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Gazia F, Callejo À, Pérez-Grau M, Lareo S, Prades J, Roca-Ribas F, Amilibia E. Pre- and intra-operative prognostic factors of facial nerve function in cerebellopontine angle surgery. Eur Arch Otorhinolaryngol 2023; 280:1055-1062. [PMID: 35907000 PMCID: PMC9899719 DOI: 10.1007/s00405-022-07556-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/12/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The study assesses whether pre- and intraoperative factors linked to electromyography and direct electrical stimulation (DES) of facial nerve can predict facial nerve function in the short- (12 days) and long-term (1 year) after cerebellopontine angle (CPA) tumor resection. METHODS 157 patients who underwent surgical resection of CPA tumors with facial nerve monitoring. Pre-operative factors (age, tumor size, pure tone average), surgical time and intra-operative parameters regarding facial function, minimum stimulation threshold (MST), compound muscle action potential (CMAP) and the difference between proximal and distal CMAP (DPDC) were evaluated. RESULTS A correlation between tumor size, MST, CMAP and facial function in both short and long term was found. A higher grade of immediate facial paralysis corresponded to a higher risk of poor outcome after one year. A postoperative House-Brackmann (HB) score of V or VI was correlated with poor outcome in 88.8% and 93.8% of cases. A risk of HB 3 or more, in the long term, was correlated with a tumor size of 20.2 mm. Using an MST of 0.1 mA, for long-term predictions, sensitivity and specificity were 0.62 (95% CI 0.46-0.75) and 0.73 (95% CI 0.61-0.82), respectively. With a CMAP cut-off < 200 µV, for long-term prediction, sensitivity was 0.73 (95% CI 0.53-0.87) and specificity 0.73 (95% CI 0.55-0.85). CONCLUSION The assessment based on the cut-offs described increases the ability to predict facial function. Improving predictive accuracy enables surgeons to address patients' expectations and to establish an intervention timeline for planning facial reanimation.
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Affiliation(s)
- Francesco Gazia
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain
- Unit of Otorhinolaryngology, Department of Adult and Development Age Human Pathology "Gaetano Barresi", University of Messina, Messina, Italy
| | - Àngela Callejo
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain
| | - Marta Pérez-Grau
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain
| | - Susana Lareo
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain
| | - José Prades
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain
| | - Francesc Roca-Ribas
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain
| | - Emilio Amilibia
- Department of Otorhinolaryngology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Carretera del Canyet, Badalona, 08916, Barcelona, Spain.
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Farag AA, Ibrahim AEKSED, Alaghory IM. Clinical Benefits of Facial Nerve Monitoring during Cerebellopontine Angle Surgery. OPEN JOURNAL OF MODERN NEUROSURGERY 2022; 12:9-27. [DOI: 10.4236/ojmn.2022.121002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Haring CT, Ellsperman SE, Edwards BM, Kileny P, Kovatch D, Mannarelli GR, Meloch MA, Miller C, Pitts C, Prince MEP, Bradford CR, Wolf GT, Casper KA, Malloy KM, Chinn SB, Shuman AG, McKean EL, VanKoevering KK, Stucken CL, McLean SA, Marentette LJ, Rosko AJ, Spector ME. Assessment of Intraoperative Nerve Monitoring Parameters Associated With Facial Nerve Outcome in Parotidectomy for Benign Disease. JAMA Otolaryngol Head Neck Surg 2021; 145:1137-1143. [PMID: 31045218 DOI: 10.1001/jamaoto.2019.1041] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Prior studies suggest that the use of facial nerve monitoring decreases the rate of immediate postoperative facial nerve weakness in parotid surgery, but published data are lacking on normative values for these parameters or cutoff values to prognosticate facial nerve outcomes. Objective To identify intraoperative facial nerve monitoring parameters associated with postoperative weakness and to evaluate cutoff values for these parameters under which normal nerve function is more likely. Design, Setting, and Participants This retrospective case series of 222 adult patients undergoing parotid surgery for benign disease performed with intraoperative nerve monitoring was conducted at an academic medical institution from September 13, 2004, to October 30, 2014. The data analysis was conducted from May 2018 to January 2019. Main Outcomes and Measures The main outcome measure was facial nerve weakness. Receiver operating characteristic curves were generated to define optimal cut point to maximize the sensitivity and specificity of the stimulation threshold, mechanical events, and spasm events associated with facial nerve weakness. Results Of 222 participants, 121 were women and 101 were men, with a mean (SD) age of 51 (16) years. The rate of temporary facial nerve paresis of any nerve branch was 45%, and the rate of permanent paralysis was 1.3%. The mean predissection threshold was 0.22 milliamperes (mA) (range, 0.1-0.6 mA) and the mean postdissection threshold was 0.24 mA (range, 0.08-1.0 mA). The average number of mechanical events was 9 (range, 0-66), and mean number of spontaneous spasm events was 1 (range, 0-12). Both the postdissection threshold (area under the curve [AUC], 0.69; 95% CI, 0.62-0.77) and the number of mechanical events (AUC, 0.58; 95% CI, 0.50-0.66) were associated with early postoperative facial nerve outcome. The number of spasm events was not associated with facial nerve outcome. The optimal cutoff value for the threshold was 0.25 mA, and the optimal cutoff for number of mechanical events was 8. If a threshold of greater than 0.25 mA was paired with more than 8 mechanical events, there was a 77% chance of postoperative nerve weakness. Conversely, if a threshold was 0.25 mA or less and there were 8 mechanical events or less, there was 69% chance of normal postoperative nerve function. No parameters were associated with permanent facial nerve injury. Conclusions and Relevance Postdissection threshold and the number of mechanical events are associated with immediate postoperative facial nerve function. Accurate prediction of facial nerve function may provide anticipatory guidance to patients and may provide surgeons with intraoperative feedback allowing adjustment in operative techniques and perioperative management.
