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Simon M, Althaus L, Burggraf M, Albrecht A, Schipper J, Kristin J. Delayed facial nerve palsy after vestibular schwannoma resection: risk factors, extent and prognosis. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08883-8. [PMID: 39127799 DOI: 10.1007/s00405-024-08883-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Facial nerve palsies may develop during the postoperative period of microsurgical removal of vestibular schwannomas (VSs), even after normal facial function for days or weeks after surgery. The aim of this study was to identify the pathomechanism and predictive factors of delayed palsy. MATERIAL AND METHOD The clinical data of 193 patients who underwent vestibular schwannoma surgery between 2012 and 2021 were retrospectively analyzed. A total of 134 patients were included. The patients showed intact facial nerve function up to 24 h after surgery. All patients (n = 20) with palsy from postoperative day 4 were included and collectively referred to as delayed facial nerve palsy (DFNP). Various factors were checked using a binomial regression analysis. RESULTS The mean age of patients with DFNP was 57.8 years (55% female, 45% male). 70% had VS with KOOS ≥ 3, and 60% underwent surgery via a translabyrinthine approach Among the 16 patients with DFNP-related neurotropic pathogens, 25% were seropositive for herpes simplex virus. Most patients (n = 9/20) experienced onset of palsy between postoperative days 6 and 10. Of the four variables included in the significance test, three were significant: KOOS ≥ 3 (p < .04), ipsilateral vestibular organ failure (p < .05), and age group (p < .03). After therapy, 100% of patients recovered almost complete facial nerve function. The parameters mentioned above (KOOS classification and ipsilateral vestibular dysfunction) could be proven risk factors for the occurrence of DFNP.
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Affiliation(s)
- Miriam Simon
- Department of Otorhinolaryngology, University Hospital Düesseldorf Head and Neck Surgery, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Laurenz Althaus
- Department of Otorhinolaryngology, University Hospital Düesseldorf Head and Neck Surgery, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Manuel Burggraf
- Department of Trauma surgery and Orthopedics, Essen University Hospital, Hufelandstraße 55, 45147, Essen, Germany
| | - Angelika Albrecht
- Department of Otorhinolaryngology, University Hospital Düesseldorf Head and Neck Surgery, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Jörg Schipper
- Department of Otorhinolaryngology, University Hospital Düesseldorf Head and Neck Surgery, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Julia Kristin
- Department of Otorhinolaryngology, University Hospital Düesseldorf Head and Neck Surgery, Moorenstrasse 5, 40225, Düsseldorf, Germany
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Silva VAR, Lavinsky J, Pauna HF, Vianna MF, Santos VM, Ikino CMY, Sampaio ALL, Tardim Lopes P, Lamounier P, Maranhão ASDA, Soares VYR, Polanski JF, Denaro MMDC, Chone CT, Bento RF, Castilho AM. Brazilian Society of Otology task force - Vestibular Schwannoma ‒ evaluation and treatment. Braz J Otorhinolaryngol 2023; 89:101313. [PMID: 37813009 PMCID: PMC10563065 DOI: 10.1016/j.bjorl.2023.101313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To review the literature on the diagnosis and treatment of vestibular schwannoma. 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 vestibular schwannoma 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 parts: (1) Diagnosis - audiologic, electrophysiologic tests, and imaging; (2) Treatment - wait and scan protocols, surgery, radiosurgery/radiotherapy, and systemic therapy. CONCLUSIONS Decision making in VS treatment has become more challenging. MRI can diagnose increasingly smaller tumors, which has disastrous consequences for the patients and their families. It is important to develop an individualized approach for each case, which highly depends on the experience of each surgical team.
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Affiliation(s)
- Vagner Antonio Rodrigues Silva
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Campinas, SP, Brazil; Sociedade Brasileira de Otologia - SBO
| | - Joel Lavinsky
- Sociedade Brasileira de Otologia - SBO; Universidade Federal do Rio Grande do Sul (UFRGS), Departamento de Ciências Morfológicas, Porto Alegre, RS, Brazil
| | - Henrique Furlan Pauna
- Hospital Universitário Cajuru, Departamento de Otorrinolaringologia, Curitiba, PR, Brazil
| | - Melissa Ferreira Vianna
- Sociedade Brasileira de Otologia - SBO; Irmandade Santa Casa de Misericórdia de São Paulo, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Vanessa Mazanek Santos
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Curitiba, PR, Brazil
| | - Cláudio Márcio Yudi Ikino
- Universidade Federal de Santa Catarina, Hospital Universitário, Departamento de Cirurgia, Florianópolis, SC, Brazil
| | - André Luiz Lopes Sampaio
- Sociedade Brasileira de Otologia - SBO; Universidade de Brasília (UnB), Faculdade de Medicina, Laboratório de Ensino e Pesquisa em Otorrinolaringologia, Brasília, DF, Brazil
| | - Paula Tardim Lopes
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Pauliana Lamounier
- Centro de Reabilitação e Readaptação Dr. Henrique Santillo (CRER), Departamento de Otorrinolaringologia, Goiânia, GO, Brazil
| | - André Souza de Albuquerque Maranhão
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Vitor Yamashiro Rocha Soares
- Hospital Flavio Santos e Hospital Getúlio Vargas, Grupo de Otologia e Base Lateral do Crânio, Teresina, PI, Brazil
| | - José Fernando Polanski
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Curitiba, PR, Brazil; Faculdade Evangélica Mackenzie do Paraná, Faculdade de Medicina, Curitiba, PR, Brazil
| | | | - Carlos Takahiro Chone
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Campinas, SP, Brazil
| | - Ricardo Ferreira Bento
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Arthur Menino Castilho
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Campinas, SP, Brazil; Sociedade Brasileira de Otologia - SBO.
