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Zohdy YM, Alawieh AM, Bray D, Pradilla G, Garzon-Muvdi T, Ashram YA. An Artificial Neural Network Model for Predicting Postoperative Facial Nerve Outcomes After Vestibular Schwannoma Surgery. Neurosurgery 2024; 94:805-812. [PMID: 37962366 DOI: 10.1227/neu.0000000000002757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/25/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The emergence of machine learning models has significantly improved the accuracy of surgical outcome predictions. This study aims to develop and validate an artificial neural network (ANN) model for predicting facial nerve (FN) outcomes after vestibular schwannoma (VS) surgery using the proximal-to-distal amplitude ratio (P/D) along with clinical variables. METHODS This retrospective study included 71 patients who underwent VS resection between 2018 and 2022. At the end of surgery, the FN was stimulated at the brainstem (proximal) and internal acoustic meatus (distal) and the P/D was calculated. Postoperative FN function was assessed using the House-Brackmann grading system at discharge (short-term) and after 9-12 months (long-term). House-Brackmann grades I-II were considered good outcome, whereas grades III-VI were considered fair/poor. An ANN model was constructed, and the performance of the model was evaluated using the area under the ROC curve for internal validation and accuracy, sensitivity, specificity, and positive and negative predictive values for external validation. RESULTS The short-term FN outcome was grades I-II in 57.7% and grades III-VI in 42.3% of patients. Initially, a model using P/D had an area under the curve of 0.906 (internal validation) and an accuracy of 89.1% (95% CI: 68.3%-98.8%) (external validation) for predicting good vs fair/poor short-term FN outcomes. The model was then refined to include only muscles with a P/D with a proximal latency between 6 and 8 ms. This improved the accuracy to 100% (95% CI: 79%-100%). Integrating clinical variables (patient's age, tumor size, and preoperative HB grade) in addition to P/D into the model did not significantly improve the predative value. A model was then created to predict the long-term FN outcome using P/D with latencies between 6 and 8 ms and had an accuracy of 90.9% (95% CI: 58.7%-99.8%). CONCLUSION ANN models incorporating P/D can be a valuable tool for predicting FN outcomes after VS surgery. Refining the model to include P/D with latencies between 6 and 8 ms further improves the model's prediction. A user-friendly interface is provided to facilitate the implementation of this model.
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Affiliation(s)
- Youssef M Zohdy
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | - Ali M Alawieh
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | - David Bray
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | | | - Yasmine A Ashram
- Department of Physiology, Faculty of Medicine, Alexandria University, Alexandria , Egypt
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2
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Machetanz K, Roegele M, Liebsch M, Oberle L, Weinbrenner E, Gorbachuk M, Wang SS, Tatagiba M, Naros G. Predictive value of facial motor-evoked potential and electromyography for facial motor function in vestibular schwannoma surgery. Acta Neurochir (Wien) 2024; 166:23. [PMID: 38240816 PMCID: PMC10799139 DOI: 10.1007/s00701-024-05927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/02/2024] [Indexed: 01/22/2024]
Abstract
PURPOSE Intraoperative neuromonitoring (IONM) aims to preserve facial nerve (FN) function during vestibular schwannoma (VS) surgery. However, current techniques such as facial nerve motor evoked potentials (FNMEP) or electromyography (fEMG) alone are limited in predicting postoperative facial palsy (FP). The objective of this study was to analyze a compound fEMG/FNMEP approach. METHODS Intraoperative FNMEP amplitude and the occurrence of fEMG-based A-trains were prospectively determined for the orbicularis oris (ORI) and oculi (OCU) muscle in 322 VS patients. Sensitivity and specificity of techniques to predict postoperative FN function were calculated. Confounding factors as tumor size, volume of intracranial air, or IONM duration were analyzed. RESULTS A relevant immediate postoperative FP was captured in 105/322 patients with a significant higher risk in large VS. While fEMG demonstrated a high sensitivity (77% and 86% immediately and 15 month postoperative, respectively) for identifying relevant FP, specificity was low. In contrast, FNMEP have a significantly higher specificity of 80.8% for predicting postoperative FP, whereas the sensitivity is low. A retrospective combination of techniques demonstrated still an incorrect prediction of FP in ~ 1/3 of patients. CONCLUSIONS FNMEP and fEMG differ in sensitivity and specificity to predict postoperative FP. Although a combination of IONM techniques during VS surgery may improve prediction of FN function, current techniques are still inaccurate. Further development is necessary to improve IONM approaches for FP prediction.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Martin Roegele
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marina Liebsch
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Linda Oberle
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Eliane Weinbrenner
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Mykola Gorbachuk
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Sophie S Wang
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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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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Dhayalan D, Perry A, Graffeo CS, Tveiten ØV, Muñoz Casabella A, Pollock BE, Driscoll CLW, Carlson ML, Link MJ, Lund-Johansen M. Salvage radiosurgery following subtotal resection of vestibular schwannomas: does timing influence tumor control? J Neurosurg 2023; 138:420-429. [PMID: 35907189 DOI: 10.3171/2022.5.jns22249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The goal of microsurgical resection of vestibular schwannoma (VS) is gross-total resection (GTR) to provide oncological cure. However, a popular strategy is to halt the resection if the surgical team feels the risk of cranial nerve injury is imminent, achieving a maximally safe subtotal resection (STR) instead. The tumor remnant can then be treated with stereotactic radiosurgery (SRS) once the patient has recovered from the immediate postoperative period, or it can be followed with serial imaging and treated with SRS in a delayed fashion if residual tumor growth is seen. In this study, the authors evaluated the efficacy of this multimodality approach, particularly the influence of timing and dose of SRS on radiological tumor control, need for salvage treatment, and cranial nerve function. METHODS VS patients treated with initial microsurgery and subsequent radiosurgery were retrospectively included from two tertiary treatment centers and dichotomized depending on whether SRS was given upfront (defined as before 12 months) or later. Radiological tumor control was defined as less than 20% tumor volume expansion and oncological tumor control as an absence of salvage treatment. Facial and cochlear nerve functions were assessed after surgery, at the time of SRS, and at last follow-up. Finally, a systematic literature review was conducted according to PRISMA guidelines. RESULTS A total of 110 VS patients underwent SRS following microsurgical resection, with a mean preradiosurgical tumor volume of 2.2 cm3 (SD 2.5 cm3) and mean post-SRS follow-up time of 5.8 years (SD 4.1 years). The overall radiological tumor control and oncological tumor control were 77.3% and 90.9%, respectively. Thirty-five patients (31.8%) received upfront SRS, while 75 patients (68.2%) were observed for a minimum of 12 months prior to SRS. The timing of SRS did not influence the radiological tumor control (p = 0.869), the oncological tumor control (p = 0.560), or facial nerve (p = 0.413) or cochlear nerve (p = 0.954) function. An escalated marginal dose (> 12 Gy) was associated with greater tumor shrinkage (p = 0.020) and superior radiological tumor control (p = 0.020), but it did not influence the risk of salvage treatment (p = 0.904) or facial (p = 0.351) or cochlear (p = 0.601) nerve deterioration. CONCLUSIONS Delayed SRS after close observation of residuals following STR is a safe alternative to upfront SRS regarding tumor control and cranial nerve preservation in selected patients.
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Affiliation(s)
- Dhanushan Dhayalan
- 1Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,3Department of Clinical Medicine, University of Bergen, Norway; and
| | - Avital Perry
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Bruce E Pollock
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L W Driscoll
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Morten Lund-Johansen
- 1Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,3Department of Clinical Medicine, University of Bergen, Norway; and
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Morota N, Deletis V. Brainstem Surgery: Functional Surgical Anatomy with the Use of an Advanced Modern Intraoperative Neurophysiological Procedure. Adv Tech Stand Neurosurg 2023; 48:21-55. [PMID: 37770680 DOI: 10.1007/978-3-031-36785-4_2] [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] [Indexed: 09/30/2023]
Abstract
Intraoperative neurophysiology (ION) in brainstem surgery evolved as brainstem surgery advanced.The original idea of brainstem mapping (BSM) is a neurophysiological procedure to locate cranial nerve motor nuclei (CNMN) on the floor of the fourth ventricle. With the introduction of various skull base approaches to the brainstem, BSM is carried out on any surface of the brainstem to expose the safe entry zone to the intrinsic brainstem lesion. It is the modern concept of BSM, a broader definition of BSM. BSM enables to avoid direct damage to the CNMN when approaching the brainstem through the negative mapping region.The corticobulbar tract (CBT) motor evoked potential (MEP) is another ION procedure in brainstem surgery. It enables monitoring of the functional integrity of the whole cranial motor pathway without interrupting surgical procedures. Combined application of both BSM and CBT-MEP monitoring is indispensable for the functional preservation of the CNMN and their supranuclear innervation during the brainstem surgery.In this paper, the neurophysiological aspect of BSM and the CBT-MEP was fully described. Normal anatomical background of the floor of the fourth ventricle and the detail of the CBT anatomy were demonstrated to better understand their clinical usefulness, limitations, and surgical implications derived from ION procedures. Finally, a future perspective in the role of ION procedures in brainstem surgery was presented. The latest magnetic resonance imaging (MRI) technology can allow surgeons to find an "on the image" safe entry zone to the brainstem. However, the role of BSM and the CBT-MEP monitoring in terms of safe brainstem surgery stays unshakable. Special attention was paid for the recent trend of management in diffuse intrinsic pontine gliomas. A new role of BSM during a stereotactic biopsy was discussed.It is the authors' expectation that the paper enhances the clinical application of a contemporary standard of the ION in brainstem surgery and supports safer brainstem surgery more than ever and in the future.