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Affiliation(s)
- Catherine T Haring
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Susan E Ellsperman
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Bruce M Edwards
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Paul Kileny
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Deborah Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Gregory R Mannarelli
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Melanie A Meloch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Claire Miller
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Crystal Pitts
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Gregory T Wolf
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Erin L McKean
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Scott A McLean
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | | | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
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Quimby AE, Lui J, Chen J. Predictive Ability of Direct Electrical Stimulation on Facial Nerve Function Following Vestibular Schwannoma Surgery: A Systematic Review and Meta-analysis. Otol Neurotol 2021; 42:493-504. [PMID: 33394939 DOI: 10.1097/mao.0000000000003007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Facial nerve preservation is critical in vestibular schwannoma (VS) surgery. Direct electrical stimulation (DES) is a widely used method for intraoperative localization of the facial nerve and assessment of nerve integrity. We sought to assess the predictive ability of DES parameters on facial nerve function post-VS surgery. DATABASES REVIEWED A systematic literature search of English-language studies published from 1946 to 2019 was undertaken using EMBASE, MedLine/PubMed, and the Cochrane Central Register of Controlled Trials. METHODS Included studies involved patients undergoing VS surgery and assessed predictive ability of any DES parameter on postoperative facial function. Two authors independently reviewed studies and extracted data. Meta-analysis of diagnostic accuracy of DES parameters was used to calculate pooled sensitivities and specificities of common cutoffs. For DES parameters reported by less than four studies, outcomes were reported descriptively. RESULTS A MST cutoff of 0.10 mA had sensitivity of 0.76 (95% CI 0.53-0.90) and specificity 0.68 (95% CI 0.42-0.87) for facial function in the long term, and MST 0.05 mA had sensitivity 0.73 (95% CI 0.58-0.84) and specificity 0.74 (95% CI 0.59-0.85). CMAP amplitude < 500 μV had sensitivity of 0.87 (95% CI 0.78-0.93) for poor short-term facial function. CONCLUSIONS A CMAP amplitude response < 500 μV is sensitive for poor short-term facial function, whereas MST values of 0.05 mA and 0.10 mA are both sensitive and specific in the long term. Other DES parameters may be able to accurately predict both short- and long-term postoperative facial function, but have been less studied.
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Affiliation(s)
- Alexandra E Quimby
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa
| | - Justin Lui
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Chen
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Taha I, Hyvärinen A, Ranta A, Kämäräinen OP, Huttunen J, Mervaala E, Löppönen H, Rauramaa T, Ronkainen A, Jääskeläinen JE, Immonen A, Danner N. Facial nerve function and hearing after microsurgical removal of sporadic vestibular schwannomas in a population-based cohort. Acta Neurochir (Wien) 2020; 162:43-54. [PMID: 31494730 PMCID: PMC6942003 DOI: 10.1007/s00701-019-04055-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/29/2019] [Indexed: 10/29/2022]
Abstract
BACKGROUND Vestibular schwannoma (VS) is a benign tumor originating from the vestibulocochlear nerve. The optimal treatment strategy is debated, since surgery may result in iatrogenic facial nerve injury. We report the results of VS surgery in a population-based unselected cohort in a center with access to Cyber Knife (CK) radiosurgery. METHODS We reviewed 117 consecutive operations and found 95 patients who had their primary operation due to vestibular schwannoma between 2001 and 2017. Facial nerve function was evaluated with the House-Brackmann (HB) scale and hearing with the EU classification. RESULTS The population consisted of 37 males and 58 females with a median age of 54 years (range 19-79). One year after surgery 67% of patients had a good outcome (HB 1-2). The rate of good outcome was 90% if no facial nerve damage was observed during intraoperative monitoring, the size of the tumor was under 30 mm and no hydrocephalus was present. During the study period, the treatment strategy changed from total to near-total resection after the introduction of CK radiosurgery, which could be used as a second-line treatment in case of residual tumor regrowth. This resulted in an improvement of outcomes (0% HB 5-6) despite the larger tumor sizes (25 ± 14 mm vs. 31 ± 9 mm, p < 0.05). Hearing preservation rates did not increase. CONCLUSIONS Near-total resection and subsequent CK radiosurgery in case of residual tumor regrowth during follow-up seems to provide a good outcome of facial nerve function even in large VSs.
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Helal AE, Abouzahra H, Fayed AA, Rayan T, Abbassy M. Socioeconomic restraints and brain tumor surgery in low-income countries. Neurosurg Focus 2019; 45:E11. [PMID: 30269590 DOI: 10.3171/2018.7.focus18258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Healthcare spending has become a grave concern to national budgets worldwide, and to a greater extent in low-income countries. Brain tumors are a serious disease that affects a significant percentage of the population, and thus proper allocation of healthcare provisions for these patients to achieve acceptable outcomes is a must. The authors reviewed patients undergoing craniotomy for tumor resection at their institution for the preceding 3 months. All the methods used for preoperative planning, intraoperative management, and postoperative care of these patients were documented. Compromises to limit spending were made at each stage to limit expenditure, including low-resolution MRI, sparse use of intraoperative monitoring and image guidance, and lack of dedicated postoperative neurocritical ICU. This study included a cohort of 193 patients. The average cost from diagnosis to discharge was $1795 per patient (costs are expressed in USD). On average, there was a mortality rate of 10.5% and a neurological morbidity rate of 14%, of whom only 82.2% improved on discharge or at follow-up. The average length of stay at the hospital for these patients was 9.09 days, with a surgical site infection rate of only 3.5%. The authors believe that despite the great number of financial limitations facing neurosurgical practice in low-income countries, surgery can still be performed with reasonable outcomes.