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Kanaya K, Horiuchi T. Postoperative hematoma can be a risk factor in delayed facial palsy after vestibular schwannoma resection via a retrosigmoid approach: a retrospective single-center cohort study. Acta Neurol Belg 2023; 123:1703-1707. [PMID: 35674908 DOI: 10.1007/s13760-022-01959-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/13/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Delayed facial palsy (DFP) is a rare postoperative complication after vestibular schwannoma (VS) surgery. The exact mechanism of DFP remains uncertain and the risk factors for DFP are still controversial. The authors aimed to investigate the characteristics, risk factors, and etiology of DFP after VS resection retrospectively. METHODS Ninety-one consecutive surgeries with VS were analyzed. Patients with neurofibromatosis 2 in eight surgeries and postoperative facial palsy House-Brackmann (HB) grade more than 3 in two surgeries were excluded. Eighty-one surgeries were included in this research. Facial nerve function was evaluated using the HB grade. Delayed facial palsy was defined as deterioration in the facial function of at least 1 HB grade more than 1 day after undergoing VS resection. The characteristics of patients with VS and risk factors for DFP were analyzed. RESULTS All surgeries were performed via a retrosigmoid approach. DFP was observed in nine patients. There were no statistically significant differences between the DFP group and non-DFP group in terms of the following characteristics: sex, age, side, size, Koos grading system, postoperative facial palsy, or extent of resection. Postoperative hematoma in the cerebellopontine angle (CPA) cistern was significantly higher in the DFP group than in the non-DFP group (p = 0.0023), and was significantly associated with DFP after VS surgery (odds ratio 18.40, p < 0.001). DFP improved in seven patients, but two patients did not improve. CONCLUSION DFP occurred in 11.1% of patients after VS surgery. This study revealed that postoperative hematoma in the CPA cistern was significantly associated with DFP after VS surgery.
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Affiliation(s)
- Kohei Kanaya
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
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Singh R, Spinner RJ. Delayed motor weakness following peripheral nerve schwannoma resection: illustrative cases. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22510. [PMID: 36593673 PMCID: PMC9811574 DOI: 10.3171/case22510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/01/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Delayed facial palsy (DFP) after vestibular schwannoma resection is a well-documented, yet poorly understood condition. The exact pathophysiological mechanisms of DFP are unknown, although diminished intraoperative nerve response has been shown to be a prognostic factor. To date, no such condition has been described in regard to peripheral nerve schwannomas. OBSERVATIONS Here the authors present the first reported cases of delayed motor weakness (DMW) after peripheral schwannoma resection of the ulnar nerve at the elbow and peroneal nerve in the popliteal fossa. Both patients presented with a mass lesion and radiating paresthesias and had normal motor function preoperatively. Immediately after surgical resection, the patients had full strength. Within 24 hours, both patients exhibited marked weakness that gradually resolved over the course of several weeks. LESSONS DMW after peripheral schwannoma resection is a rare condition likely akin to delayed facial nerve palsy after VS resection. The mechanism of this phenomenon remains unknown, although symptoms appear to self-resolve with time. A better understanding of the processes driving this condition may allow for therapies that can expedite and improve long-term outcomes.
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Affiliation(s)
- Rohin Singh
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona; and
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Webb MJ, Neth BJ, Webb LM, Van Gompel JJ, Link MJ, Neff BA, Carlson ML, Driscoll CL, Dornhoffer J, Ruff MW, Anderson KA, Kizilbash SH, Campian JL, Uhm JH, Lane JI, Benson JC, Blezek DJ, Mehta PM, Bathla G, Sener UT. Withdrawal of bevacizumab is associated with rebound growth of vestibular schwannomas in neurofibromatosis type 2-related schwannomatosis patients. Neurooncol Adv 2023; 5:vdad123. [PMID: 37841698 PMCID: PMC10576512 DOI: 10.1093/noajnl/vdad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Background Neurofibromatosis type 2 (NF2)-related schwannomatosis is an autosomal dominant tumor-predisposition syndrome characterized by bilateral vestibular schwannomas (VS). In patients with VS associated with NF2, vascular endothelial growth factor A inhibitor, bevacizumab, is a systemic treatment option. The aim of this study is to retrospectively evaluate NF2 patient responses to bevacizumab on VS growth and symptom progression. Methods This is a retrospective analysis of patients seen at the Mayo Clinic Rochester Multidisciplinary NF2 Clinic. Results Out of 76 patients with NF2 evaluated between 2020 and 2022, we identified 19 that received treatment with bevacizumab. Thirteen of these patients discontinued bevacizumab after median treatment duration of 12.2 months. The remaining 6 patients are currently receiving bevacizumab treatment for a median duration of 9.4 months as of March, 2023. Fifteen patients had evaluable brain MRI data, which demonstrated partial responses in 5 patients, stable disease in 8, and progression in 2. Within 6 months of bevacizumab discontinuation, 5 patients had rebound growth of their VS greater than 20% from their previous tumor volume, while 3 did not. Three patients with rebound growth went on to have surgery or irradiation for VS management. Conclusions Our single-institution experience confirms prior studies that bevacizumab can control progression of VS and symptoms associated with VS growth. However, we note that there is the potential for rapid VS growth following bevacizumab discontinuation, for which we propose heightened surveillance imaging and symptom monitoring for at least 6 months upon stopping anti-VEGF therapy.
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Affiliation(s)
- M J Webb
- Department of Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bryan J Neth
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neuro-Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lauren M Webb
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian A Neff
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew L Carlson
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin L Driscoll
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jim Dornhoffer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael W Ruff
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neuro-Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelsey A Anderson
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jian L Campian
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joon H Uhm
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neuro-Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack I Lane
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Blezek
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Parv M Mehta
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Girish Bathla
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ugur T Sener
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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ORHAN SOYLEMEZ UP, ATALAY B, GÜNDÜZ N. The Relationship Between Koos Classification and ADC-Post-Contrast Signal Intensity Values of Vestibular Schwannomas. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2021. [DOI: 10.25000/acem.984043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Delayed Facial Nerve Palsy Following Resection of Vestibular Schwannoma: Clinical and Surgical Characteristics. Otol Neurotol 2021; 43:244-250. [PMID: 34699397 DOI: 10.1097/mao.0000000000003392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Analyze delayed facial nerve palsy (DFNP) following resection of vestibular schwannoma (VS) to describe distinct characteristics and facial nerve (FN) functional course. STUDY DESIGN Prospective cohort with retrospective review. SETTING Academic medical center. PATIENTS Consecutive patients undergoing VS resection 11/2017 to 08/2020. Exclusion criteria: preoperative House-Brackmann (HB) ≥ III, postoperative HB ≥ III without delayed palsy, <30 days follow-up. INTERVENTIONS VS resection with intraoperative electromyographic monitoring. MAIN OUTCOME MEASURES FN outcomes utilizing the HB scale; comparison between patients with DFNP (deterioration greater than one HB grade 24 hours to 30 days postoperatively) vs. those with HBI-II throughout. RESULTS Two hundred eighty-eight patients met criteria: mean age 47.6 years, 36.1% male; 24.0% middle cranial fossa, 28.5% retrosigmoid, 47.6% translabyrinthine. DFNP occurred in 31 (10.8%) patients with average time to onset of 8.1 days. Of these, 22 (71.0%) recovered HBI-II and 3 (9.7%) recovered HBIII. Patients who experienced DFNP, on average, had larger maximum tumor diameter (23.4 vs. 18.7 mm, p = 0.014), lower rate of gross-total resection (54.8% vs. 75.5%, p = 0.014), and lower rate of ≥100 μV FN response to 0.05 mA stimulus intraoperatively (80.6% vs. 94.9%, p = 0.002). Compared to overall incidence of DFNP, translabyrinthine approach demonstrated higher incidence (15.3%, p = 0.017) while retrosigmoid lower (3.7%, p = 0.014). In multivariable logistic regression, patients with FN response ≥100 μV to 0.05 mA stimulus were 72.0% less likely to develop DFNP (p = 0.021). CONCLUSIONS Intraoperative electromyographic facial nerve response, tumor size, surgical approach, and extent of resection may play a role in development of DFNP following resection of VS. Most patients who develop DFNP recover near-normal function.