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Affiliation(s)
- Nobuhito Morota
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital, Zagreb, Croatia
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6
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Sahana D, Kumar S, Rathore L, Mittal J, Sahu RK, Jain AK, Tawari M. Is Preoperative Facial Palsy a Deterrent to Facial Nerve Preservation after Gross-Total Removal of Giant Vestibular Schwannomas? INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1757919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Background Although rare in small vestibular schwannomas, preoperative facial nerve paresis is often present in giant schwannomas. Preserving facial nerve function in these cases remains a herculean task. This study evaluates the facial functions after complete tumor removal and whether preoperative facial nerve involvement affects postoperative functional status.
Methods This retrospective study from January 2014 to August 2021 excluded nongiant tumors (< 4 cm), neurofibromatosis type 2 cases, incomplete removals, redo surgeries, deaths, and cases done without nerve monitoring. These were grouped into preoperative facial palsy present (PFP) and no preoperative facial palsy (NFP). Facial nerve functions were assessed on first postoperative day, at the time of discharge, and at last follow-up and dichotomized into two groups: nondisfiguring (House–Brackmann [HB] grades I–III) and disfiguring (HB grades IV–VI). The cohort outcomes of patients with nondisfiguring PFP (HB grades I–III) were also analyzed.
Results There were 88 cases (PFP, n = 57; NFP, n = 31). Facial nerve was preserved anatomically in 62 (70.45%) patients (PFP, n = 38; NFP, n = 24) without any statistical difference (p = 0.29). Statistically significant disfiguring facial outcomes (HB IV, V, VI) were seen in patients with preoperative facial palsy (p = 0.01); however, a comparison of facial functions in patients with only nondisfiguring PFP with those in NFP group did not show the statistical difference (p = 0.12).
Conclusions Facial nerve palsy present before surgery does not seem to be a deterrent to intraoperative preservation of facial nerve during complete removal of giant vestibular schwannomas. Patients with nondisfiguring facial palsies have postoperative facial functions comparable to those without facial palsy.
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Affiliation(s)
- Debabrata Sahana
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Sanjeev Kumar
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Lavlesh Rathore
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Jatinder Mittal
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Rajiv K. Sahu
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Amit K. Jain
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Manish Tawari
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
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7
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Della Pepa GM, Stifano V, D'Alessandris QG, Menna G, Burattini B, Di Domenico M, Izzo A, D'Ercole M, Lauretti L, Olivi A, Montano N. Intraoperative Corticobulbar Motor Evoked Potential in Cerebellopontine Angle Surgery: A Clinically Meaningful Tool to Predict Early and Late Facial Nerve Recovery. Neurosurgery 2022; 91:406-413. [PMID: 35612564 DOI: 10.1227/neu.0000000000002039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intraoperative neuromonitoring is crucial for facial nerve preservation in cerebellopontine angle (CPA) surgery. Among the available techniques, the role of intraoperative corticobulbar facial motor evoked potentials (FMEPs) is unclear. OBJECTIVE To evaluate the significance of intraoperative FMEPs as indicators for early and late postoperative facial nerve function (FNF) in CPA tumor resection and the feasibility of their integration with standard monitoring techniques. METHODS An institutional series of 83 patients who underwent surgery under intraoperative monitoring for CPA extra-axial tumor resection was reported. A pair of needle electrodes was used to record FMEP from orbicularis oculi (OOc) and orbicularis oris (OOr) muscles at baseline, at the end of surgery and minimum values recorded. From FMEP amplitudes, minimum-to-baseline amplitude ratio (MBR), final-to-baseline amplitude ratio (FBR), and recovery value, intended as FBR minus MBR, were calculated. These indices were correlated with early and late postoperative FNF. RESULTS Our analysis demonstrated that higher FBR (both from OOc and OOr) and MBR (from OOr only) were associated with a good early and late FNF; a higher MBR from OOc was significantly associated with a good late FNF. The most accurate index in predicting early FNF was FBR measured from OOr with a cutoff of 35.56%, whereas the most accurate index in predicting late FNF was FBR as measured from OOc with a cutoff of 14.29%. CONCLUSION Our study confirmed that FMEPs are reliable predictors of early and late postoperative FNF in CPA surgery and could be easily integrated with standard intraoperative neuromonitoring techniques.
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Affiliation(s)
- Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Grazia Menna
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Benedetta Burattini
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
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8
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Schipmann S, Lohmann S, Al Barim B, Suero Molina E, Schwake M, Toksöz ÖA, Stummer W. Applicability of contemporary quality indicators in vestibular surgery-do they accurately measure tumor inherent postoperative complications of vestibular schwannomas? Acta Neurochir (Wien) 2022; 164:359-372. [PMID: 34859305 PMCID: PMC8854327 DOI: 10.1007/s00701-021-05044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 10/28/2021] [Indexed: 12/01/2022]
Abstract
Background Due to rising costs in health care delivery, reimbursement decisions have progressively been based on quality measures. Such quality indicators have been developed for neurosurgical procedures, collectively. We aimed to evaluate their applicability in patients that underwent surgery for vestibular schwannoma and to identify potential new disease-specific quality indicators. Methods One hundred and three patients operated due to vestibular schwannoma were subject to analysis. The primary outcomes of interest were 30-day and 90-day reoperation, readmission, mortality, nosocomial infection and surgical site infection (SSI) rates, postoperative cerebral spinal fluid (CSF) leak, facial, and hearing function. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. Results Thirty-day (90-days) outcomes in terms of reoperation were 10.7% (14.6%), readmission 9.7% (13.6%), mortality 1% (1%), nosocomial infection 5.8%, and SSI 1% (1%). A 30- versus 90-day outcome in terms of CSF leak were 6.8% vs. 10.7%, new facial nerve palsy 16.5% vs. 6.1%. Hearing impairment from serviceable to non-serviceable hearing was 6.8% at both 30- and 90-day outcome. The degree of tumor extension has a significant impact on reoperation (p < 0.001), infection (p = 0.015), postoperative hemorrhage (p < 0.001), and postoperative hearing loss (p = 0.026). Conclusions Our data demonstrate the importance of entity-specific quality measurements being applied even after 30 days. We identified the occurrence of a CSF leak within 90 days postoperatively, new persistent facial nerve palsy still present 90 days postoperatively, and persisting postoperative hearing impairment to non-serviceable hearing as potential new quality measurement variables for patients undergoing surgery for vestibular schwannoma.
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Affiliation(s)
- Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Sebastian Lohmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Bilal Al Barim
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Özer Altan Toksöz
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Strommen JA, Skinner S, Crum BA. Neurophysiology during peripheral nerve surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:295-318. [PMID: 35772892 DOI: 10.1016/b978-0-12-819826-1.00022-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Electrophysiological monitoring of the peripheral nervous system during a variety of surgeries provides useful information that supplements and complements preoperative assessment. Monitoring improves localization and understanding of the underlying pathophysiology of peripheral nerve lesions leading to more rational treatment decisions and improved outcomes. Monitoring is accomplished by adaptation of routine electrodiagnostic techniques (i.e., nerve conduction studies, evoked potentials, and electromyography) with special attention to technical factors including electrical and movement artifact. These techniques have been successfully applied during surgery for entrapment neuropathies, traumatic nerve injury and repair, peripheral nerve tumors, and adjacent structure procedures that risk peripheral nerve injury. A clear understanding of the anatomy and neurophysiology is necessary, as is understanding and performing the difficult technical aspects of these studies to provide accurate information to enhance patient outcome and recovery. As in any intraoperative neurophysiologic monitoring (IONM) setting, constant and accurate communication between the IONM team, surgeon, and anesthesia team is critically important to meet these goals.
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Affiliation(s)
- Jeffrey A Strommen
- Department of Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Stanley Skinner
- Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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10
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Matsushima K, Kohno M, Ichimasu N, Nakajima N, Yoshino M. Preoperative Facial Nerve Palsy in Patients With Vestibular Schwannoma: Clinical Features and Postoperative Functional Prognosis in a Case Series of 34 Among 1228 Consecutive Patients. Oper Neurosurg (Hagerstown) 2022; 22:14-19. [PMID: 34982900 DOI: 10.1227/ons.0000000000000011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Facial nerve palsy is a rare presenting symptom of vestibular schwannomas and has not been investigated in detail. OBJECTIVE To investigate the incidence, clinical features, and postoperative long-term outcomes of facial nerve function in patients with vestibular schwannomas causing preoperative facial nerve palsy. METHODS After excluding patients with neurofibromatosis type 2 and those with prior treatment, 1228 consecutive patients who underwent vestibular schwannoma surgery were retrospectively investigated. Patients with and without preoperative facial nerve palsy were compared statistically to clarify their clinical features. RESULTS Preoperative tumoral facial nerve palsy was seen in 34 patients (2.8%). Their clinical features included older age, having large cystic tumors with significant meatal extension, and showing abnormal electrogustometric responses, compared with patients without preoperative facial nerve palsy. Owing to the frequent insufficient intraoperative responses on facial nerve electromyography, the tumor resection rate was lower in the group with preoperative facial nerve palsy (mean: 95.2%). Among the 33 patients with sufficient follow-up data (mean: 63.9 mo), additional treatment was required only in 1 patient and facial nerve function improved in 25 patients (75.8%) within 2 yr postoperatively. CONCLUSION Facial nerve palsy is a rare preoperative symptom that occurs in less than 3% of patients with vestibular schwannoma. Tumor resection in such patients tends to be challenging owing to their advanced age, having large cystic tumors with significant meatal extension, and difficulties in intraoperative facial nerve monitoring, but surgical decompression of the facial nerve can assist in the improvement of their long-term functions.