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The utility of “low current” stimulation threshold of intraoperative electromyography monitoring in predicting facial nerve function outcome after vestibular schwannoma surgery: a prospective cohort study of 103 large tumors. J Neurooncol 2018; 138:383-390. [DOI: 10.1007/s11060-018-2806-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/14/2018] [Indexed: 10/18/2022]
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Role of Facial Nerve Motor-Evoked Potential Ratio in Predicting Facial Nerve Function in Vestibular Schwannoma Surgery Both Immediate and at 1 Year. Otol Neurotol 2017; 37:1162-7. [PMID: 27525626 DOI: 10.1097/mao.0000000000001137] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether transcranial electrical stimulation-induced facial motor-evoked potential (FMEP) monitoring of the facial nerve (FN) during vestibular schwannoma (VS) tumor resection can predict both immediate and 1 year postoperative FN functional outcome. DESIGN Prospective consecutive non-comparative observational case series. SETTING Tertiary referral center. MAIN OUTCOME MEASURES Facial function, immediate post operation and at 1 year using House-Brackmann (HB) grading scale. METHODS The study included 367 consecutive patients (men 178; women 189; age 13-81 years) monitored during primary sporadic VS microsurgery between November 2002 and April 2015. Neurofibromatosis type II, revision surgery, previous radiotherapy treatment, preoperative facial nerve weakness, and non-VS cases were excluded retrospectively during analysis of data. Data of facial function were missing from eight patients at 1 year and were excluded. The correlation between the final-to-baseline FMEP ratio and immediate and 1 year facial nerve function was examined. RESULTS Using logistic regression model, the cut-off points of FMEP ratio were 0.62 (PPV 0.96) and 0.59 (PPV 0.98) which predicted satisfactory FN function (HB grades 1 or 2) immediately postoperative and at 1 year after surgery, respectively. CONCLUSION Transcranial electrical stimulation FMEP is a valuable tool for monitoring facial nerve function during resection of vestibular schwannoma. Maintaining a FMEP event-to-baseline ratio of 60% or greater is predictive of satisfactory long-term FN function.
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Grosheva M, Rink S, Jansen R, Bendella H, Pavlov SP, Sarikcioglu L, Angelov DN, Dunlop SA. Early and continued manual stimulation is required for long‐term recovery after facial nerve injury. Muscle Nerve 2017; 57:100-106. [DOI: 10.1002/mus.25613] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 02/03/2017] [Accepted: 02/14/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Maria Grosheva
- Department of Oto‐Rhino‐LaryngologyUniversity of CologneCologne Germany
| | - Svenja Rink
- Anatomical Institute IUniversity of CologneJoseph‐Stelzmann‐Strasse 9, D‐50924Köln Germany
| | - Ramona Jansen
- Anatomical Institute IUniversity of CologneJoseph‐Stelzmann‐Strasse 9, D‐50924Köln Germany
| | - Habib Bendella
- Department of NeurosurgeryUniversity of Witten/HerdeckeCologne Merheim Medical Center, Cologne Germany
| | | | - Levent Sarikcioglu
- Department of AnatomyAkdeniz University Faculty of MedicineAntalya Turkey
| | - Doychin N. Angelov
- Anatomical Institute IUniversity of CologneJoseph‐Stelzmann‐Strasse 9, D‐50924Köln Germany
| | - Sarah A. Dunlop
- Experimental and Regenerative Neuroscience, School of Biological SciencesThe University of Western AustraliaCrawley Western Australia Australia
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Singh H, Vogel RW, Lober RM, Doan AT, Matsumoto CI, Kenning TJ, Evans JJ. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide. SCIENTIFICA 2016; 2016:1751245. [PMID: 27293965 PMCID: PMC4886091 DOI: 10.1155/2016/1751245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.
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Affiliation(s)
- Harminder Singh
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Richard W. Vogel
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Robert M. Lober
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Adam T. Doan
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Craig I. Matsumoto
- Sentient Medical Systems, 11011 McCormick Road, Suite 200, Hunt Valley, MD 21031, USA
| | - Tyler J. Kenning
- Department of Neurosurgery, Albany Medical Center, Physicians Pavilion, First Floor, 47 New Scotland Avenue, MC 10, Albany, NY 12208, USA
| | - James J. Evans
- Thomas Jefferson University Hospital, Department of Neurosurgery, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
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Breen JT, Carlson ML, Voss SG, Link MJ, Driscoll CL, Neff BA. Intracranial supramaximal facial nerve stimulation: a murine model. Am J Otolaryngol 2014; 35:164-70. [PMID: 24315628 DOI: 10.1016/j.amjoto.2013.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 09/14/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Supramaximal facial nerve stimulation is an applied current sufficient to evoke a maximal electromyographic response of facial musculature. It is used during cerebellopontine angle surgery for prognostication of postoperative nerve function. We utilized a rat model to examine safe parameters for intracranial electrical stimulation. MATERIALS AND METHODS Intracranial facial nerve stimulation with electromyographic monitoring of 14 rats was performed. Supramaximal current level was determined and 50 additional pulses of supramaximal (4 rats), 3 times supramaximal (4), 10 times supramaximal (3), or zero (3) current were applied. To monitor progression of facial nerve injury, video recordings of vibrissae movements and eye closure were captured at 1, 3 and 28 days after surgery; animals were sacrificed on day 28, when nerve morphometry was performed. RESULTS One rat in the supramaximal stimulation group (of 4), and one rat in the 10 times supramaximal stimulation group (of 3) demonstrated persistent impairment of facial nerve function as evidenced by decreased amplitude of vibrissae sweeping and eye closure impairment. The remainder of rats in all experimental groups demonstrated symmetric and normal facial nerve function at all time points. CONCLUSIONS A novel animal model for supramaximal stimulation of the rat intracranial facial nerve is described. A small proportion of animals demonstrated functional evidence of nerve injury postoperatively. Function was preserved in some animals after stimulation with current order of magnitude higher than supramaximal levels. Further study with this model is necessary to definitively isolate the effects of surgical trauma from those of supramaximal electrical stimulation.