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Perkins EL, Manzoor NF, Totten DJ, Sherry AD, Cass N, Thompson R, Tawfik K, O'Malley M, Bennett M, Haynes DS. The Influence of Extent of Resection and Tumor Morphology on Facial Nerve Outcomes Following Vestibular Schwannoma Surgery. Otol Neurotol 2021; 42:e1346-e1352. [PMID: 34238899 DOI: 10.1097/mao.0000000000003253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the influence extent of resection and tumor characteristics on facial nerve (FN) outcomes following microsurgical resection of vestibular schwannoma (VS). STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Three hundred eighty-five patients who underwent VS microsurgical resection. INTERVENTIONS Microsurgical VS resection. MAIN OUTCOME MEASURES House-Brackmann (HB) scores postoperatively. Good FN function was defined as HB grade I and II and poor FN function was defined as HB grade III and VI. Gross total resection (GTR) versus subtotal resection (STR). Propensity-score matching was used in subset analysis to balance tumor volume between the surgical cohorts, followed by multivariable analysis. RESULTS Seventy-one patients (18%) underwent STR and 314 patients (82%) underwent GTR. Two hundred fourteen patients (63%) had good FN function at 2 to 3 weeks postoperatively, and 80% had good FN function at 1 year. In single predictor analysis, STR did not influence FN function at 2 to 3 weeks (p = 0.65). In propensity-score matched subset analysis (N = 178), patients with STR were less likely to have poor FN function at 2 to 3 weeks (p = 0.02) independent of tumor volume (p = 0.004), but there was no correlation between STR and FN function at 1 year (p = 0.09). Ventral extension of tumor relative to the internal auditory canal plane was associated with poor FN outcomes at 2 to 3 weeks (p = 0.0001) and 1-year postop (p = 0.002). CONCLUSIONS When accounting for tumor volume, STR is protective in immediate postoperative FN function compared to GTR. Ventral extension of the tumor is a clinical predictor of long-term FN outcomes.
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Affiliation(s)
- Elizabeth L Perkins
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nauman F Manzoor
- Department of Otolaryngology/Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals ENT Institute, Cleveland, Ohio
| | - Douglas J Totten
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center
| | - Nathan Cass
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reid Thompson
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kareem Tawfik
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew O'Malley
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Bennett
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David S Haynes
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Botulinum Toxin a Treatment of Delayed Facial Palsy in a Randomized Trial. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2021. [DOI: 10.2478/sjecr-2020-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Delayed facial palsy (DFP) is a common complication appearing ≥3 days after neurosurgery. In cases where glucocorticoids are contraindicated, other treatments are needed. Methods: The efficacy of BoNT-A injections was evaluated in patients with DFP after vestibular schwannoma resection. Patients received: Group I, BoNT-A (40–50 IU); Group II, prednisolone (1 mg/kg per day, 5–7 days); Group III, glucocorticoids with BoNT-A; Group IV, refused treatment. Functional efficacy was assessed. Results: Among 75 patients, pretreatment facial nerve dysfunction was mild, moderate, and moderate-to-severe in 48.0%, 33.3%, and 18.7%, respectively. One month post-treatment initiation, Group III had a significantly higher rate of facial symmetry normalization versus Groups II and IV (P < 0.05). After 3 months, complete recovery of facial nerve function was significantly higher in Groups I–III versus Group IV (P < 0.05). Conclusion: BoNT-A injections may be recommended for DFP treatment to attenuate facial asymmetry and improve functional recovery.
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Tawfik KO, Coulter M, Alexander TH, Saliba J, Mastrodimos B, Cueva RA. Delayed Facial Palsy After Resection of Vestibular Schwannoma: An Analysis of Long-term Facial Nerve Outcomes. Otol Neurotol 2021; 42:e764-e770. [PMID: 33900232 DOI: 10.1097/mao.0000000000003158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) Identify clinical factors associated with delayed facial palsy (DFP) after microsurgical resection of vestibular schwannoma. 2) Determine whether DFP predicts worse facial nerve (FN) outcomes. METHODS Adult patients (≥18 yrs) who underwent vestibular schwannoma resection between February 2008 and December 2017 were retrospectively reviewed. Postoperative House-Brackmann (HB) FN function was assessed on the day of surgery, daily during patients' inpatient admissions, and at postoperative clinic visits. Follow-up exceeded ≥12 months for all patients. DFP was defined as a decline (≥1 HB grade) in FN function (relative to the preoperative state) occurring between postoperative days 1 and 30. RESULTS Two hundred ninety-one patients were analyzed. Mean age was 51.5 years (±12.3) and mean tumor size 20.6 mm (±10.8). Immediate FP occurred in 61 (21%) patients, and DFP occurred in 112 (38%) patients. Tumor size was largest in patients with immediate FP (p < 0.0001). On univariate analysis, DFP was associated with better final FN outcomes (OR 0.447, p = 0.0101) compared with immediate FP. Multivariate analysis, however, showed that timing of FP was no longer significant, whereas larger tumor size and preoperative HB2 function predicted worse FN outcomes (OR 2.718, p < 0.0001 and OR 9.196, p = 0.0039, respectively). In patients with DFP, longer time to onset of palsy predicted more favorable FN outcomes. CONCLUSIONS When accounting for tumor size, the timing of onset of postoperative facial palsy does not predict final FN outcomes. In patients who develop DFP, the longer the interval between surgery and onset of weakness, the better the chances of good long-term FN function.