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Affiliation(s)
- Ken Matsushima
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan.,Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Norio Ichimasu
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | | | - Masanori Yoshino
- Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan
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11
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Vakharia K, Mikula AL, Nassiri AM, Driscoll CLW, Link MJ. Right medium-sized vestibular schwannoma with trigeminal neuralgia post-fractionated radiotherapy. NEUROSURGICAL FOCUS: VIDEO 2021; 5:V10. [PMID: 36285235 PMCID: PMC9551635 DOI: 10.3171/2021.7.focvid21112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
A patient with trigeminal neuralgia secondary to a vestibular schwannoma underwent fractionated radiotherapy without relief of her pain. She was then effectively treated with microsurgical resection of her tumor. Early identification of the lower cranial nerves and the origin of the facial and vestibulocochlear nerves is key to determining the operative corridors for vestibular schwannoma resection. To effectively treat trigeminal neuralgia, the trigeminal nerve root entry zone and motor branch are clearly identified and decompressed. Fractioned radiotherapy does not effectively treat trigeminal neuralgia secondary to vestibular schwannoma compression. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21112
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12
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Elsayed M, Jia H, Hochet B, Sterkers O, Torres R, Nguyen Y, Bernat I, Lahlou G, Kalamarides M. Intraoperative facial nerve electromyography parameters to optimize postoperative facial nerve outcome in patients with large unilateral vestibular schwannoma. Acta Neurochir (Wien) 2021; 163:2209-2217. [PMID: 33825973 DOI: 10.1007/s00701-021-04814-2] [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: 11/08/2020] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decision-making for large sporadic vestibular schwannomas (VS) resection guided by the intraoperative change in supramaximal facial nerve (FN) amplitude and latency response to optimize post-operative FN outcome. METHODS Prospectively study of 43 patients, from January to December 2018, of large sporadic VS with preoperative normal FN function at our center. Tumors were removed through retrosigmoid (81%) or translabyrinthine (19%) approaches with FN monitoring. Intraoperative pre- and post-VS resection supramaximal (2 mA) amplitude and latency responses at the proximal FN root were recorded. RESULTS Total, near-/subtotal VS resections (TR, NTR, STR) were achieved in 51%, 38%, and 11% of tumors, respectively, guided by no more than 40% decrease in supramaximal amplitude. Pre- and post-resection supramaximal amplitude and latency responses were lower and longer, respectively, in NTR+STR than in TR. At day 8, FN function was grade I-II in 77% of patients and grade III-V in 23%, and after 6 months, it was in grade I-II in 95% and grade III in 5%, and there was no significant difference between TR and NTR+STR. Facial palsy occurred in older patients and in the case of severe FN adhesion. At day 8, pre- and post-resection supramaximal amplitude but not latency responses were different between FN grade III-V and grade I-II. Serviceable hearing was preserved in 28% of large VS. CONCLUSIONS Intraoperative FN monitoring guided VS resection in large VS so that 49% retained some residual tumor. Accordingly, 95% good postoperative FN function and significant hearing preservation were achieved after 6 months.
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Affiliation(s)
- Mohamed Elsayed
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Faculty of Medicine, ORL Department, Alexandria University, Alexandria, Egypt
| | - Huan Jia
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France.
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Department of Otolaryngology Head & Neck Surgery, Shanghai 9th People's Hospital, Shanghai Jiat Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Baptiste Hochet
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Olivier Sterkers
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Renato Torres
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Facultad de Medicina, Centro de Investigación y Desarrollo Científico, Universidad Nacional de San Agustín, Arequipa, Peru
| | - Yann Nguyen
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Isabelle Bernat
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Ghizlene Lahlou
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Michel Kalamarides
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France.
- Department of Neurosurgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Service de Neurochirurgie, Hôpital Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013, Paris, France.
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Hostettler IC, Jayashankar N, Bikis C, Wanderer S, Nevzati E, Karuppiah R, Waran V, Kalbermatten D, Mariani L, Marbacher S, Guzman R, Madduri S, Roethlisberger M. Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives. Front Bioeng Biotechnol 2021; 9:659413. [PMID: 34239858 PMCID: PMC8259738 DOI: 10.3389/fbioe.2021.659413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury. Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base. Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones. Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.
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Affiliation(s)
- Isabel C Hostettler
- Department of Neurosurgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Narayan Jayashankar
- Department of Oto-Rhino-Laryngology, Nanavati Super Speciality Hospital, Mumbai, India
| | - Christos Bikis
- Department of Biomedical Engineering, Biomaterials Science Center, University of Basel, Allschwil, Switzerland.,Integrierte Psychiatrie Winterthur - Zürcher Unterland, Winterthur, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Edin Nevzati
- Department of Neurosurgery, Kantonsspital Luzern, Lucerne, Switzerland
| | - Ravindran Karuppiah
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Vicknes Waran
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Daniel Kalbermatten
- Department of Plastic Surgery, University Hospital Geneva, Geneva, Switzerland.,Department of Surgery, Biomaterials and Neuro Tissue Bioengineering, University of Geneva, Geneva, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Biomedicine, Brain Ischemia and Regeneration, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
| | - Srinivas Madduri
- Department of Surgery, Biomaterials and Neuro Tissue Bioengineering, University of Geneva, Geneva, Switzerland.,Department of Biomedicine, Brain Ischemia and Regeneration, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia.,Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
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14
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Helal A, Graffeo CS, Perry A, Van Abel KM, Carlson ML, Neff BA, Driscoll CLW, Link MJ. Differential Impact of Advanced Age on Clinical Outcomes After Vestibular Schwannoma Resection in the Very Elderly: Cohort Study. Oper Neurosurg (Hagerstown) 2021; 21:104-110. [PMID: 34038941 DOI: 10.1093/ons/opab170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 03/19/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Vestibular schwannomas (VS) have a peak incidence in the sixth and seventh decades of life. Stereotactic radiosurgery is often the preferred treatment for VS among patients of advanced age. The fraction of elderly patients potentially requiring consideration for surgical treatment is anticipated to expand, mandating an update to management paradigms in this population. OBJECTIVE To describe our experience with surgical management of VS in patients aged 75 yr and older. METHODS Cohort study of all patients aged ≥75 yr with sporadic VS requiring surgical treatment at our institution between 1999 and 2020. Data included preoperative baseline characteristics and outcome data including extent of resection, facial nerve and hearing status, functional outcome, length of stay, and complications. RESULTS A total of 24 patients were included, spanning an age range of 75 to 90 yr. Average tumor size was 2.76 ± 1.04 cm, and average baseline Modified 5-item Frailty Index (mFI-5) score was 1.08 ± 0.93. Extent of resection was gross total in 5 (20.8%), near total in 3 (12.5%), and sub-total resection in the remaining 16 (66.7%). One patient died in the postoperative period because of an acute sub-dural hematoma. Favorable facial nerve function (HB1-2) was preserved in 12 patients (75%) between 75 and 79 yr and 2 patients (28.6%) aged ≥ 80 yr. No cerebrospinal fluid leak or surgical site infection was observed; 3 patients developed hydrocephalus requiring ventriculo-peritoneal shunt placement. Nine patients required out-of-home disposition; all patients eventually returned to independent living. CONCLUSION Microsurgical resection of VS can be safely undertaken in patients greater than 75 y/o but may carry an increased risk of poor facial function.
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Affiliation(s)
- Ahmed Helal
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | - Avital Perry
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Kathryn M Van Abel
- Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brian A Neff
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L W Driscoll
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,Department of Otolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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15
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Intraoperative monitoring of the facial nerve during parotid gland surgery in Otolaryngology services – Head and Neck Surgery. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2021. [DOI: 10.1016/j.otoeng.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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16
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Predicting Long-Term Facial Nerve Outcomes After Resection of Vestibular Schwannoma. Otol Neurotol 2021; 41:e1328-e1332. [PMID: 33492809 DOI: 10.1097/mao.0000000000002883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES 1) Describe the effect of tumor size on facial nerve (FN) outcomes after microsurgical resection of vestibular schwannoma (VS).2) Describe the effect of surgical approach, preoperative radiation, and early postoperative facial function on long-term FN outcomes. STUDY DESIGN Retrospective analysis. SETTING Tertiary referral center. PATIENTS Adult (≥18 yr) patients underwent translabyrinthine or retrosigmoid VS resection by a single neurotologist and single neurosurgeon between February 2008 and December 2017. MAIN OUTCOME MEASURES Long-term FN outcomes (≥12 mo) according to House-Brackmann (HB) grade. RESULTS During the study period, 350 patients underwent VS resection, of whom 290 met inclusion criteria. Translabyrinthine surgery was performed in 54% (n = 158) and retrosigmoid in 45% (n = 131). One patient underwent a combined approach. Among patients who underwent retrosigmoid approach, none had a tumor more than 30 mm. Gross total resection was achieved in 98% (n = 283). Long-term HB1-2 function was achieved in 90% (n = 261). On univariate analysis, tumor size (per cm increase), history of preoperative radiation, and worse HB score at discharge predicted worse FN function. Multivariate analysis showed that tumor size (per cm increase) and history of radiation were independent predictors of FN function. For patients with tumors less than 30 mm, multivariate analysis of tumor size and surgical approach was performed; tumor size remained predictive of worse FN function (odds ratio [OR] 2.362, p = 0.0035), whereas surgical approach was not significantly predictive (p = 0.7569). CONCLUSION Tumor size and history of radiation predict long-term FN function after VS resection. When accounting for tumor size, the translabyrinthine and retrosigmoid approaches yield equivalent FN results.