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Schick B, Dlugaiczyk J. Surgery of the ear and the lateral skull base: pitfalls and complications. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc05. [PMID: 24403973 PMCID: PMC3884540 DOI: 10.3205/cto000097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills. Following a summary about general aspects in pre-, intra-and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation and surgery of vestibular schwannomas and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "dos and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed. An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.
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Affiliation(s)
- Bernhard Schick
- Dept. of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Julia Dlugaiczyk
- Dept. of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
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Acioly MA, Liebsch M, de Aguiar PHP, Tatagiba M. Facial Nerve Monitoring During Cerebellopontine Angle and Skull Base Tumor Surgery: A Systematic Review from Description to Current Success on Function Prediction. World Neurosurg 2013; 80:e271-300. [DOI: 10.1016/j.wneu.2011.09.026] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 09/06/2011] [Indexed: 11/17/2022]
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Cosetti MK, Xu M, Rivera A, Jethanamest D, Kuhn MA, Beric A, Golfinos JG, Roland JT. Intraoperative Transcranial Motor-Evoked Potential Monitoring of the Facial Nerve during Cerebellopontine Angle Tumor Resection. J Neurol Surg B Skull Base 2013; 73:308-15. [PMID: 24083121 DOI: 10.1055/s-0032-1321507] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 03/28/2012] [Indexed: 10/28/2022] Open
Abstract
Objective To determine whether transcranial motor-evoked potential (TCMEP) monitoring of the facial nerve (FN) during cerebellopontine angle (CPA) tumor resection can predict both immediate and long-term postoperative FN function. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures DeltaTCMEP (final-initial) and immediate and long-term facial nerve function using House Brackmann (HB) rating scale. Results Intraoperative TCMEP data and immediate and follow-up FN outcome are reported for 52 patients undergoing CPA tumor resection. Patients with unsatisfactory facial outcome (HB >2) at follow-up had an average deltaTCMEP of 57 V, whereas those with HB I or II had a mean deltaTCMEP of 0.04 V (t = -2.6, p < 0.05.) Intraoperative deltaTCMEP did not differ significantly between groups with satisfactory (HB I, II) and unsatisfactory (HB > 2) facial function in the immediate postoperative period. Conclusion Intraoperative TCMEP of the facial nerve can be a valuable adjunct to conventional facial nerve electromyography during resection of tumors at the CPA. Intraoperative deltaTCMEP >57 V may be worrisome for long-term recovery of satisfactory facial nerve function.
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Affiliation(s)
- Maura K Cosetti
- Departments of Otolaryngology, New York University School of Medicine, New York, New York, United States
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Oh T, Nagasawa DT, Fong BM, Trang A, Gopen Q, Parsa AT, Yang I. Intraoperative neuromonitoring techniques in the surgical management of acoustic neuromas. Neurosurg Focus 2013; 33:E6. [PMID: 22937857 DOI: 10.3171/2012.6.focus12194] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Unfavorable outcomes such as facial paralysis and deafness were once unfortunate probable complications following resection of acoustic neuromas. However, the implementation of intraoperative neuromonitoring during acoustic neuroma surgery has demonstrated placing more emphasis on quality of life and preserving neurological function. A modern review demonstrates a great degree of recent success in this regard. In facial nerve monitoring, the use of modern electromyography along with improvements in microneurosurgery has significantly improved preservation. Recent studies have evaluated the use of video monitoring as an adjunctive tool to further improve outcomes for patients undergoing surgery. Vestibulocochlear nerve monitoring has also been extensively studied, with the most popular techniques including brainstem auditory evoked potential monitoring, electrocochleography, and direct compound nerve action potential monitoring. Among them, direct recording remains the most promising and preferred monitoring method for functional acoustic preservation. However, when compared with postoperative facial nerve function, the hearing preservation is only maintained at a lower rate. Here, the authors analyze the major intraoperative neuromonitoring techniques available for acoustic neuroma resection.
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Affiliation(s)
- Taemin Oh
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095-1761, USA
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Facial corticobulbar motor-evoked potential monitoring during the clipping of large and giant aneurysms of the anterior circulation. J Clin Neurosci 2013; 20:873-8. [PMID: 23313523 DOI: 10.1016/j.jocn.2012.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 04/04/2012] [Accepted: 04/14/2012] [Indexed: 11/23/2022]
Abstract
Surgical outcomes for large and giant intracranial aneurysms are suboptimal. Two important reasons for higher complication rates are either occlusion of perforators or parent arteries during aneurysm clipping, or prolonged temporary occlusion of the main arteries. Somatosensory-evoked potential (SSEP) monitoring and transcranial motor-evoked potential (TcMEP) monitoring are standard techniques for monitoring ischemia either during temporary arterial occlusion or after permanent clipping. In our study, facial corticobulbar motor-evoked potential (FCoMEP) monitoring was included to determine whether this modality improved intraoperative monitoring. FCoMEP were recorded intraoperatively in 21 patients undergoing surgical clipping of large and giant aneurysms of the anterior circulation. Valid TcMEP parameters were obtained for all patients. A correlation tending to significance between a prolonged temporary clipping time and TcMEP decrement was observed. In addition to this, the inclusion of FCoMEP improved the sensitivity of extremity muscle motor-evoked potential (ExMEP, which included TcMEP) monitoring (from 80% to 100%). In the long-term assessment, a favorable outcome was achieved in 16 of the 21 patients (76%). In conclusion, FCoMEP provides complementary corticobulbar tract information for detecting perforating vessel compromise that may lead to motor impairment and that is not identified by ExMEP.