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Affiliation(s)
- Kareem O Tawfik
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Joe Saliba
- University of Montreal, Montreal, Canada
| | | | - Roberto A Cueva
- University of California, San Diego, Kaiser Permanente Southern California Medical Group, San Diego, California, USA
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Li LPH, Chen JKC, Coelho DH. Optimizing Location of Subdermal Recording Electrodes for Intraoperative Facial Nerve Monitoring. Laryngoscope 2021; 131:E2329-E2334. [PMID: 33749869 DOI: 10.1002/lary.29518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/10/2021] [Accepted: 03/03/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The purpose of this study is to determine if different facial muscle groups demonstrate different responses to facial nerve stimulation, the results of which could potentially improve intraoperative facial nerve monitoring (IOFNM). METHODS IOFNM data were prospectively collected from patients undergoing cochlear implantation. At different stages of nerve exposure, three sites were stimulated using a monopolar pulse. Peak electromyography (EMG) amplitude (μV) in four muscle groups innervated by four different branches of the facial nerve (frontalis-temporal, inferior orbicularis oculi-zygomatic, superior oribularis oris-buccal, and mentalis-marginal mandibular) were recorded. RESULTS A total of 279 peak EMG amplitudes were recorded in 93 patients. At all three stimulating sites, the zygomatic branch mean peak EMG amplitudes were statistically greater than those of the temporal, buccal, and marginal mandibular branches (P < .05). At stimulating Site C, the marginal mandibular branch mean peak EMG was stronger than the temporal or buccal branches (P < .05). Of the 279 stimulations, the zygomatic branch demonstrated the highest amplitude in 128 (45.9%) trials, followed by the marginal mandibular branch (22.2%). CONCLUSIONS When utilized, IOFNM should be performed with at least two electrodes, one of which is placed in the orbicularis oculi muscles and the other in the mentalis muscle. However, there is wide variability between patients. As such, in cases of suspected variant nerve anatomy or increased risk of injury (intradural procedures), surgeons should consider using more than two recording electrodes, with at least one in the orbicularis oculi muscle. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2329-E2334, 2021.
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Affiliation(s)
- Lieber Po-Hung Li
- Faculty of Medicine, Institute of Brain Science, National Yang-Ming Chiao-Tung University, Taipei, Taiwan.,Department of Otolaryngology, Cheng Hsin General Hospital, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Department of Speech Language Pathology and Audiology, College of Health Technology, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Joshua Kuang-Chao Chen
- Department of Otolaryngology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Daniel H Coelho
- Department of Otolaryngology - Head and Neck Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A
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Goldbrunner R, Weller M, Regis J, Lund-Johansen M, Stavrinou P, Reuss D, Evans DG, Lefranc F, Sallabanda K, Falini A, Axon P, Sterkers O, Fariselli L, Wick W, Tonn JC. EANO guideline on the diagnosis and treatment of vestibular schwannoma. Neuro Oncol 2021; 22:31-45. [PMID: 31504802 DOI: 10.1093/neuonc/noz153] [Citation(s) in RCA: 177] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The level of evidence to provide treatment recommendations for vestibular schwannoma is low compared with other intracranial neoplasms. Therefore, the vestibular schwannoma task force of the European Association of Neuro-Oncology assessed the data available in the literature and composed a set of recommendations for health care professionals. The radiological diagnosis of vestibular schwannoma is made by magnetic resonance imaging. Histological verification of the diagnosis is not always required. Current treatment options include observation, surgical resection, fractionated radiotherapy, and radiosurgery. The choice of treatment depends on clinical presentation, tumor size, and expertise of the treating center. In small tumors, observation has to be weighed against radiosurgery, in large tumors surgical decompression is mandatory, potentially followed by fractionated radiotherapy or radiosurgery. Except for bevacizumab in neurofibromatosis type 2, there is no role for pharmacotherapy.
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Affiliation(s)
- Roland Goldbrunner
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France
| | - Morten Lund-Johansen
- Department of Neurosurgery, Bergen University Hospital and Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Pantelis Stavrinou
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - David Reuss
- Department of Neuropathology, University Hospital Heidelberg, Heidelberg, Germany
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine and NW Laboratory Genetics Hub, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Florence Lefranc
- Department of Neurosurgery, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Kita Sallabanda
- Department of Neurosurgery, University Hospital San Carlos, Complutense University of Madrid, Madrid, Spain; University Hospital San Carlos, CyberKnife Centre, Genesiscare Madrid, Madrid, Spain
| | - Andrea Falini
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Patrick Axon
- Cambridge Skull Base Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Olivier Sterkers
- Department of Otolaryngology, Unit of Otology, Auditory implants and Skull Base Surgery, Public Assistance-Paris Hospital, Pitié-Salpêtrière Group Hospital, Paris, France
| | - Laura Fariselli
- Unit of Radiotherapy, Neurological Institute Carlo Best, Milan, Italy
| | - Wolfgang Wick
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery Ludwig-Maximilians University and DKTK partner site, University of Munich, Munich, Germany
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Combs SE, Baumert BG, Bendszus M, Bozzao A, Brada M, Fariselli L, Fiorentino A, Ganswindt U, Grosu AL, Lagerwaard FL, Niyazi M, Nyholm T, Paddick I, Weber DC, Belka C, Minniti G. ESTRO ACROP guideline for target volume delineation of skull base tumors. Radiother Oncol 2020; 156:80-94. [PMID: 33309848 DOI: 10.1016/j.radonc.2020.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE For skull base tumors, target definition is the key to safe high-dose treatments because surrounding normal tissues are very sensitive to radiation. In the present work we established a joint ESTRO ACROP guideline for the target volume definition of skull base tumors. MATERIAL AND METHODS A comprehensive literature search was conducted in PubMed using various combinations of the following medical subjects headings (MeSH) and free-text words: "radiation therapy" or "stereotactic radiosurgery" or "proton therapy" or "particle beam therapy" and "skull base neoplasms" "pituitary neoplasms", "meningioma", "craniopharyngioma", "chordoma", "chondrosarcoma", "acoustic neuroma/vestibular schwannoma", "organs at risk", "gross tumor volume", "clinical tumor volume", "planning tumor volume", "target volume", "target delineation", "dose constraints". The ACROP committee identified sixteen European experts in close interaction with the ESTRO clinical committee who analyzed and discussed the body of evidence concerning target delineation. RESULTS All experts agree that magnetic resonance (MR) images with high three-dimensional spatial accuracy and tissue-contrast definition, both T2-weighted and volumetric T1-weighted sequences, are required to improve target delineation. In detail, several key issues were identified and discussed: i) radiation techniques and immobilization, ii) imaging techniques and target delineation, and iii) technical aspects of radiation treatments including planning techniques and dose-fractionation schedules. Specific target delineation issues with regard to different skull base tumors, including pituitary adenomas, meningiomas, craniopharyngiomas, acoustic neuromas, chordomas and chondrosarcomas are presented. CONCLUSIONS This ESTRO ACROP guideline achieved detailed recommendations on target volume definition for skull base tumors, as well as comprehensive advice about imaging modalities and radiation techniques.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany; Institute of Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Munich, Germany; German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany
| | - Brigitta G Baumert
- Institute of Radiation Oncology, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | - Alessandro Bozzao
- Dipartimento NESMOS, Università Sapienza Roma, Azienda Ospedaliera Sant'Andrea, Rome, Italy
| | - Michael Brada
- Department of Radiation Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, United Kingdom
| | - Laura Fariselli
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle fonti, Italy
| | - Ute Ganswindt
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Faculty, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany
| | - Frank L Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, The Netherlands
| | - Maximilian Niyazi
- German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany; Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Tufve Nyholm
- Department of Radiation Sciences, Radiation Physics, Umeå University, Umeå, Sweden
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | | | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; IRCCS Neuromed, Pozzilli, Italy.