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17
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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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18
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Kartush JM, Rice KS, Minahan RE, Balzer GK, Yingling CD, Seubert CN. Best Practices in Facial Nerve Monitoring. Laryngoscope 2021; 131 Suppl 4:S1-S42. [PMID: 33729584 DOI: 10.1002/lary.29459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/21/2021] [Accepted: 02/02/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS Facial nerve monitoring (FNM) has evolved into a widely used adjunct for many surgical procedures along the course of the facial nerve. Even though majority opinion holds that FNM reduces the incidence of iatrogenic nerve injury, there are few if any studies yielding high-level evidence and no practice guidelines on which clinicians can rely. Instead, a review of the literature and medicolegal cases reveals significant variations in methodology, training, and clinical indications. STUDY DESIGN Literature review and expert opinion. METHODS Given the lack of standard references to serve as a resource for FNM, we assembled a multidisciplinary group of experts representing more than a century of combined monitoring experience to synthesize the literature and provide a rational basis to improve the quality of patient care during FNM. RESULTS Over the years, two models of monitoring have become well-established: 1) monitoring by the surgeon using a stand-alone device that provides auditory feedback of facial electromyography directly to the surgeon, and 2) a team, typically consisting of surgeon, technologist, and interpreting neurophysiologist. Regardless of the setting and the number of people involved, the reliability of monitoring depends on the integration of proper technical performance, accurate interpretation of responses, and their timely application to the surgical procedure. We describe critical steps in the technical set-up and provide a basis for context-appropriate interpretation and troubleshooting of recorded signals. CONCLUSIONS We trust this initial attempt to describe best practices will serve as a basis for improving the quality of patient care while reducing inappropriate variations. LEVEL OF EVIDENCE 4 Laryngoscope, 131:S1-S42, 2021.
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Affiliation(s)
- Jack M Kartush
- Michigan Ear Institute, Farmington Hills, Michigan, U.S.A
| | | | - Robert E Minahan
- Department of Neurology, Georgetown University, Washington, District of Columbia, U.S.A
| | - Gene K Balzer
- Real Time Neuromonitoring Associates, Real Time Neuromonitoring AssociatesNashville, Tennessee, U.S.A
| | - Charles D Yingling
- The Golden Gate Neuromonitoring, Department of Otolaryngology and Head and Neck Surgery, Stanford University, San Francisco, California, U.S.A
| | - Christoph N Seubert
- Department of Anesthesiology, Division of Neuroanesthesiology, University of Florida College of Medicine, Gainesville, Florida, U.S.A
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19
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Prell J, Scheller C, Simmermacher S, Strauss C, Rampp S. Facial Nerve EMG: Low-Tech Monitoring with a Stopwatch. J Neurol Surg A Cent Eur Neurosurg 2021; 82:308-316. [PMID: 33418594 DOI: 10.1055/s-0040-1701616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The quantity of A-trains, a high-frequency pattern of free-running facial nerve electromyography, is correlated with the risk for postoperative high-grade facial nerve paresis. This correlation has been confirmed by automated analysis with dedicated algorithms and by visual offline analysis but not by audiovisual real-time analysis. METHODS An investigator was presented with 29 complete data sets measured during actual surgeries in real time and without breaks in a random order. Data were presented either strictly via loudspeaker (audio) or simultaneously by loudspeaker and computer screen (audiovisual). Visible and/or audible A-train activity was then quantified by the investigator with the computerized equivalent of a stopwatch. The same data were also analyzed with quantification of A-trains by automated algorithms. RESULTS Automated (auto) traintime (TT), known to be a small, yet highly representative fraction of overall A-train activity, ranged from 0.01 to 10.86 s (median: 0.58 s). In contrast, audio-TT ranged from 0 to 1,357.44 s (median: 29.69 s), and audiovisual-TT ranged from 0 to 786.57 s (median: 46.19 s). All three modalities were correlated to each other in a highly significant way. Likewise, all three modalities correlated significantly with the extent of postoperative facial paresis. As a rule of thumb, patients with visible/audible A-train activity < 1 minute presented with a more favorable clinical outcome than patients with > 1 minute of A-train activity. CONCLUSION Detection and even quantification of A-trains is technically possible not only with intraoperative automated real-time calculation or postoperative visual offline analysis, but also with very basic monitoring equipment and real-time good quality audiovisual analysis. However, the investigator found audiovisual real-time-analysis to be very demanding; thus tools for automated quantification can be very helpful in this respect.
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Affiliation(s)
- Julian Prell
- Department of Neurosurgery, University of Halle, Halle, Germany
| | | | | | | | - Stefan Rampp
- Department of Neurosurgery, University of Halle, Halle, Germany
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20
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Chiesa-Estomba CM, Saga-Gutiérrez C, González-García JÁ, Calvo-Henríquez C, Larruscain E, Sistiaga-Suárez JA, Díaz de Cerio-Canduela P, Parente-Arias P, Quer M. Intraoperative monitoring of the facial nerve during parotid gland surgery in Otolaryngology services - Head and Neck Surgery. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020; 72:158-163. [PMID: 33243418 DOI: 10.1016/j.otorri.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/20/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Facial nerve injury remains the most severe complication of parotid gland surgery. Due to the increasing evidence about the advantage of the use of intraoperative facial nerve monitoring, a survey was distributed among members of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery with the objective of determining patterns of its use. MATERIAL AND METHODS A questionnaire which included 12 separate questions in 3 sections was distributed via email through the official email of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery. The first section of questions was in relation to demographic characteristics, the second section was related to the pattern of monitoring use and the third section referred to litigation related to facial palsy. RESULTS 1544 anonymous questionnaires were emailed. 255 surveys were returned, giving an overall response rate of 16.5%. From these, 233 (91.3%) respondents perform parotid gland surgery. Two-hundred nineteen (94%) respondents use intraoperative facial nerve monitoring. Of the respondents,94% used intraoperative facial nerve monitoring if in their current practice they performed fewer than 10 parotidectomies per year and 93.8% if they performed more than 10 (OR, 1.02; 95% CI, 0.68-1.45; p=.991). With regard to lawsuits, just 3 (1.2%) of the respondents had a history of a parotid gland surgery-associated lawsuit and in just one case the facial nerve monitor was not used. CONCLUSION Our data demonstrate that most otolaryngologists in Spain use intraoperative facial nerve monitoring during parotid gland surgery. Almost all of them use it to improve patient safety and consider that facial nerve monitoring should be helpful preventing inadvertent injury.
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Affiliation(s)
- Carlos Miguel Chiesa-Estomba
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España.
| | - Carlos Saga-Gutiérrez
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - José Ángel González-García
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - Christian Calvo-Henríquez
- Servicio de Otorrinolaringología, Complejo Hospitalario de Santiago de Compostela, Santiago de Compostela, España
| | - Ekhiñe Larruscain
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - Jon Alexander Sistiaga-Suárez
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | | | - Pablo Parente-Arias
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Complejo Hospitalario Universitario A Coruña, A Coruña, España
| | - Miquel Quer
- Servicio de Otorrinolaringología - Cirugía de Cabeza y Cuello, Hospital Universitario Santa Creu i Sant Pau, Barcelona, España
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21
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Daoudi H, Lahlou G, Degos V, Sterkers O, Nguyen Y, Kalamarides M. Improving facial nerve outcome and hearing preservation by different degrees of vestibular schwannoma resection guided by intraoperative facial nerve electromyography. Acta Neurochir (Wien) 2020; 162:1983-1993. [PMID: 32424567 DOI: 10.1007/s00701-020-04397-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/06/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Facial nerve (FN) outcome has been improved by deciding upon the degree of vestibular schwannoma (VS) resection guided by intraoperative facial nerve monitoring (IOFM). This study aimed to evaluate hearing and FN outcomes following IOFM-guided VS removal through a retrosigmoid approach (RS). METHODS Between January 2015 and August 2017, 77 patients undergoing VS resection through RS, regardless of their preoperative hearing or tumor size, were included in this monocentric retrospective study. Total or near-/subtotal resection was decided intraoperatively according to IOFM. Partial resection was planned preoperatively. Pre- and postoperative FN function (House-Brackmann) and hearing level (AAO-HNS and Gardner-Robertson (GR) scales) were reported. Predictive factors for hearing preservation were analyzed according to a score developed to take into account pre-/postoperative hearing evolution. RESULTS The mean extrameatal diameter was 17 ± 8.5 mm. VS resection was total, near-/subtotal, and partial in 71%, 21%, and 8% of cases, respectively. Postoperative grade I and II FN function was achieved in 91% of patients. Serviceable (A+B or GR I+II) hearing and hearing with intelligibility (A+B+C or GR I-III) were preserved in 30% and 43% of cases, respectively. In multivariate analysis, preoperative synchronized auditory brainstem responses (ABR) were the only predictive factor (p = 0.006) imparting a five times greater chance of hearing preservation. CONCLUSION IOFM-guided VS excision through RS, whatever the VS size and hearing level, achieved a high rate of good postoperative FN function together with significant hearing preservation, and it should be used if hearing with some intelligibility is still present preoperatively, even in large VS.