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Schmitt WR, Daube JR, Carlson ML, Mandrekar JN, Beatty CW, Neff BA, Driscoll CL, Link MJ. Use of supramaximal stimulation to predict facial nerve outcomes following vestibular schwannoma microsurgery: results from a decade of experience. J Neurosurg 2013; 118:206-12. [DOI: 10.3171/2012.10.jns12915] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goal of vestibular schwannoma surgery is tumor removal and preservation of neural function. Intraoperative facial nerve (FN) monitoring has emerged as the standard of care, but its role in predicting long-term facial function remains a matter of debate. The present report seeks to describe and critically assess the value of applying current at supramaximal levels in an effort to identify patients destined for permanent facial paralysis.
Methods
Over more than a decade, the protocol for stimulating and assessing the FN during vestibular schwannoma surgery at the authors' institution has consisted of applying pulsed constant-current stimulation at supramaximal levels proximally and distally following tumor resection to generate an amplitude ratio, which subtracted from 100% yields the degree to which the functional integrity of the FN “dropped off” intraoperatively. These data were prospectively collected and additional variables that might impact postoperative FN function were retrospectively reviewed from the medical record. Only patients with anatomically intact FNs and > 12 months of follow-up data were analyzed.
Results
There were 267 patients available for review. The average posterior fossa tumor diameter was 24 mm and the rate of long-term good (House-Brackmann Grade I–II) FN function was 84%. Univariate logistic regression analysis revealed that prior treatment, neurofibromatosis Type 2 status, tumor size, cerebellopontine angle extension, subjectively thinned FN at the time of operation, minimal stimulation threshold, percent dropoff by supramaximal stimulation (SMS), and postoperative FN function all correlated statistically (p < 0.05) with long-term FN function. When evaluating patients with significant FN weakness at the time of hospital discharge, only the percent dropoff by SMS remained a significant predictor of long-term FN function. However, the positive predictive value of SMS for long-term weakness is low, at 46%.
Conclusions
In a large cohort of patients, the authors found that interrogating intraoperative FN function with SMS is safe and technically simple. It is useful for predicting which patients will ultimately have good facial function, but is very limited in identifying patients destined for long-term facial weakness. This test may prove helpful in the future in tailoring less than gross-total tumor removal to limit postoperative facial weakness.
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Affiliation(s)
| | | | | | | | | | - Brian A. Neff
- 1Departments of Otolaryngology-Head and Neck Surgery,
| | - Colin L. Driscoll
- 1Departments of Otolaryngology-Head and Neck Surgery,
- 4Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Michael J. Link
- 4Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
- 1Departments of Otolaryngology-Head and Neck Surgery,
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Neurophysiologic Intraoperative Monitoring of Trigeminal and Facial Nerves. J Clin Neurophysiol 2011; 28:551-65. [DOI: 10.1097/wnp.0b013e318241de1a] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Marin P, Pouliot D, Fradet G. Facial nerve outcome with a Peroperative stimulation threshold under 0.05 mA. Laryngoscope 2011; 121:2295-8. [DOI: 10.1002/lary.22359] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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A Model for Early Prediction of Facial Nerve Recovery After Vestibular Schwannoma Surgery. Otol Neurotol 2011; 32:826-33. [DOI: 10.1097/mao.0b013e31821b0afd] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhao X, Wang Z, Ji Y, Wang C, Yu R, Ding X, Wei S. Long-term facial nerve function evaluation following surgery for large acoustic neuromas via retrosigmoid transmeatal approach. Acta Neurochir (Wien) 2010; 152:1647-52. [PMID: 20544362 DOI: 10.1007/s00701-010-0705-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 05/27/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE By evaluating the postoperative facial nerve function of large acoustic neuromas, the purpose of this study was to analyze the factors that influence the facial nerve function outcome and to explore the surgical strategy for large acoustic neuromas. METHODS A retrospective study of surgical outcome was performed on 89 patients with large acoustic neuromas. All operations were performed via the retrosigmoid transmeatal approach using the intraoperative electrophysiological monitoring. RESULTS Gross total resection was performed in 38 (42.7%) of the 89 patients, near total resection in 35 (39.3%), and subtotal resection in 16 (18.0%). The facial nerve was anatomically intact at the end of surgery in 83 (93.3%) patients. At 1 year after surgery, 48 (53.9%) patients had good facial nerve function (House-Brackmann (HB) Grades I-II), 23 (25.8%) patients had regular facial nerve function (HB Grades III-IV), and 18 (20.2%) patients had poor facial nerve function (HB Grades V-VI). CONCLUSIONS For large acoustic neuromas, the goal of complete tumor resection and preservation of acceptable facial nerve function can be attained via the retrosigmoid transmeatal approach, using the intraoperative facial nerve monitoring. The surgical strategy of near total resection is indicated for the large acoustic neuromas with severe adherence or inclusion in order to preserve facial nerve function.