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14
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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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Sayyahmelli S, Aydin P, Baskaya MK. Delayed Onset Abducens Nerve Palsy following Uncomplicated Large Cystic Vestibular Schwannoma Resection: Case Report. J Neurol Surg Rep 2019; 80:e37-e40. [PMID: 31673483 PMCID: PMC6821525 DOI: 10.1055/s-0039-1694737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 06/18/2019] [Indexed: 10/27/2022] Open
Abstract
Although delayed facial palsy after vestibular schwannoma (VS) surgery is a poorly understood but a well-known phenomenon, other delayed cranial nerve palsies in the cerebellopontine angle have not been reported after VS surgery. In this report, we describe a 54-year-old woman with a large cystic VS who experienced double vision and a new delayed onset right abducens nerve (AbN) palsy, 3 weeks after gross total resection of VS via a translabyrinthine approach. To the best of our knowledge, this is the first report describing delayed isolated AbN palsy after uncomplicated VS surgery. Magnetic resonance imaging findings and the management of this complication following VS surgery are discussed in this case report.
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Affiliation(s)
- Sima Sayyahmelli
- Department of Neurological Surgery, University of Wisconsin Medical School, Madison, Wisconsin, United States
| | - Pinar Aydin
- Department of Neurological Surgery, University of Wisconsin Medical School, Madison, Wisconsin, United States
| | - Mustafa K Baskaya
- Department of Neurological Surgery, University of Wisconsin Medical School, Madison, Wisconsin, United States
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16
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Chang S, Makarenko S, Despot I, Dong C, Westerberg BD, Akagami R. Differential Recovery in Early- and Late-Onset Delayed Facial Palsy Following Vestibular Schwannoma Resection. Oper Neurosurg (Hagerstown) 2019; 18:34-40. [DOI: 10.1093/ons/opz083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/25/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDDelayed facial palsy (DFP) after resection of vestibular schwannomas (VS) is worsening of facial nerve function after an initially normal postoperative result.OBJECTIVETo characterize different types of DFP, compare recovery rates, and review of series of outcomes in patients following resection of VS.METHODSBetween 2001 and 2017, 434 patients (51% female) with VS underwent resection. We categorized the patients who developed facial palsy into groups based on timing of onset after surgery, immediate facial palsy (IFP), early-onset DFP (within 48 h), and late-onset DFP (after 48 h). Introduction of facial nerve motor-evoked potentials (fMEP) in 2002 and a change of practice utilizing perioperative minocycline in 2005 allowed for historical analysis of these interventions.RESULTSMean age of study cohort was 49.1 yr (range 13-81 yr), with 19.8% developing facial palsy. The late-onset DFP group demonstrated a significantly faster recovery than the early-onset DFP group (2.8 ± 0.5 vs 47 ± 8 wk, P < .0001), had prolonged latency to palsy onset after initiating perioperative minocycline (7.3 vs 12.5 d, P = .001), and had a nonsignificant trend towards faster recovery from facial palsy with use of minocycline (2.6 vs 3.4 wk, P = .11).CONCLUSIONGiven the timings, it is likely axonal degeneration is responsible for early-onset DFP, while demyelination and remyelination lead to faster facial nerve recovery in late-onset DFP. Reported anti-apoptotic properties of minocycline could account for the further delay in onset of DFP, and possibly reduce the rate and duration of DFP in the surgical cohort.