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Affiliation(s)
- Hannah Daoudi
- Sorbonne Université, Groupe Hospitalo-Universitaire Pitié-salpêtrière, Paris, France
- Department of Otolaryngology, GHU Pitié-salpétrière, Paris, France
| | - Ghizlene Lahlou
- Sorbonne Université, Groupe Hospitalo-Universitaire Pitié-salpêtrière, Paris, France.
- Department of Otolaryngology, GHU Pitié-salpétrière, Paris, France.
| | - Vincent Degos
- Sorbonne Université, Groupe Hospitalo-Universitaire Pitié-salpêtrière, Paris, France
- Department of Anesthesiology and Reanimation, GHU Pitié-salpétrière, Paris, France
| | - Olivier Sterkers
- Sorbonne Université, Groupe Hospitalo-Universitaire Pitié-salpêtrière, Paris, France
- Department of Otolaryngology, GHU Pitié-salpétrière, Paris, France
| | - Yann Nguyen
- Sorbonne Université, Groupe Hospitalo-Universitaire Pitié-salpêtrière, Paris, France
- Department of Otolaryngology, GHU Pitié-salpétrière, Paris, France
| | - Michel Kalamarides
- Sorbonne Université, Groupe Hospitalo-Universitaire Pitié-salpêtrière, Paris, France
- Department of Neurosurgery, GHU Pitié-salpétrière, Paris, France
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22
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Chiesa-Estomba CM, Larruscain-Sarasola E, Lechien JR, Mouawad F, Calvo-Henriquez C, Diom ES, Ramirez A, Ayad T. Facial nerve monitoring during parotid gland surgery: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2020; 278:933-943. [PMID: 32654023 DOI: 10.1007/s00405-020-06188-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/03/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Facial nerve injury remains the most severe complication of parotid gland surgery. However, the use of intraoperative facial nerve monitoring (IFNM) during parotid gland surgery among Otolaryngologist-Head and Neck Surgeons continues to be a matter of debate. MATERIALS AND METHODS A systematic review and meta-analysis of the literature was conducted including articles from 1970 to 2019 to try to determine the effectiveness of intraoperative facial nerve monitoring in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without intraoperative facial nerve monitoring. RESULTS Ten articles met inclusion criteria, with a total of 1069 patients included in the final meta-analysis. The incidence of immediate and permanent postoperative weakness following parotidectomy was significantly lower in the IFNM group compared to the unmonitored group (23.4% vs. 38.4%; p = 0.001) and (5.7% vs. 13.6%; p = 0.001) when all studies were included. However, when we analyze just prospective data, we are not able to find any significant difference. CONCLUSION Our study suggests that IFNM may decrease the risk of immediate post-operative and permanent facial nerve weakness in primary parotid gland surgery. However, due to the low evidence level, additional prospective-randomized trials are needed to determine if these results can be translated into improved surgical safety and improved patient satisfaction.
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Affiliation(s)
- Carlos Miguel Chiesa-Estomba
- Otorhinolaryngology-Head and Neck Surgery Department, Hospital Universitario Donostia, Calle Doctor Begiristain, #1. CP. 20014, San Sebastian-Donostia, Guipuzkoa, Basque Country, Spain.
- Head and Neck Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France.
| | - Ekhiñe Larruscain-Sarasola
- Otorhinolaryngology-Head and Neck Surgery Department, Hospital Universitario Donostia, Calle Doctor Begiristain, #1. CP. 20014, San Sebastian-Donostia, Guipuzkoa, Basque Country, Spain
| | - Jérome Rene Lechien
- Department of Human Anatomy and Experimental Oncology, University of Mons, Mons, Belgium
- Head and Neck Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
| | - Francois Mouawad
- Department of Otorhinolaryngology-Head and Neck Surgery, CHRU de Lille, Lille, France
| | - Christian Calvo-Henriquez
- Department of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
- Head and Neck Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
| | - Evelyne Siga Diom
- ENT and Head and Neck Departement, CHU de La Paix, UFR Santé de l'Université Assane Seck, Ziguinchor, Sénégal
| | - Adonis Ramirez
- Head and Neck Surgery, Clinica Medilaser Neiva, Neiva, Colombia
| | - Tareck Ayad
- Division of Otolaryngology-Head and Neck Surgery, Center Hospitalier de l'Université de Montréal, Montreal, Canada
- Head and Neck Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France
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23
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Matsuoka R, Takeshima Y, Hayashi H, Takatani T, Nishimura F, Nakagawa I, Motoyama Y, Park YS, Kawaguchi M, Nakase H. Feasibility of adjunct facial motor evoked potential monitoring to reduce the number of false-positive results during cervical spine surgery. J Neurosurg Spine 2020; 32:570-577. [PMID: 31835248 DOI: 10.3171/2019.9.spine19800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE False-positive intraoperative muscle motor evoked potential (mMEP) monitoring results due to systemic effects of anesthetics and physiological changes continue to be a challenging issue. Although control MEPs recorded from the unaffected side are useful for identifying a true-positive signal, there are no muscles on the upper or lower extremities to induce control MEPs in cervical spine surgery. Therefore, this study was conducted to clarify if additional MEPs derived from facial muscles can feasibly serve as controls to reduce false-positive mMEP monitoring results in cervical spine surgery. METHODS Patients who underwent cervical spine surgery at the authors' institution who did not experience postoperative neurological deterioration were retrospectively studied. mMEPs were induced with transcranial supramaximal stimulation. Facial MEPs (fMEPs) were subsequently induced with suprathreshold stimulation. The mMEP and subsequently recorded fMEP waveforms were paired during each moment during surgery. The initial pair was regarded as the baseline. A significant decline in mMEP and fMEP amplitude was defined as > 80% and > 50% decline compared with baseline, respectively. All mMEP alarms were considered false positives. Based on 2 different alarm criteria, either mMEP alone or both mMEP and fMEP, rates of false-positive mMEP monitoring results were calculated. RESULTS Twenty-three patients were included in this study, corresponding to 102 pairs of mMEPs and fMEPs. This included 23 initial and 79 subsequent pairs. Based on the alarm criterion of mMEP alone, 17 false-positive results (21.5%) were observed. Based on the alarm criterion of both mMEP and fMEP, 5 false-positive results (6.3%) were observed, which was significantly different compared to mMEP alone (difference 15.2%; 95% CI 7.2%-23.1%; p < 0.01). CONCLUSIONS fMEPs might be used as controls to reduce false-positive mMEP monitoring results in cervical spine surgery.
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Affiliation(s)
| | | | | | - Tsunenori Takatani
- 3Division of Central Clinical Laboratory, Nara Medical University Hospital, Kashihara, Japan
| | | | | | | | - Young-Su Park
- 1Department of Neurosurgery, Nara Medical University
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24
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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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25
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Natural History of Facial Weakness Following Surgery of the Cerebellopontine Angle: A Tertiary Care Cohort. Otol Neurotol 2019; 41:e1284-e1289. [PMID: 31644478 DOI: 10.1097/mao.0000000000002427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Facial function is a key outcome in surgery of the cerebellopontine angle (CPA). This study describes the natural history of facial weakness after CPA surgery. STUDY DESIGN AND SETTING Retrospective study of two tertiary centers. PATIENTS AND INTERVENTION Patients undergoing surgery for CPA tumors from 2003 to 2017 with preoperatively normal facial function and without subsequent surgical or adjuvant therapy. MAIN OUTCOME MEASURE Serial facial nerve examinations using the House-Brackmann (HB) scale. RESULTS Of 301 patients examined, 149 (49.5%) had facial weakness postoperatively and 74.5% of these occurred within 24 hours. Of patients with HB-1 function within 24 hours after surgery, 95.3% had HB-1 function and 100% had HB-3 or better function at last follow-up. Of patients with HB-4 or worse function within 24 hours after surgery, 22.6% ultimately achieved HB-1 function and 83.9% ultimately achieved HB-3 or better function. By 180 days postoperatively, 83.7% of patients' facial function had stabilized. At last follow-up, 3.0% of patients had facial function poorer than HB-3, which was associated with subtotal resections (12.9% vs. 4.4% for near total and 0.6% for gross total resections, p = 0.002), aspirin use (10.6% vs. 1.6%, p = 0.001), larger tumors (p < 0.0005), longer surgery (p < 0.002), and immediate versus delayed postoperative facial weakness (p = 0.002). CONCLUSIONS Facial function over time after CPA surgery is presented. While facial function immediately after surgery correlates with future function, delayed weakness or improvement is common. These data inform patient counseling both preceding and following surgery.