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Affiliation(s)
- Xu Zhao
- Department of Neurosurgery, the Second Hospital of Shandong University, Jinan, Shandong Province, China
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Factors associated with preservation of facial nerve function after surgical resection of vestibular schwannoma. J Neurooncol 2010; 102:281-6. [PMID: 20694574 PMCID: PMC3052445 DOI: 10.1007/s11060-010-0315-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 07/12/2010] [Indexed: 11/09/2022]
Abstract
Avoidance of facial nerve palsy is one of the major goals of vestibular schwannoma (VS) microsurgery. In this study, we examined the significance of previously implicated prognostic factors (age, tumor size, the extent of resection and the surgical approach) on post-operative facial nerve function. We selected all VS patients from prospectively collected database (1984–2009) who underwent microsurgical resection as their initial treatment for histopathologically confirmed VS. The effect of variables such as surgical approach, tumor size, patient age and extent of resection on rates facial nerve dysfunction after surgery, were analyzed using multivariate logistic regression. Patients with preoperative facial nerve dysfunction (House-Brackman [HB] score 3 or higher) were excluded, and HB grade of 1 or 2 at the last follow-up visit was defined as “facial nerve preservation.” A total of 624 VS patients were included in this study. Multivariate logistic regression analysis found that only pre-operative tumor size significantly predicted poorer facial nerve outcome for patients followed-up for ≥6 and ≥12 months (OR 1.27, 95% CI 1.09–1.49, p < 0.01; OR 1.35, 95% CI 1.10–1.67, P < 0.01, respectively). We found no significant relationship between facial nerve function and age, extent of resection, surgical approach, or tumor size (when extent of resection and surgical approach were included in the regression analysis). Because facial nerve palsy is a debilitating and psychologically devastating condition for the patient, we suggest altering surgical aggressiveness in patients with unfavorable tumor anatomy, particularly in cases with large tumors where overaggressive resection might subject the patient to unwarranted risk. Residual disease can be followed and controlled with radiosurgery if interval growth is noted.
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Ng WH, Mukhida K, Rutka JT. Image guidance and neuromonitoring in neurosurgery. Childs Nerv Syst 2010; 26:491-502. [PMID: 20174925 DOI: 10.1007/s00381-010-1083-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 01/18/2010] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The localization of tumors and epileptogenic foci within the somatosensory or language cortex of the brain of a child poses unique neurosurgical challenges. In the past, lesions in these regions were not treated aggressively for fear of inducing neurological deficits. As a result, while function may have been preserved, the underlying disease may not have been optimally treated, and repeat neurosurgical procedures were frequently required. Today, with the advent of preoperative brain mapping, image guidance or neuronavigation, and intraoperative monitoring, peri-Rolandic and language cortex lesions can be approached directly and definitively with a high degree of confidence that neurosurgical function will be maintained. METHODS AND RESULTS The preoperative brain maps can now be achieved with magnetic resonance imaging (MRI), functional MRI, magnetoencephalography, and diffusion tensor imaging. Image guidance systems have improved significantly and include the use of the intraoperative MRI. Somatosensory, motor, and brainstem auditory-evoked potentials are used as standard neuromonitoring techniques in many centers around the world. Added to this now is the use of continuous train-of-five monitoring of the integrity of the corticospinal tract while operating in the peri-Rolandic region. CONCLUSION We are in an era where continued advancements can be expected in mapping additional pathways such as visual, memory, and hearing pathways. With these new advances, neurosurgeons can expect to significantly improve their surgical outcomes further.
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Affiliation(s)
- Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
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Intraoperative Electromyography and Surgical Observations as Predictive Factors of Facial Nerve Outcome in Vestibular Schwannoma Surgery. Otol Neurotol 2010; 31:306-12. [DOI: 10.1097/mao.0b013e3181be6228] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Attias J, Nageris B, Ralph J, Vajda J, Rappaport ZH. Hearing preservation using combined monitoring of extra-tympanic electrocochleography and auditory brainstem responses during acoustic neuroma surgery. Int J Audiol 2009; 47:178-84. [DOI: 10.1080/14992020701802422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Arle JE, Shils JL. Neurosurgical decision-making with IOM: DBS surgery. Neurophysiol Clin 2007; 37:449-55. [PMID: 18083501 DOI: 10.1016/j.neucli.2007.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 09/24/2007] [Indexed: 11/30/2022] Open
Abstract
Intraoperative monitoring (IOM) adds new information to intraoperative surgical decision-making. When presented clearly and accurately, it can help guide decision processes during the procedure, but can be a detriment overall if the information is inaccurate or misleading. Troubleshooting abilities and vigilance of the IOM staff play a large role in bolstering the level of trust a surgeon develops in IOM. Additionally, a surgeon may impart his own interpretation and experience with this new information that can undermine or enhance its impact on the case. In this article, we explore these issues with IOM in general and as they relate to the special context of DBS for movement disorders.