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Affiliation(s)
- Stephano Chang
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Serge Makarenko
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Ivan Despot
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Charles Dong
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Brian D Westerberg
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Ryojo Akagami
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada
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MARCOS-ALONSO S, VILLAOSLADA-FUENTES R, MUÑOZ-HERRERA Á, BATUECAS-CALETRÍO Á, SANTA-CRUZ-RUÍZ S, MARTÍNEZ-CARRANZA RA. Cirugía del schwannoma vestibular. Factores predisponentes y predictores de parálisis facial. REVISTA ORL 2019. [DOI: 10.14201/orl.20152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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18
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Akulov MA, Tanyashin SV, Shimansky VN, Usachev DY, Orlova OR, Zakharov VO, Karnaukhov VV, Kolycheva MV, Khat'kova SE, Latysheva KD, Orlova AS. [The efficacy of botulinum therapy in treatment of delayed facial palsy after resection of vestibular schwannoma]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:81-87. [PMID: 30412160 DOI: 10.17116/neiro20188205181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Delayed facial palsy is a complication developing 3 or more days after surgery. The etiology and pathogenesis of this condition has not been fully explored, and there are no treatment standards for it. As in the case of Bell's paralysis, glucocorticosteroids (GCSs) are currently used to treat delayed facial palsy. However, patients with contraindications to GCSs need new therapy modalities. AIM We aimed to evaluate the efficacy and safety of botulinum therapy in patients with delayed facial palsy after neurosurgical interventions. MATERIAL AND METHODS We examined 33 patients with delayed facial palsy developed 3 or more days after resection of vestibular schwannoma. The main group included 18 patients with contraindications to GCSs who received injections of botulinum toxin A (BTA) into the facial muscles of the healthy side for muscle relaxation. The comparison group consisted of 15 patients who received a course of prednisolone (1 mg/kg/day) for 5-7 days. The efficacy of treatment was assessed using the House-Brackmann scale and Clinical Global Impression Scale. The follow-up period after therapy was 3 months. RESULTS Delayed facial palsy was more common in the following cases: the facial nerve was located near the antero-inferior tumor pole; the tumor was adherent to the facial nerve; the tumor extended in the oral direction; the tumor had with unclear borders and was 11 to 30 mm in size. In most patients of both groups, facial muscle palsy developed more than 11 days after surgery. Treatment both in the main and control groups resulted in a significant improvement: complete regression of the facial asymmetry in patients of the main group and comparison groups 3 months after treatment onset was 83.3 and 93.3% (House-Brackmann scale), respectively. CONCLUSION Botulinum therapy may be recommended for patients with delayed facial palsy developed after vestibular schwannoma resection, who have contraindications to GCSs.
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Affiliation(s)
- M A Akulov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - D Yu Usachev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - O R Orlova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V O Zakharov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - S E Khat'kova
- Treatment and Rehabilitation Center, Moscow, Russia; Burnazyan Federal Medical Biophysical Center, Moscow, Russia
| | - K D Latysheva
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A S Orlova
- Sechenov First Moscow State Medical University, Moscow, Russia
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Yawn RJ, Dedmon MM, Xie D, Thompson RC, O'Malley MR, Bennett ML, Rivas A, Haynes DS. Delayed Facial Nerve Paralysis after Vestibular Schwannoma Resection. J Neurol Surg B Skull Base 2018; 80:283-286. [PMID: 31143572 DOI: 10.1055/s-0038-1669941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022] Open
Abstract
Objective To describe the incidence and clinical course of patients who develop delayed facial nerve paralysis (DFNP) after surgical resection of vestibular schwannoma. Setting Tertiary skull base center. Methods Retrospective chart review. Results Two hundred and forty six consecutive patients, who underwent surgical resection for vestibular schwannoma at a single center between 2010 and 2015, were analyzed. Of these patients, 22 (8.9%) developed DFNP, defined here as deterioration of function by at least 2 House-Brackmann (HB) grades within 30 days in patients with immediate postoperative HB ≤ 3. The mean age of DFNP patients was 47.2 years (range: 17-67) and 16 (73%) were female. The mean tumor size in greatest dimension was 2.1 cm (range: 0.7-3.5 cm). At the conclusion of each case, the facial nerve stimulated at the brainstem. Mean immediate postoperative facial nerve function was HB 1.8 (range: 1-3). Average facial nerve function at the 3-week-postoperative visit was 4.4 (range: 2-6). In 1-year, 8 patients (36%) recovered HB 1 function, 10 patients (46%) recovered to HB 2, and 2 patients (9%) were HB 3. The remaining 2 patients did not recover function and were HB 6 at last follow-up. Initial postoperative facial nerve function (HB 1 or HB 2) was associated with improved recovery to normal (HB 1) function ( p = 0.018). Conclusion A majority of patients that develop delayed paralysis will recover excellent facial nerve function. Patients should be counseled; however, a small percentage of patients will not recover function long-term, despite having a previously functioning and anatomically intact nerve.
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Affiliation(s)
- Robert J Yawn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Matthew M Dedmon
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Deborah Xie
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Reid C Thompson
- Department of Neurologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Matthew R O'Malley
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Marc L Bennett
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David S Haynes
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Nakagawa Y, Toda M, Shibao S, Yoshida K. Delayed and isolated oculomotor nerve palsy following minor head trauma. Surg Neurol Int 2017; 8:20. [PMID: 28217399 PMCID: PMC5309438 DOI: 10.4103/2152-7806.199556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/05/2016] [Indexed: 11/12/2022] Open
Abstract
Background: The purpose of this study was to consider the mechanism of isolated oculomotor nerve palsy after minor head trauma. Case Description: We report a rare case of delayed and isolated oculomotor nerve palsy following minor head trauma. A 19-year-old boy complained of double vision 1 day after a minor head trauma. Neuro-ophthalmic examination showed isolated left oculomotor nerve palsy. Computed tomography and magnetic resonance imaging examination revealed no abnormal findings and steroid therapy was administered for a week. Three months after the injury, the ptosis and extraocular movements had fully resolved, although the pupillary light reflex was still abnormal. Conclusions: Delayed and isolated oculomotor nerve palsy may be caused by an injury at the point where the oculomotor nerve runs over the posterior petroclinoid ligament. Because edema of the damaged oculomotor nerve might result in constriction at the point where the nerve pierces the dura of the cavernous sinus, symptoms of oculomotor nerve palsy appeared late after trauma. Steroid treatment reducing edema could be effective for delayed and isolated oculomotor nerve palsy following minor head trauma.
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Affiliation(s)
- Yu Nakagawa
- Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan
| | - Shunsuke Shibao
- Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan
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Torres R, Nguyen Y, Vanier A, Smail M, Ferrary E, Sterkers O, Kalamarides M, Bernardeschi D. Multivariate Analysis of Factors Influencing Facial Nerve Outcome following Microsurgical Resection of Vestibular Schwannoma. Otolaryngol Head Neck Surg 2016; 156:525-533. [PMID: 28248607 DOI: 10.1177/0194599816677711] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To assess through multivariate analysis the clinical pre- and intraoperative factors of facial nerve outcomes at day 8 and 1-year recovery of facial palsy, as compared with day 8 status among patients who underwent total resection of unilateral vestibular schwannoma. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods This study included 229 patients with preoperative normal facial function and anatomic preservation of the facial nerve. Clinical, radiologic, and intraoperative factors were assessed according to facial nerve function at day 8 and 1 year. Results We observed that 74% and 84% of patients had good facial function (House-Brackmann [HB] I-II) at day 8 and 1 year, respectively. Of 60 patients, 26 (43%) who had impaired facial function (HB III-VI) at day 8 recovered good facial function (HB I-II) 1 year after surgery. A structured equation model showed that advanced tumor stage and strong facial nerve adhesion were independently associated with facial nerve conduction block at day 8. No predictive factor of impaired facial function recovery was seen at 1 year. In terms of the extracanalicular diameter of the tumor, the cutoff point to minimize the risk of impaired facial function was 16 mm. Conclusion At day 8 after vestibular schwannoma resection, facial function was impaired in the case of large tumors or strong facial nerve adhesion to the tumor. After 1 year, less than half of the patients recovered good facial function, and no predictive factor was found to be associated with this possible recovery.