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26
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Link MJ, Lund-Johansen M, Lohse CM, Driscoll CLW, Myrseth E, Tveiten OV, Carlson ML. Quality of Life in Patients with Vestibular Schwannomas Following Gross Total or Less than Gross Total Microsurgical Resection: Should We be Taking the Entire Tumor Out? Neurosurgery 2019; 82:541-547. [PMID: 29554375 DOI: 10.1093/neuros/nyx245] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The goal of microsurgical removal of a vestibular schwannoma is to completely remove the tumor, to provide long-term durable cure. In many cases, less than gross total resection (GTR) is performed to preserve neurological, and especially facial nerve function. OBJECTIVE To analyze long-term quality of life (QoL) in a cohort of patients who received either GTR or less than GTR. METHODS Patients operated for vestibular schwannoma less than 3.0 cm in posterior fossa diameter at 1 of 2 international tertiary care centers were surveyed using generic and disease-specific QoL instruments. RESULTS A total of 143 patients were analyzed. GTR was performed in 122, and 21 underwent less than GTR. QoL was assessed at a mean of 7.7 yr after surgery (interquartile range: 5.7-9.6). Patients who underwent GTR had smaller tumors; otherwise, there were no baseline differences between groups. Patients who underwent GTR, after multivariable adjustment for baseline features and facial nerve and hearing outcomes, reported statistically significantly better Short Form Health Survey-36 (SF-36) physical and mental scores, Patient-Reported Outcomes Measurement Information System (PROMIS-10) physical and mental scores, and Penn Acoustic Neuroma Quality of Life (PANQOL) facial, energy, general health, and total scores compared to patients receiving less than GTR. CONCLUSION GTR is associated with better QoL using the general QoL measures SF-36 and PROMIS-10 and the disease-specific PANQOL, even after controlling for baseline and outcome differences. This is especially significant in the assessment of mental health, indicating there may indeed be a psychological advantage to the patient that translates to overall well-being to have the entire tumor removed if microsurgical resection is undertaken.
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Affiliation(s)
- Michael J Link
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Morten Lund-Johansen
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway
| | - Christine M Lohse
- Department of Biostatistics and Informatics, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Colin L W Driscoll
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Ehrling Myrseth
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway
| | - Oystein Vesterli Tveiten
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway
| | - Matthew L Carlson
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
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27
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Tawfik KO, Walters ZA, Kohlberg GD, Lipschitz N, Breen JT, O’Neal K, Zuccarello M, Samy RN. Impact of Motor-Evoked Potential Monitoring on Facial Nerve Outcomes after Vestibular Schwannoma Resection. Ann Otol Rhinol Laryngol 2018; 128:56-61. [DOI: 10.1177/0003489418803969] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Assess the utility of intraoperative transcranial facial motor-evoked potential (FMEP) monitoring in predicting and improving facial function after vestibular schwannoma (VS) resection. Study Design: Retrospective chart review. Methods: Data were obtained from 82 consecutive VS resections meeting inclusion criteria. Sixty-two cases were performed without FMEP and 20 with FMEP. Degradation of FMEP response was defined as a final-to-baseline amplitude ratio of 0.5 or less. House-Brackmann (HB) grade was assessed preoperatively, postoperatively, at follow-up assessments, and it was compared between pre- and post-FMEP cohorts. Positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity of FMEP degradation in predicting facial weakness were calculated. Results: In the pre-FMEP group, at length of follow-up (LOF) ⩾9 months, 83.9% (52/62) of patients exhibited HB 1-2 outcome. In the post-FMEP cohort, 75.0% (15/20) exhibited HB 1-2 function at LOF ⩾9 months. There was no difference in rates of HB 1-2 outcomes between groups in the immediate postoperative period ( P = .35) or at long-term follow-up ( P = 1.0). With respect to predicting immediate postoperative facial function, FMEP demonstrated high specificity (88.9%) and moderate sensitivity (54.5%). The PPV and NPV for immediate postoperative facial function were 85.7% and 61.5%, respectively. With respect to long-term (⩾9 months LOF) facial function, intraoperative FMEP was moderately sensitive (71.4%) and highly specific (84.6%); PPV was moderate (71.4%), and NPV was high (84.6%). Conclusions: Intraoperative FMEP is highly specific and moderately sensitive in predicting postoperative facial function for patients undergoing VS resection, but its use may not be associated with improved facial nerve outcomes. Level of Evidence: 4
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Affiliation(s)
- Kareem O. Tawfik
- Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, University of California, San Diego School of Medicine, San Diego, CA, USA
| | - Zoe A. Walters
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gavriel D. Kohlberg
- Department of Otolaryngology – Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Noga Lipschitz
- Department of Otolaryngology – Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph T. Breen
- Department of Otolaryngology – Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ravi N. Samy
- Department of Otolaryngology – Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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28
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Hatch J, Oyer SL. Vestibular Schwannoma Complicated by Facial Paralysis: Considerations of Techniques and Timing for Facial Reanimation. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0201-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Chen LH, Zhang HT, Xu RX, Zhang L, Li WD, Sun K. Microsurgery for patients diagnosed with neurofibromatosis type 2 complicated by vestibular schwannomas: Clinical experience and strategy for treatments. Medicine (Baltimore) 2018; 97:e0270. [PMID: 29702972 PMCID: PMC5944529 DOI: 10.1097/md.0000000000010270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Most patients diagnosed with neurofibromatosis type 2 (NF2) have bilateral vestibular schwannomas (VS). Through reviewing surgical method and clinical outcomes, we tried to find out a strategy for treatments in NF2 patients with VS.We retrospectively reviewed patients diagnosed pathological NF2 and have had microsurgery (MS) for VS in the PLA Army General Hospital. Seventeen patients were included from January 2000 to December 2016. Fifteen patients had progressive hearing impairment, and 7 ears were totally deaf. Computed tomography and magnetic resonance imaging were used for preoperative and postoperative evaluation. House-Brackmann (H-B) classification was used to evaluate facial function, and the hearing outcome was classified according to American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification system. The outcomes included functional hearing, facial function, and complications.In the 17 patients, 9 were men, and the mean age was 27.2 years old. The mean duration of disease was 38.4 months. Twenty-six VS were excised. Nine patients with bilateral VS and unilateral surgery had repeated surgery for the contralateral tumor after 3 to 12 months. The hearing preservation rate was 41.6%. In the 26 excisions for VS, 24 had intact facial nerve. In the other 2 tumor excision, damaged facial nerves had head-to-head adhesion using biological fibrin glue. The rate of facial nerve function preservation was 60%. No mortality or major complication was reported. The follow-up time ranged from 11 to 78 months with a mean value of 39 months.MS is an effective treatment for NF2 patients with VS. The operation for bilateral VS should be staged according to tumor size and bilateral hearing function. However, methods on how to preserve functional hearing and facial function remain the issue. Further randomized controlled studies are needed to find out a better treatment for NF2 patients with VS according to the overall condition.
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30
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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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31
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Hou B. The medium and long-term effect of electrophysiologic monitoring on the facial nerve function in minimally invasive surgery treating acoustic neuroma. Exp Ther Med 2018; 15:2347-2350. [PMID: 29563978 PMCID: PMC5854939 DOI: 10.3892/etm.2018.5683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/13/2017] [Indexed: 11/05/2022] Open
Abstract
The medium and long-term effects of electrophysiologic monitoring on the facial nerve function in minimally invasive surgery treating acoustic neuroma were studied. Sixty-two patients with acoustic neuroma taking minimally invasive surgeries in Dezhou Hospital from August 2014 to September 2015 were selected and randomly divided into 29 cases of the control group and 33 cases of the observation group. Intraoperative electrophysiologic monitoring was applied to the observation group, but not to the control group. The effects of the surgeries were compared. Comparisons on the surgical resection rate and the surgery length between two groups showed no statistical differences (P>0.05); the anatomical and functional preservation rate of facial nerves, as well as the score of survival quality in the observation group prominently proceeded that in the control group, and the differences were statistically significant (P>0.05). In conclusion, the application of the electrophysiologic monitoring on facial nerve function in minimally invasive surgery treating acoustic neuroma can effectively increase the anatomical and functional preservation rate of facial nerves, providing certain clinical significance to the improvement of living quality.
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Affiliation(s)
- Baohui Hou
- Department of Neurosurgery, Dezhou Municipal Hospital, Dezhou, Shandong 253012, P.R. China
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32
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Monfared A, Corrales CE, Theodosopoulos PV, Blevins NH, Oghalai JS, Selesnick SH, Lee H, Gurgel RK, Hansen MR, Nelson RF, Gantz BJ, Kutz JW, Isaacson B, Roland PS, Amdur R, Jackler RK. Facial Nerve Outcome and Tumor Control Rate as a Function of Degree of Resection in Treatment of Large Acoustic Neuromas: Preliminary Report of the Acoustic Neuroma Subtotal Resection Study (ANSRS). Neurosurgery 2017; 79:194-203. [PMID: 26645964 DOI: 10.1227/neu.0000000000001162] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with large vestibular schwannomas are at high risk of poor facial nerve (cranial nerve VII [CNVII]) function after surgery. Subtotal resection potentially offers better outcome, but may lead to higher tumor regrowth. OBJECTIVE To assess long-term CNVII function and tumor regrowth in patients with large vestibular schwannomas. METHODS Prospective multicenter nonrandomized cohort study of patients with vestibular schwannoma ≥2.5 cm who received gross total resection, near total resection, or subtotal resection. Patients received radiation if tumor remnant showed signs of regrowth. RESULTS Seventy-three patients had adequate follow-up with mean tumor diameter of 3.33 cm. Twelve received gross total resection, 22 near total resection, and 39 subtotal resection. Fourteen (21%) remnant tumors continued to grow, of which 11 received radiation, 1 had repeat surgery, and 2 no treatment. Four of the postradiation remnants (36%) required surgical salvage. Tumor regrowth was related to non-cystic nature, larger residual tumor, and subtotal resection. Regrowth was 3 times as likely with subtotal resection compared to gross total resection and near total resection. Good CNVII function was achieved in 67% immediately and 81% at 1-year. Better immediate nerve function was associated with smaller preoperative tumor size and percentage of tumor left behind on magnetic resonance image. Degree of resection defined by surgeon and preoperative tumor size showed weak trend toward better late CNVII function. CONCLUSION Likelihood of tumor regrowth was 3 times higher in subtotal resection compared to gross total resection and near total resection groups. Rate of radiation control of growing remnants was suboptimal. Better immediate but not late CNVII outcome was associated with smaller tumors and larger tumor remnants. ABBREVIATIONS CNVII, cranial nerve VIIGTR, gross total resectionHB, House-BrackmannMRI, magnetic resonance imageNTR, near total resectionSTR, subtotal resection.