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Affiliation(s)
- Jeffrey E Arle
- Department of Neurosurgery, The Lahey Clinic, Tufts University School of Medicine, 41, Mall Road, Burlington, MA 01867, United States
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Rampp S, Prell J, Thielemann H, Posch S, Strauss C, Romstöck J. Baseline correction of intraoperative electromyography using discrete wavelet transform. J Clin Monit Comput 2007; 21:219-26. [PMID: 17520331 DOI: 10.1007/s10877-007-9076-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Accepted: 04/20/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE In intraoperative analysis of electromygraphic signals (EMG) for monitoring purposes, baseline artefacts frequently pose considerable problems. Since artefact sources in the operating room can only be reduced to a limited degree, signal-processing methods are needed to correct the registered data online without major changes to the relevant data itself. We describe a method for baseline correction based on "discrete wavelet transform" (DWT) and evaluate its performance compared to commonly used digital filters. METHODS EMG data from 10 patients who underwent removal of acoustic neuromas were processed. Effectiveness, preservation of relevant EMG patterns and processing speed of a DWT based correction method was assessed and compared to a range of commonly used Butterworth, Resistor-Capacitor and Gaussian filters. RESULTS Butterworth and DWT filters showed better performance regarding artefact correction and pattern preservation compared to Resistor-Capacitor and Gaussian filters. Assuming equal weighting of both characteristics, DWT outperformed the other methods: While Butterworth, Resistor-Capacitor and Gaussian provided good pattern preservation, the effectiveness was low and vice versa, while DWT baseline correction at level 6 performed well in both characteristics. CONCLUSIONS The DWT method allows reliable and efficient intraoperative baseline correction in real-time. It is superior to commonly used methods and may be crucial for intraoperative analysis of EMG data, for example for intraoperative assessment of facial nerve function.
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Affiliation(s)
- Stefan Rampp
- Department of Neurosurgery, University of Halle-Wittenberg, Ernst-Grube-Str. 40, Halle (Saale), Germany.
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Lin VYW, Houlden D, Bethune A, Nolan M, Pirouzmand F, Rowed D, Nedzelski JM, Chen JM. A Novel Method in Predicting Immediate Postoperative Facial Nerve Function Post Acoustic Neuroma Excision. Otol Neurotol 2006; 27:1017-22. [PMID: 17006353 DOI: 10.1097/01.mao.0000235308.87689.35] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED To determine whether the percentage calculated by dividing the amplitude of postexcision direct facial nerve stimulus responses (at pontomedullary junction) by the amplitude of distal ipsilateral transcutaneous (stylomastoid region) maximal stimulus responses and response amplitude progression by increasing stimulus intensities have predictive value for determining normal or near-normal (House-Brackmann Grade 1 or 2) immediate postoperative facial nerve function. STUDY DESIGN Intraoperative recordings of three muscle groups: 1) frontalis, 2) orbicularis oculi, and 3) orbicularis oris. Postexcision direct facial nerve stimulation at the pontomedullary junction and transcutaneous maximal facial nerve stimulation at the ipsilateral stylomastoid region and their associated response amplitudes were recorded. SETTING Tertiary referral center. PATIENTS AND METHODS Patients who underwent acoustic neuroma surgery from January 2004 to March 2006 with intraoperative facial nerve monitoring and an intact facial nerve after tumor excision were included. Recordings were available for 38 patients. RESULTS With a stimulus intensity of 0.3 mA at the root exit zone, there was an 81% positive predictive value in patients that exhibited a compound action potential of greater than 20% of maximum (sensitivity, 81%). This increased to 93% when the compound action potential was greater than 50% of maximum. When the amplitude increase was greater than 5 microV, there was a 77% positive predictive value (sensitivity, 87%). CONCLUSION The percentage of the response amplitude of direct facial nerve stimulation at the pontomedullary junction when compared with the maximum response amplitude of ipsilateral transcutaneous stimulation at the stylomastoid foramen is a good predictor of normal to near-normal immediate postoperative facial nerve function. Progression of amplitude response also seems to be a good predictor of normal to near-normal immediate postoperative facial nerve function.
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Affiliation(s)
- Vincent Y W Lin
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Bozorg Grayeli A, Kalamarides M, Fraysse B, Deguine O, Favre G, Martin C, Mom T, Sterkers O. Comparison between intraoperative observations and electromyographic monitoring data for facial nerve outcome after vestibular schwannoma surgery. Acta Otolaryngol 2005; 125:1069-74. [PMID: 16298788 DOI: 10.1080/00016480510038608] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A four-channel device may enhance the sensitivity of electromyography (EMG). Determination of stimulation thresholds (STs) below 0.05 mA improves facial prognostic information after vestibular schwannoma (VS) surgery. To compare intraoperative observations with electromyographic data for predicting the immediate facial function outcome after VS surgery.A total of 111 VS patients operated on and intraoperatively monitored using four-channel facial EMG between October 2002 and September 2003 were included in this multicentre, prospective study. Mascular activity detection was performed in the frontal, orbicularis oculi, orbicularis oris and platysma muscles. Intraoperative observations were made concerning adhesion and nerve stretch, and facial function was graded (House-Brackmann classification) at postoperative Days 1 and 8.Facial function at postoperative Days 1 and 8 was related to the intraoperative nerve STs at the brainstem and in the adhesion zone (range 0.01-3 mA for a response > 100 microV). At postoperative Day 8, good facial function (Grades 1 or 2) was observed in 93% of cases for STs in the adhesion zone of 0.01-0.04 mA, 85% for STs of 0.05-0.3 mA and 79% for STs > 0.3 mA. These STs were related to the degree of tumor adhesion and not to the nerve stretch. The maximal EMG response was detected in the frontal or platysma muscles in 26% of cases, and in the orbicularis oris and orbicularis oculi muscles in 74%.