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Affiliation(s)
- Renato Torres
- 1 Unit of Otology, Auditory Implants and Skull Base Surgery, Otorhinolaryngology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,2 Sorbonne Universities, UPMC Univ, France.,3 "Minimally Invasive Robot-based Hearing Rehabilitation", Inserm, UMR S-1159, Paris, France
| | - Yann Nguyen
- 1 Unit of Otology, Auditory Implants and Skull Base Surgery, Otorhinolaryngology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,2 Sorbonne Universities, UPMC Univ, France.,3 "Minimally Invasive Robot-based Hearing Rehabilitation", Inserm, UMR S-1159, Paris, France
| | - Antoine Vanier
- 2 Sorbonne Universities, UPMC Univ, France.,4 Biostatistics Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Mustapha Smail
- 1 Unit of Otology, Auditory Implants and Skull Base Surgery, Otorhinolaryngology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Evelyne Ferrary
- 1 Unit of Otology, Auditory Implants and Skull Base Surgery, Otorhinolaryngology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,2 Sorbonne Universities, UPMC Univ, France.,3 "Minimally Invasive Robot-based Hearing Rehabilitation", Inserm, UMR S-1159, Paris, France
| | - Olivier Sterkers
- 1 Unit of Otology, Auditory Implants and Skull Base Surgery, Otorhinolaryngology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,2 Sorbonne Universities, UPMC Univ, France.,3 "Minimally Invasive Robot-based Hearing Rehabilitation", Inserm, UMR S-1159, Paris, France
| | - Michel Kalamarides
- 2 Sorbonne Universities, UPMC Univ, France.,5 Neurosurgery Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Daniele Bernardeschi
- 1 Unit of Otology, Auditory Implants and Skull Base Surgery, Otorhinolaryngology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,2 Sorbonne Universities, UPMC Univ, France.,3 "Minimally Invasive Robot-based Hearing Rehabilitation", Inserm, UMR S-1159, Paris, France
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22
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Carlstrom LP, Copeland WR, Neff BA, Castner ML, Driscoll CLW, Link MJ. Incidence and Risk Factors of Delayed Facial Palsy After Vestibular Schwannoma Resection. Neurosurgery 2016; 78:251-5. [PMID: 26352097 DOI: 10.1227/neu.0000000000001015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Preservation of facial nerve function following vestibular schwannoma surgery is a high priority. Even those patients with normal to near-normal function in the early postoperative period remain at risk for delayed facial palsy (DFP). OBJECTIVE To evaluate the incidence and prognosis of DFP and to identify risk factors for its occurrence. METHODS A retrospective cohort study of 489 patients who underwent vestibular schwannoma resection at our institution between 2000 and 2014. Delayed facial palsy was defined as deterioration in facial function of at least 2 House-Brackmann (HB) grades between postoperative days 5 to 30. Only patients with a HB grade of I to III by postoperative day 5 were eligible for study inclusion. RESULTS One hundred twenty-one patients with HB grade IV to VI facial weakness at postoperative day 5 were excluded from analysis. Of the remaining 368, 60 (16%) patients developed DFP (mean 12 days postoperatively, range: 5-25 days). All patients recovered function to HB grade I to II by a mean of 33 days (range: 7-86 days). Patients that developed DFP had higher rates of gross total resections (83% vs 71%, P = .05) and retrosigmoid approaches (72% vs 52%, P < .01). There was no difference in recovery time between patients who received treatment with steroids, steroids with antivirals, or no treatment at all (P = .530). CONCLUSION Patients with a gross total tumor resection or undergoing a retrosigmoid approach may be at higher risk of DFP. The prognosis is favorable, with patients likely recovering to normal or near-normal facial function within 1 month of onset.
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Affiliation(s)
- Lucas P Carlstrom
- *Medical Scientist Training Program, Mayo Clinic, Rochester, Minnesota; ‡Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota; §Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
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Predictive value of intraoperative neurophysiologic monitoring in assessing long-term facial function in grade IV vestibular schwannoma removal. Acta Neurochir (Wien) 2015; 157:1991-7; discussion 1998. [PMID: 26347044 DOI: 10.1007/s00701-015-2571-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite routine use of intraoperative neuromonitoring in acoustic neuroma removal, its application in predicting long-term facial function is limited. METHODS Prospective recording of facial nerve function and subsequent review of intraoperative neurophysiologic data. Stimulation of the facial nerve was performed proximal and distal to the tumor locus after tumor removal with measurement of amplitude and latency responses in the orbicularis oculi and oris muscles. Prospective review of current facial nerve function was performed using the House-Brackmann (HB) scoring system. Good facial function was determined as HB I/II and HB III-VI was considered poor facial function. Minimum follow-up time was 15 months, and averaged 40 months. RESULTS Twenty-four grade IV acoustic neuromas (54 % larger than 4 cm) were completely removed from October 2008 to November 2013. Nine patients (37.5 %) had HB I/II and 15 (62.5 %) had HB III-VI. The poor prognosis group had a higher latency than the good prognosis group (p = 0.045). Lower proximal amplitude was detected in the poor prognosis group (p = 0.046). Lower proximal-to-distal amplitude ratio was also detected in the poor prognosis group (p = 0.052). Amplitude ratio cut-offs of 0.44 and 0.25 were able to predict poor prognosis with sensitivity of 0.73 and 0.4 and specificity of 0.78 and 1, respectively (p = 0.046). CONCLUSIONS Lower proximal amplitude and proximal-distal amplitude ratio were previously reported as predictors of poor facial function in different sizes of vestibular schwannomas. We observed that the same applies specifically for large-sized, completely removed, grade IV tumors. Additionally, we describe a difference in proximal latency time between the good and poor prognosis groups, which was not previously reported.