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Affiliation(s)
- Ashkan Monfared
- *Departments of Otolaryngology and Neurosurgery, George Washington University, Washington, DC; ‡Departments of Otolaryngology-Head and Neck Surgery and Neurosurgery, Stanford University, Palo Alto, California; §Department of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; ¶Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio; ‖Department of Neurosurgery, University of California San Francisco, San Francisco, California; #Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas; **Department of Otolaryngology-Head and Neck Surgery, Weill Cornell School of Medicine, New York, New York; ‡‡Department of Statistics, California State University, Northridge, Northridge, California; §§Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah; ¶¶Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa; ‖‖Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana; ##Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas
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Mooney MA, Hendricks B, Sarris CE, Spetzler RF, Almefty KK, Porter RW. Long-Term Facial Nerve Outcomes after Microsurgical Resection of Vestibular Schwannomas in Patients with Preoperative Facial Nerve Palsy. J Neurol Surg B Skull Base 2017; 79:309-313. [PMID: 29765830 DOI: 10.1055/s-0037-1607320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022] Open
Abstract
Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House-Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1-4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House-Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Benjamin Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Randall W Porter
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Copeland WR, Carlson ML, Neff BA, Driscoll CL, Link MJ. Management of Residual Tumor After Limited Subtotal Resection of Large Vestibular Schwannomas: Lessons Learned and Rationale for Specialized Care. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bernardeschi D, Pyatigorskaya N, Vanier A, Bielle F, Smail M, Lamas G, Sterkers O, Kalamarides M. Role of electrophysiology in guiding near-total resection for preservation of facial nerve function in the surgical treatment of large vestibular schwannomas. J Neurosurg 2017; 128:903-910. [PMID: 28409723 DOI: 10.3171/2016.11.jns161737] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In large vestibular schwannoma (VS) surgery, the facial nerve (FN) is at high risk of injury. Near-total resection has been advocated in the case of difficult facial nerve dissection, but the amount of residual tumor that should be left and when dissection should be stopped remain controversial factors. The objective of this study was to report FN outcome and radiological results in patients undergoing near-total VS resection guided by electromyographic supramaximal stimulation of the FN at the brainstem. METHODS This study was a retrospective analysis of a prospectively maintained database. Inclusion criteria were surgical treatment of a large VS during 2014, normal preoperative FN function, and an incomplete resection due to the strong adherence of the tumor to the FN and the loss of around 50% of the response of supramaximal stimulation of the proximal FN at 2 mA. Facial nerve function and the amount and evolution of the residual tumor were evaluated by clinical examination and by MRI at a mean of 5 days postoperatively and at 1 year postoperatively. RESULTS Twenty-five patients met the inclusion criteria and were included in the study. Good FN function (Grade I or II) was observed in 16 (64%) and 21 (84%) of the 25 patients at Day 8 and at 1 year postoperatively, respectively. At the 1-year follow-up evaluation (n = 23), 15 patients (65%) did not show growth of the residual tumor, 6 patients (26%) had regression of the residual tumor, and only 2 patients (9%) presented with tumor progression. CONCLUSIONS Near-total resection guided by electrophysiology represents a safe option in cases of difficult dissection of the facial nerve from the tumor. This seems to offer a good compromise between the goals of preserving facial nerve function and achieving maximum safe resection.
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Affiliation(s)
- Daniele Bernardeschi
- Departments of1Otology, Auditory Implants, and Skull Base Surgery.,2Sorbonne Universités, UPMC Université Paris VI; and.,3Inserm UMR-S1159, Réhabilitation Chirurgicale Mini-Invasive et Robotisée de L'Audition, Paris,France
| | | | | | - Franck Bielle
- 2Sorbonne Universités, UPMC Université Paris VI; and.,7Neuropathology, AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix
| | - Mustapha Smail
- Departments of1Otology, Auditory Implants, and Skull Base Surgery
| | - Georges Lamas
- Departments of1Otology, Auditory Implants, and Skull Base Surgery.,2Sorbonne Universités, UPMC Université Paris VI; and.,3Inserm UMR-S1159, Réhabilitation Chirurgicale Mini-Invasive et Robotisée de L'Audition, Paris,France
| | - Olivier Sterkers
- Departments of1Otology, Auditory Implants, and Skull Base Surgery.,2Sorbonne Universités, UPMC Université Paris VI; and.,3Inserm UMR-S1159, Réhabilitation Chirurgicale Mini-Invasive et Robotisée de L'Audition, Paris,France
| | - Michel Kalamarides
- 2Sorbonne Universités, UPMC Université Paris VI; and.,6Neurosurgery, and
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Graffeo CS, Perry A, Copeland WR, Giannini C, Neff BA, Driscoll CL, Link MJ. Synchronous Tumors of the Cerebellopontine Angle. World Neurosurg 2017; 98:632-643. [DOI: 10.1016/j.wneu.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 01/28/2023]
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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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Carlson ML, Deep NL, Patel NS, Lundy LB, Tombers NM, Lohse CM, Link MJ, Driscoll CL. Facial Nerve Schwannomas: Review of 80 Cases Over 25 Years at Mayo Clinic. Mayo Clin Proc 2016; 91:1563-1576. [PMID: 27720200 DOI: 10.1016/j.mayocp.2016.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/08/2016] [Accepted: 07/01/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To elucidate the long-term clinical behavior, treatment, and outcomes of sporadic facial nerve schwannoma (FNS) in a large cohort of patients managed in the post-magnetic resonance imaging era. PATIENTS AND METHODS Retrospective review at a single tertiary health care system (January 1, 1990, through December 31, 2015), evaluating 80 consecutive patients with sporadic FNS. RESULTS Ninety-eight patients with FNS were identified; 10 with incomplete data and 8 with neurofibromatosis type 2 were excluded. The remaining 80 patients (median age, 47 years; 58% women) were analyzed. Forty-three (54%) patients presented with asymmetrical hearing loss, 33 (41%) reported facial paresis, and 21 (26%) reported facial spasm. Seventeen (21%) exhibited radiologic features mimicking vestibular schwannoma, 14 (18%) presented as a parotid mass, and 5 (6%) were discovered incidentally. Factors predictive of facial nerve paresis or spasm before treatment were female sex and tumor involvement of the labyrinthine/geniculate and tympanic facial nerve segments. The median growth rate among growing FNS was 2.0 mm/y. Details regarding clinical outcome according to treatment modality are described. CONCLUSION In patients with FNS, female sex and involvement of the labyrinthine/geniculate and tympanic segments of the facial nerve predict a higher probability of facial paresis or spasm. When isolated to the posterior fossa or parotid gland, establishing a preoperative diagnosis of FNS is challenging. Treatment should be tailored according to tumor location and size, existing facial nerve function, patient priorities, and age. A management algorithm is presented, prioritizing long-term facial nerve function.
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Affiliation(s)
- Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, MN.