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Parhizkar N, Hiltzik DH, Selesnick SH. Facial Nerve Rerouting in Skull Base Surgery. Otolaryngol Clin North Am 2005; 38:685-710, ix. [PMID: 16005726 DOI: 10.1016/j.otc.2005.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Facial nerve rerouting techniques were developed to facilitate re-section of extensive tumors occupying the skull base. Facial nerve rerouting has its own limitations and risks, requiring microsurgical expertise, additional surgical time, and often some degree of facial nerve paresis. This article presents different degrees of anterior and posterior facial nerve rerouting, techniques of facial nerve rerouting, and a comprehensive review of outcomes. It then reviews anatomic and functional preservation of the facial nerve in acoustic neuroma resection, technical aspects of facial nerve dissection, intracranial facial nerve repair options, and outcomes for successful acoustic neuroma surgery.
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Affiliation(s)
- Nooshin Parhizkar
- Department of Otolaryngology, Weill Medical College of Cornell University, New York, 530 East 70th Street, New York, NY 10021, USA
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Edwards BM, Kileny PR. Intraoperative Neurophysiologic Monitoring: Indications and Techniques for Common Procedures in Otolaryngology–Head and Neck Surgery. Otolaryngol Clin North Am 2005; 38:631-42, viii. [PMID: 16005722 DOI: 10.1016/j.otc.2005.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Intraoperative cranial nerve monitoring can be an effective adjunct in otolaryngology-head and neck surgery. Monitoring is not considered standard of care, despite indications of cost effectiveness and improved functional outcomes. Lessons learned performing facial nerve monitoring are applicable to upper and lower cranial motor nerves. Auditory nerve monitoring can be modified accord-ing to need for selected otologic and neurotologic surgery. Process standardization and effective communication can lead to improved patient outcomes.
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Affiliation(s)
- Bruce M Edwards
- Division of Audiology and Electrophysiology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, 1500 East Medical Center Drive, TC 1904, Ann Arbor, Michigan 43109, USA.
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Isaacson B, Kileny PR, El-Kashlan HK. Prediction of Long-Term Facial Nerve Outcomes with Intraoperative Nerve Monitoring. Otol Neurotol 2005; 26:270-3. [PMID: 15793418 DOI: 10.1097/00129492-200503000-00025] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate the utility of a statistical equation using two independent intraoperative monitoring parameters in predicting long-term facial nerve function. STUDY DESIGN Retrospective case review. SETTING Tertiary care hospital. PATIENTS Sixty patients undergoing resection of vestibular schwannomas with intraoperative facial nerve monitoring at a single institution. INTERVENTION All patients underwent microsurgical resection of vestibular schwannomas with the use of intraoperative cranial nerve monitoring. MAIN OUTCOME MEASURE Final facial nerve outcome measured using the House-Brackmann scale at least 6 months after microsurgical resection. RESULTS Five out of 60 (8.3%) patients demonstrated significant long-term weakness (i.e., House-Brackmann grade III or worse). Intraoperative monitoring parameters (proximal stimulation threshold, proximal-to-distal response amplitude ratio) were accurate in predicting increased risk of long-term facial nerve dysfunction when used in a logistic regression model. A Student's t test confirmed the equation result was statistically significant in differentiating long-term facial nerve outcomes. CONCLUSION Patients with immediate weakness are at higher risk of having long-term poor facial nerve function. The use of intraoperative monitoring parameters was reliable in predicting facial nerve outcomes. Patients with permanent facial nerve dysfunction often require rehabilitative procedures. The ability to predict facial nerve outcomes with intraoperative monitoring may allow early rehabilitative procedures to improve quality of life and prevent ocular complications.
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Affiliation(s)
- Brandon Isaacson
- University of Michigan Hospitals, Department of Otolaryngology-Head and Neck Surgery, Ann Arbor, Michigan, USA
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Grayeli AB, Guindi S, Kalamarides M, El Garem H, Smail M, Rey A, Sterkers O. Four-Channel Electromyography of the Facial Nerve in Vestibular Schwannoma Surgery: Sensitivity and Prognostic Value for Short-Term Facial Function Outcome. Otol Neurotol 2005; 26:114-20. [PMID: 15699731 DOI: 10.1097/00129492-200501000-00021] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the short-term facial prognostic value of a four-channel facial electromyographic device in vestibular schwannoma surgery. STUDY DESIGN Eighty-nine vestibular schwannomas operated on and intraoperatively monitored by a four-channel facial electromyographic device between October 2002 and September 2003 were included in this prospective study. Detection was performed in frontal, orbicularis oculi, orbicularis oris, and platysma muscles. MAIN OUTCOME MEASURE Facial function grading at postoperative Days 1, 8, 30, and 180 (House-Brackmann classification). SETTING Tertiary referral center. RESULTS Postoperative facial function at Day 180 was assessed as Grade 1 or 2 in 80%, as Grade 3 or 4 in 16%, and as Grade 5 or 6 in 4% (n=80). The postoperative facial function was related to the intraoperative nerve stimuli thresholds (range, 0.01-3 mA for a response >100 microV) near the brainstem and the proximal-to-distal ratio of the stimulation threshold. A proximal threshold between 0.01 and 0.04 mA had a positive predictive value of 94% for good facial function (Grade 1 or 2). The proximal threshold was lower in patients with improving or stable facial function in comparison with those with a delayed deterioration between Days 8 and 30. The stimulation threshold at the adhesion zone was related to the immediate facial function outcome. The maximal electromyographic response was detected in the frontal muscle or the platysma in 27% of cases and in orbicularis oris and oculi in 73% of cases. CONCLUSION A four-channel device may enhance electromyographic sensitivity. Determination of stimulation threshold below 0.05 mA yields facial prognostic information.
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Edwards BM, Kileny PR, Kovach DJ, McCue J, Spak C. Intraoperative Neurophysiologic Monitoring. ACTA ACUST UNITED AC 2004. [DOI: 10.1044/leader.ftr1.09062004.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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