid Release

OBJECTIVE

Facial nerve paralysis or compromise can be caused by lesions of the temporal bone and cerebellopontine angle and their treatment. When the facial nerve is transected or severely compromised and primary end-to-end repair is not possible, hypoglossal-facial nerve anastomosis remains the most popular method for accomplishing three main goals: restoring facial tone, restoring facial symmetry, and facilitating return of voluntary facial movement. Our objectives are to evaluate the surgical feasibility and long-term outcomes of our technique of direct facial-to-hypoglossal neurorrhaphy with a parotid-release maneuver.

DESIGN

Prospective cohort.

SETTING

Academic tertiary care referral center.

PATIENTS

Ten patients with facial paralysis from proximal nerve injury underwent the facial-hypoglossal neurorrhaphy with a parotid-release maneuver.

MAIN OUTCOME MEASURES

The Repaired Facial Nerve Recovery Scale, questionnaires, and photographs.

RESULTS

Facial-hypoglossal neurorrhaphy with parotid release was technically feasible in all cases, and anastomosis was performed distal to the origin of the ansa hypoglossi. All patients had good return of facial nerve function. Nine patients had scores of C or better, indicating strong eyelid and oral sphincter closure and mass motion. There was no hemilingual atrophy and no subjective tongue dysfunction.

CONCLUSIONS

The parotid-release maneuver mobilizes additional length to the facial nerve, facilitating a tensionless communication distal to the ansa hypoglossi. The technique is a viable option for facial reanimation, and our patients achieved good clinical outcomes with continual improvement.

A clear map of the lower cranial nerves at the superior carotid triangle

BACKGROUND

The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity.

METHODS

The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery.

RESULTS

A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT.

CONCLUSIONS

Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region.

Reanimation following facial palsy: present and future directions

BACKGROUND

An understanding of the management of chronic facial palsy is vital for otolaryngologists, due to its common presentation to ENT surgeons. There is currently a lack of consensus on the optimum management of this condition. This article reviews the existing literature and offers a perspective on current management, as well as an insight into future treatments.

METHODS

A literature search was performed, using the Medline, Embase and Cochrane databases from 1966 to the present, using the keywords listed below. Articles were reviewed. Selection was limited to English language articles on human subjects.

RESULTS AND CONCLUSION

A tailored, multidisciplinary approach using combinatorial therapy should be used for reanimation of the face following facial palsy. Advances in surgical and non-surgical techniques, and the exchange of information from centres of excellence via global databases, will enable objective appraisal of results and the development of an evidence-based approach to facial reanimation.

Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve

Object

The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed.

Methods

Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients.

Results

Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%.

Conclusions

Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.

Hypoglossal nucleus projections to the rat masseter muscle

We investigated in the rat whether hypoglossal innervation extended to facial muscles other than the extrinsic musculature of the mystacial pad. Results showed that hypoglossal neurons also innervate the masseter muscle. Dil injected into the XII nucleus showed hypoglossal axons in the ipsilateral main trunk of the trigeminal nerve. After Gasser's ganglion crossing, the axons entered into the infraorbital division of the trigeminal nerve and targeted the extrinsic muscles of the mystacial pad. They also spread into the masseter branch of the trigeminal nerve to target the polar portions of the masseter muscle spindles. Retrograde double labelling, performed by injecting Dil into the pad and True Blue into the ipsilateral masseter muscle, showed labelled hypoglossal neurons in the medio-dorsal portion of the XII nucleus. The majority of these neurons were small (15-20 microm diameter), showed fluorescence for Dil and projected to the mystacial pad. Other medium-size neurons (25 microm diameter) were instead labelled with True Blue and projected to the masseter muscle. Finally, in the same area, other small hypoglossal neurons showed double labelling and projected to both structures. Functional hypotheses on the role of these hypoglossal projections have been discussed.

Outcomes and complications of direct end-to-side facial-hypoglossal nerve anastomosis according to the modified May technique

OBJECT

The aim of this study was to address the efficiency and safety of direct end-to-side facial-hypoglossal nerve anastomosis for facial palsy rehabilitation.

METHODS

The authors conducted a retrospective study of 12 consecutive procedures performed between December 2000 and February 2006. Facial palsies were caused by the surgical removal of tumors in the brainstem, cerebellopontine angle, or mastoid process. Direct end-to-side facial-hypoglossal anastomosis was performed in each case. Facial function (evaluated using the overall percentage of facial function and House-Brackmann scale grades), as well as tongue trophicity and mobility, were assessed at 6, 12, and 24 months after surgery. Postoperative early and late complications were systematically reviewed.

RESULTS

The mean delay between tumoral and reparative surgery was 15.9 +/- 4 months (median 11 months). Preoperatively, the mean percentage facial function score was 11.6 +/- 1.7% (45% of patients with House-Brackmann Grade 5 facial palsy and 55% of patients with House-Brackmann Grade 6). Mean facial function scores increased to 19.3, 32.2, and 43.8% at 6, 12, and 24 months after surgery, respectively. Twenty-four months after surgery, 50% of cases had House-Brackmann Grade 3 facial palsy and 50% had Grade 4. A significantly better recovery at 24 months was observed postoperatively for neural lesions occurring in the mastoid or the brainstem compared with those in the cerebellopontine angle. Tongue hemiparesis was observed in 5 patients (41.7%), 2 of whom had tongue hypotrophy (16.7%). No patient complained of swallowing or speech disturbance. Facial synkinesis was noted in 1 patient (8.3%).

CONCLUSIONS

Facial recovery after direct end-to-side facial-hypoglossal nerve anastomosis is similar to results observed with end-to-end or end-to-side facial-hypoglossal nerve anastomosis with an interpositional graft. Tongue hypotrophy and palsy were observed in a small number of cases. This procedure allows one to minimize, although not fully prevent, facial synkinesis. The site of the neural lesion appears to be an important factor in the prognosis of recovery.