| | - Nicholas L Deep
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Scottsdale, AZ
| | - Neil S Patel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN
| | - Larry B Lundy
- Department of Otolaryngology-Head and Neck Surgery, Jacksonville, FL
| | - Nicole M Tombers
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic School of Medicine, Rochester, MN
| | - Michael J Link
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, MN
| | - Colin L Driscoll
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, MN
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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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Wise SC, Carlson ML, Tveiten ØV, Driscoll CL, Myrseth E, Lund-Johansen M, Link MJ. Surgical salvage of recurrent vestibular schwannoma following prior stereotactic radiosurgery. Laryngoscope 2016; 126:2580-2586. [DOI: 10.1002/lary.25943] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/25/2016] [Accepted: 02/02/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Stephanie C. Wise
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
| | - Matthew L. Carlson
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurologic Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
| | - Øystein Vesterli Tveiten
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Colin L. Driscoll
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurologic Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
| | - Erling Myrseth
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Michael J. Link
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurologic Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
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Cha W, Cho I, Jang JY, Cho JK, Wang SG, Park JH. Supramaximal neurostimulation with laryngeal palpation to predict postoperative vocal fold mobility. Laryngoscope 2016; 126:2863-2868. [DOI: 10.1002/lary.26011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/29/2016] [Accepted: 03/07/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Wonjae Cha
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan South Korea
- Department of Otorhinolaryngology-Head and Neck Surgery; School of Medicine, Pusan National University; Yangsan South Korea
| | - Ilyoung Cho
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan South Korea
| | - Jeon Yeob Jang
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan South Korea
| | - Jae-Keun Cho
- Department of Otolaryngology-Head and Neck Surgery; Inje University Ilsan Paik Hospital and Inje University School of Medicine; Goyang South Korea
| | - Soo-Geun Wang
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan South Korea
- Department of Otorhinolaryngology-Head and Neck Surgery; School of Medicine, Pusan National University; Yangsan South Korea
| | - Ji-Hwan Park
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute; Pusan National University Hospital; Busan South Korea
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Oldenburg MS, Carlson ML, Van Abel KM, Driscoll CL, Link MJ. Management of Geniculate Ganglion Hemangiomas: Case Series and Systematic Review of the Literature. Otol Neurotol 2015; 36:1735-40. [PMID: 26536415 DOI: 10.1097/mao.0000000000000891] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To analyze facial nerve (FN) outcomes based on duration of FN palsy and surgical strategy in patients with geniculate ganglion hemangiomas (GGH). STUDY DESIGN Case series and systematic review of the literature. SETTING Tertiary care center. SUBJECTS AND METHODS All patients undergoing surgical resection of GGH from 1992 to 2014 were studied and a review of the English literature was performed. RESULTS One hundred twenty unique patients (mean age 41.4 yrs, 44% female) were identified with GGH: 8 in the current series and 112 from the literature review. Of these patients, 94% presented with FN weakness, 18% reported hemifacial spasm, and 16% had hearing loss at presentation. Eleven patients underwent an initial period of observation, 6 of which experienced either growth or progression of FN dysfunction. One hundred fourteen subjects ultimately underwent surgical intervention. The average preoperative House-Brackmann (HB) score was 4.6 and the mean duration of preoperative FN palsy was 27 months (range, 1-132). The average postoperative HB score was 3.5 at the last follow-up. Anatomical FN preservation was reported in 44% of patients. Duration of FN palsy ≤12 months was associated with better pre- and postoperative FN outcome (HB 4.1 vs 5.1, p = 0.01 and 2.9 vs 4.0, p < 0.001, respectively). FN preservation was also associated with better postoperative FN outcome compared with interposition grafting (HB 2.6 vs 3.9, p < 0.001). CONCLUSION GGHs are rare benign vascular malformations that present with progressive FN palsy. In most patients, early surgical intervention should be considered since shorter duration of FN paralysis and anatomical preservation of the FN are significant predictors of final FN outcome.
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Affiliation(s)
- Michael S Oldenburg
- *Department of Otolaryngology-Head and Neck Surgery †Department of Neurologic Surgery, Mayo Clinic, School of Medicine, Rochester, Minnesota, U.S.A
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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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Prell J, Strauss C, Rachinger J, Scheller C, Alfieri A, Herfurth K, Rampp S. The intermedius nerve as a confounding variable for monitoring of the free-running electromyogram. Clin Neurophysiol 2015; 126:1833-9. [PMID: 25655939 DOI: 10.1016/j.clinph.2014.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 10/08/2014] [Accepted: 11/10/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A-trains, a facial nerve EMG-pattern, are correlated with postoperative functional impairment. However, an unknown confounder is suspected to cause false positive monitoring results. The intermedius nerve contains motor fibers targeting lower facial muscles; their significance for facial nerve monitoring is yet unknown. METHODS Intraoperative videotapes and free-running 9-channel facial nerve EMG assessed from 87 patients undergoing surgery for vestibular schwannoma were evaluated, and presence/absence of an identifiable intermedius nerve was determined. The prognostic value of train time, a quantitative measure for A-train activity, was evaluated for both the groups with and without an identifiable intermedius nerve. RESULTS Correlation between traintime and outcome (Spearman's Rho) rose to 0.73 (p<0.001) when only patients without an identified intermedius nerve were considered, and fell to 0.43 (p<0.05) with the other patient group. This difference was statistically significant (p=0.036), was more prominent in the channels monitoring perioral facial muscles, and resulted from additional A-train activity in patients with an identifiable intermedius nerve. CONCLUSIONS A separate intermedius nerve may be more prone to manipulation, leading to A-train activity without clinical correlate, thus causing false positive monitoring results. SIGNIFICANCE For interpretation of the free-running EMG, the intermedius nerve needs to be taken into account as a confounder.
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Affiliation(s)
- Julian Prell
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany.
| | - Christian Strauss
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Jens Rachinger
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Christian Scheller
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Alex Alfieri
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Kirsten Herfurth
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Stefan Rampp
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
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The Success of Free Gracilis Muscle Transfer to Restore Smile in Patients With Nonflaccid Facial Paralysis. Ann Plast Surg 2014; 73:177-82. [DOI: 10.1097/sap.0b013e3182a0df04] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Facial nerve palsy after vestibular schwannoma surgery: Dynamic risk-stratification based on continuous EMG-monitoring. Clin Neurophysiol 2014; 125:415-21. [DOI: 10.1016/j.clinph.2013.07.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/29/2013] [Accepted: 07/31/2013] [Indexed: 11/18/2022]
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Van Abel KM, Carlson ML, Driscoll CL, Neff BA, Link MJ. Vestibular schwannoma surgery in the elderly: a matched cohort study. J Neurosurg 2014; 120:207-17. [DOI: 10.3171/2013.6.jns122433] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors' objective was 2-fold: 1) to compare outcomes of microsurgical resection for vestibular schwannoma (VS) between patients aged 70 years or older and patients younger than 70 years and 2) to test the hypothesis that symptomatic tumors in elderly patients represent a more aggressive variant of VS than those in younger adults, resulting in increased morbidity and a higher rate of recurrence after subtotal resection (STR).
Methods
A retrospective matched cohort study was conducted. Patients aged 70 years or older who had undergone microsurgical resection of VS were matched to adult patients younger than 70 years; the matching was performed on the basis of surgical approach, completeness of resection, and tumor size. Associations between clinical, radiographic, and surgical data and postoperative outcome were analyzed using conditional logistic regression.
Results
Twenty patients aged 70 years or older (mean age ± SD 75.9 ± 5.3, range 70–86 years) were identified and matched to a cohort of younger adult patients (mean age ± SD 55.7 ± 13.8, range 25–69 years). The mean tumor size in both groups was approximately 3 cm. Overall, the elderly patients had a poorer preoperative American Society of Anesthesiology physical status score (p = 0.038), were more likely to report imbalance (OR 9.61, p = 0.016), and more commonly exhibited compromised balance and coordination (OR 9.61, p = 0.016) than patients in the younger cohort.
There were no differences between the 2 cohorts in perioperative complications (p = 0.26) or facial nerve function (p > 0.5) at any time. The elderly patients were 13 times more likely to have long-term postoperative imbalance (OR 13.00, p = 0.013) than the younger patients. Overall, 9 tumors recurred among 32 patients undergoing STR; 6 of these patients underwent additional interventions (stereotactic radiosurgery in 5 patients and microsurgery in 1) and showed no evidence of tumor progression at the last follow-up. The median growth rate of the recurrent tumor in the 6 elderly patients was 4.8 mm/year (range 2.1–14.9 mm/year) and, in the 3 control patients, 2.2 mm/year (range 1.9–4.0 mm/year). Overall, the mortality data showed a trend toward statistical significance (p = 0.068) with a higher risk of death in the elderly.
Conclusions
As the number of elderly patients with VS increases, microsurgical resection will remain an important management option for these patients. Despite a poorer preoperative physical status in elderly patients, their morbidity profiles are similar to those in adult patients younger than 70 years. However, elderly patients may require longer convalescence due to prolonged postoperative imbalance. Not surprisingly, overall diminished functional reserve and advanced comorbidities may increase the mortality risk associated with surgical intervention in the elderly patients. Finally, there was a high risk of further tumor growth following STR in the elderly patients (6 [37.5%] of 16), underscoring the need for close postoperative radiological surveillance and consideration of early stereotactic radiosurgery for the tumor remnant following the STR.
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Affiliation(s)
| | | | - Colin L. Driscoll
- 1Departments of Otolaryngology–Head and Neck Surgery and
- 2Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Brian A. Neff
- 1Departments of Otolaryngology–Head and Neck Surgery and
| | - Michael J. Link
- 1Departments of Otolaryngology–Head and Neck Surgery and
- 2Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
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Sharma M, Sonig A, Ambekar S, Nanda A. Radiological and Clinical Factors Predicting the Facial Nerve Outcome following Retrosigmoid Approach for Large Vestibular Schwannomas (VSs). J Neurol Surg B Skull Base 2013; 74:317-23. [PMID: 24436931 DOI: 10.1055/s-0033-1349060] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022] Open
Abstract
Objective The aim of our study was to identify the radiological and clinical factors that predict postoperative facial nerve outcome following retrosigmoid approach for large vestibular schwannomas (VSs). Methods A total of 72 patients with large (≥ 3 cm) vestibular schwannomas was included in this retrospective study. Various parameters evaluated were age, gender, clinical presentation, tumor diameter in three planes, intrameatal extension, and pattern of growth. Results Age of the patient and presenting symptoms such as headache, ataxia, or preoperative facial nerve dysfunction correlated with poorer facial nerve outcome (p < 0.05). Patients with larger tumor volumes and extrameatal growth experienced a worse outcome (p < 0.05). Anterior and caudal extension (p = 0.001) correlated with poorer outcome, as well. Intrameatal extension and bony changes of the internal acoustic meatus did not correlate with the outcome (p > 0.05). Of the various examined factors, preoperative facial nerve function independently predicted postoperative facial nerve outcome. Conclusion Our study suggests that young patients with small tumor volume and normal facial nerve function at presentation are more likely to experience a good postoperative facial nerve outcome. These clinical and radiological parameters can be used to predict facial nerve outcome prior to surgery.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Ashish Sonig
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Sudheer Ambekar
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
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