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Xu P, Liu W, Zuo W, Wang D, Wang H. Delayed facial palsy after tympanomastoid surgery: A report of 15 cases. Am J Otolaryngol 2015; 36:805-7. [PMID: 26545475 DOI: 10.1016/j.amjoto.2015.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/30/2015] [Accepted: 07/06/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To analyze potential etiology and outcomes of delayed facial palsy (DFP) after tympanomastoid surgery. METHODS Fifteen cases of DFP out of 1582 cases after tympanomastoid surgery were reviewed, and the potential causes and outcomes were analyzed. RESULTS 9 out of 15 patients (60%) had fallopian canal dehiscence and facial nerve exposure in contrast to 323 of 1567 patients (20.6%) without DFP, with significant difference (P<0.01). Chorda tympani was cut or overstretched in 4 cases. There were two cases with herpes labialis and IgM antibody against varicella-zoster virus. All patients fully recovered within two months. CONCLUSION Fallopian canal dehiscence and facial nerve exposure was a risk factor of DFP after tympanomastoid surgery, and chorda tympani injury and viral reactivation may be triggering factors of DFP. The outcomes DFP after tympanomastoid surgery were excellent.
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Affiliation(s)
- Peng Xu
- Department of Otolaryngology, Cangzhou Central Hospital, Cangzhou, Hebei Province, People's Republic of China
| | - Weiwei Liu
- Department of Otolaryngology, Cangzhou Central Hospital, Cangzhou, Hebei Province, People's Republic of China
| | - Wenna Zuo
- Department of Otolaryngology, Cangzhou Central Hospital, Cangzhou, Hebei Province, People's Republic of China
| | - Daowen Wang
- Department of Otolaryngology Head and Neck Surgery, Peking University Health Science Center, Beijing, People's Republic of China
| | - Hongqin Wang
- Department of Otolaryngology, Cangzhou Central Hospital, Cangzhou, Hebei Province, People's Republic of China.
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Liu SW, Jiang W, Zhang HQ, Li XP, Wan XY, Emmanuel B, Shu K, Chen JC, Chen J, Lei T. Intraoperative neuromonitoring for removal of large vestibular schwannoma: Facial nerve outcome and predictive factors. Clin Neurol Neurosurg 2015; 133:83-9. [DOI: 10.1016/j.clineuro.2015.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 02/27/2015] [Accepted: 03/21/2015] [Indexed: 11/27/2022]
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Nonaka Y, Fukushima T, Watanabe K, Friedman AH, Sampson JH, Mcelveen JT, Cunningham CD, Zomorodi AR. Contemporary surgical management of vestibular schwannomas: analysis of complications and lessons learned over the past decade. Neurosurgery 2013; 72:ons103-15; discussion ons115. [PMID: 23037828 DOI: 10.1227/neu.0b013e3182752b05] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery. OBJECTIVE To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications. METHODS Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1-116 months; mean, 32.7 months). RESULTS Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%. CONCLUSION Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.
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Affiliation(s)
- Yoichi Nonaka
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
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Starmer HM, Ward BK, Best SR, Gourin CG, Akst LM, Hillel A, Brem H, Francis HW. Patient-perceived long-term communication and swallow function following cerebellopontine angle surgery. Laryngoscope 2013; 124:476-80. [DOI: 10.1002/lary.24252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Heather M. Starmer
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Bryan K. Ward
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Simon R.A. Best
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Lee M. Akst
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Alexander Hillel
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Henry Brem
- Department of Neurosurgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
| | - Howard W. Francis
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institution; Baltimore Maryland U.S.A
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Thom JJ, Carlson ML, Olson MD, Neff BA, Beatty CW, Facer GW, Driscoll CLW. The prevalence and clinical course of facial nerve paresis following cochlear implant surgery. Laryngoscope 2013; 123:1000-4. [DOI: 10.1002/lary.23316] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/12/2012] [Accepted: 02/29/2012] [Indexed: 11/10/2022]
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Starmer HM, Best SR, Agrawal Y, Chien WW, Hillel AT, Francis HW, Tamargo RJ, Akst LM. Prevalence, Characteristics, and Management of Swallowing Disorders following Cerebellopontine Angle Surgery. Otolaryngol Head Neck Surg 2011; 146:419-25. [DOI: 10.1177/0194599811429259] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective. To describe swallowing disorders encountered after cerebellopontine angle surgery and to explore variables associated with increased incidence of postoperative dysphagia. Study Design. Case series with chart review. Setting. Single academic medical institution. Subjects and Methods. Chart review of 181 consecutive patients undergoing surgical excision of cerebellopontine angle pathology from January 2008 to December 2010 at the Johns Hopkins Hospital. Presence and characteristics of dysphagia were determined by review of speech pathologist reports. Other clinical variables were extracted from the electronic medical record, and statistical analyses were applied to determine factors associated with postoperative dysphagia. Results. Immediate postoperative dysphagia was identified in 57 of 181 patients (31%). Oral, oropharyngeal, and pharyngeal deficits accounted for 51%, 37%, and 12% of dysphagic symptoms, respectively. Facial nerve weakness in the immediate postoperative period was noted in 91% of dysphagic subjects compared with 43% of those without. Mean House-Brackmann score for dysphagic individuals was 4 compared with 2 in the nondysphagic group. Diet alterations were required for 65% of dysphagic individuals, and an additional 9% required tube feeding. Common findings during videofluoroscopic swallowing studies were pharyngeal residue, reduced pharyngeal constriction, and anterior bolus loss. Abnormal penetration-aspiration scores (≥3) were found in 59% of those undergoing videofluoroscopic swallow studies. Conclusions. Oral and pharyngeal swallowing deficits are commonly encountered after cerebellopontine angle surgery. Consultation with the speech-language pathologist appears most critical for any individuals demonstrating postoperative cranial nerve dysfunction, particularly for those with evidence of facial nerve weakness. Early consultation may help to manage short- and long-term functional difficulties.
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Affiliation(s)
- Heather M. Starmer
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Simon R. Best
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yuri Agrawal
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Wade W. Chien
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alexander T. Hillel
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Howard W. Francis
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Rafael J. Tamargo
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lee M. Akst
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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