Global assessment of outcomes after varying reinnervation techniques for patients with facial paralysis subsequent to acoustic neuroma excision

OBJECTIVE

To determine whether there are objective and/or subjective differences in facial function, tongue function and quality of life in patients who have undergone 1) direct facial-to-facial (Primary, 4 patients), 2) direct facial-to-hypoglossal (End-to-End, 7 patients), 3) end-to-side facial-to-hypoglossal nerve anastomoses with sural nerve/greater auricular nerve interposition (End-to-Side with Interposition Graft, 7 patients), and 4) end-to-side facial-to-hypoglossal nerve anastomoses (End-to-Side, 7 patients) after acoustic neuroma excision.

SETTING

Tertiary university referral center.

STUDY DESIGN

Case series.

METHODS

Twenty-five patients with complete facial paralysis after acoustic neuroma surgery who have also undergone 1 of 4 types of facial musculature reinnervation volunteered for the study. The mean duration of follow-up was 11.5 years (range, 1-25 yr). Each patient was globally assessed using the Sunnybrook Facial Grading scale (objective), Facial Disability Index (subjective), Oral-Pharyngeal Disability Index (subjective), Tongue Movement/Muscle symmetry (objective), and short-form SF-36 quality-of-life index (subjective).

RESULTS

Patients who underwent direct facial-to-hypoglossal anastomosis had generally poorer outcomes some of which were statistically significant (p < 0.05) in some components of the Oral-Pharyngeal Disability Index. All of these patients had reduced lateral tongue movement as well as ipsilateral tongue atrophy. There was no significant difference in the Sunnybrook Facial Grading scale scores in those patients in whom end-to-side interposition reinnervation surgery was performed compared with those in whom direct end-to-side anastomosis surgery was performed.

CONCLUSION

Complete sacrifice of the ipsilateral hypoglossal nerve does present with clinically and statistically significant morbidity in patients. Facial function is statistically similar in patients who underwent an end-to-side anastomosis with or without an interposition graft. These findings suggest thatin the setting of the posttranslabryinthine approach, the technicallyeasier interposition graft procedure is not acompromise.

The "babysitter" procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting

BACKGROUND

In 1984, Terzis introduced the "babysitter" procedure, a new concept in facial reanimation. It involves two stages, with coaptation of ipsilateral 40 percent hypoglossal to facial nerve on the affected side, performed concomitantly with cross-facial nerve grafting and secondary microcoaptations 8 to 15 months later. This article presents the senior author's (J.K.T.) experience with the original procedure.

METHODS

Of 75 patients who had minihypoglossal nerve transfer, 20 fulfilled the selection criteria for the original babysitter procedure. All patients' records, photographs, videotapes, and needle electromyography studies were reviewed. The clinical results were scored using Terzis' Grading Scale. Eye closure, smile, and lower lip depression were each assessed separately. Functional and aesthetic outcomes and preoperative and postoperative electromyography results were analyzed.

RESULTS

Seventy-five percent of patients achieved excellent and good results, 15 percent had moderate results, and 10 percent had fair results. The difference between preoperative and postoperative eye closure was statistically significant (t test, p < 0.001). Symmetrical smile and full contraction (excellent result) was achieved in two patients (10 percent), 13 patients (65 percent) had nearly symmetrical smile (good result), and five patients (25 percent) had a moderate result. Two patients (10 percent) had full lower lip depression (excellent result) and 15 (75 percent) had good results. In three patients (15 percent), subsequent digastric or platysma muscle transfer was performed because of inadequate depression and symmetry (moderate result). A statistically significant difference was observed between preoperative and postoperative electromyography results, in eye closure, smile, and lower lip depression.

CONCLUSIONS

The original babysitter procedure offers significant improvement in selected patients with facial paralysis. Symmetry and coordinated movements can be restored, with satisfying aesthetic and functional outcomes.

Hemihypoglossal-facial neurorrhaphy after mastoid dissection of the facial nerve: results in 24 patients and comparison with the classic technique

OBJECTIVE

Hypoglossal-facial neurorrhaphy has been widely used for reanimation of paralyzed facial muscles after irreversible proximal injury of the facial nerve. However, complete section of the hypoglossal nerve occasionally results in hemiglossal dysfunction and interferes with swallowing and speech. To reduce this morbidity, a modified technique with partial section of the hypoglossal nerve after mastoid dissection of the facial nerve (HFM) has been used. We report our experience with the HFM technique, retrospectively comparing the outcome with results of the classic hypoglossal-facial neurorrhaphy.

METHODS

A retrospective review was performed in 36 patients who underwent hypoglossal-facial neurorrhaphy with the classic (n = 12) or variant technique (n = 24) between 2000 and 2006. Facial outcome was evaluated with the House-Brackmann grading system, and tongue function was evaluated with a new scale proposed to quantify postoperative tongue alteration. The results were compared, and age and time between nerve injury and surgery were correlated with the outcome.

RESULTS

There was no significant difference between the two techniques concerning facial reanimation. A worse outcome of tongue function, however, was associated with the classic technique (Mann-Whitney U test; P < 0.05). When HFM was used, significant correlations defined by the Spearman test were identified between preoperative delay (rho = 0.59; P = 0.002) or age (rho = 0.42; P = 0.031) and results of facial reanimation evaluated with the House-Brackmann grading system.

CONCLUSION

HFM is as effective as classic hypoglossal-facial neurorrhaphy for facial reanimation, and it has a much lower morbidity related to tongue function. Better results are obtained in younger patients and with a shorter interval between facial nerve injury and surgery.