Hemihypoglossal-facial nerve anastomosis in treating unilateral facial palsy after acoustic neurinoma resection

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

Dynamic Surgical Restoration of Mid and Lower Facial Paralysis: A Single-Greek-Centre Experience

Background Facial palsy detrimentally impacts an individual's quality of life due to its effects on function and appearance. There are several reconstructive surgical techniques available that aim to restore facial symmetry. Techniques such as direct neurorrhaphy, nerve grafts, dual reanimation, and reinnervation have the potential to enable varying motor functions, including the re-establishment of a dynamic smile. This study aimed to assess the outcomes of facial palsy reconstructive surgeries undertaken at a tertiary care centre for facial nerve reconstruction in Athens. Methods This study consisted of a comprehensive case series showcasing the outcomes of facial palsy reconstructive surgeries on 29 patients at our Tertiary General Oncological Anti-Cancer Hospital of Athens 'Agios Savvas'. The surgical procedures from October 2004 to December 2023 included reinnervation, nerve grafting, free muscle transfer, and myoplasties following our recommended algorithm. We categorized the patients into two groups: Group A and Group B based on the timing of the reconstruction: delayed or immediate. The House-Brackmann grading scale evaluated the degree and improvement of facial paralysis. Results In Group A, two of the seven patients exhibited activation of the mimetic musculature immediately postsurgery, while the remaining five experienced enhanced facial nerve function in the subsequent months. Adverse outcomes were temporalis dysfunction in one case and tongue atrophy in another. Conversely, in Group B, 21 of 22 patients demonstrated facial activation immediately postsurgery. Only one patient from this group did not show any facial nerve function postoperatively. Two of the 22 patients in Group B encountered complications: one with trismus and another with temporalis dysfunction. All patients were observed for a minimum of 12 months postsurgery. Conclusion With the exception of one patient, all participants showed improved postoperative results, which were satisfactory when weighed against the observed morbidity rate. While our case analysis did not reveal any clear indication of one particular technique being superior, the selection of methods should be based on several factors, and this algorithm could serve as a useful aid in that regard. A comprehensive and standardized clinical assessment of facial palsy, both before and after surgery, is crucial to establish a consensus and plan individualized therapy.

V to VII Nerve Transfer for Smile Reanimation

Using the wording "facial reanimation," surgeons mean restoring movements to the paralyzed face. According to the condition of mimic muscle, facial palsy can be classified as recent (mimic muscle still alive) and chronic (atrophy of mimic muscle) palsy. The treatment is quite different because in the former group the mimic muscles can be still used so long as a new motor source would be connected to the damaged facial nerve. In the latter group, muscular transplantation is needed to substitute the atrophied mimic muscles of the middle part of the face. In both cases, the neural impulse that makes the muscles (mimic muscle in the former, transplanted muscle in the latter) move come from a new motor nerve. Nowadays, the masseteric nerve is widely used as a new motor source in recent facial reanimation; the same nerve has also a main role in the treatment of both chronic facial palsy where it is used as the new nervous stimulus for the new transplanted muscle and facial paresis where the nervous stimulus coming from the masseteric nerve is used to empower the stimulus coming from the injured facial nerve. The masseteric nerve can be usually connected directly to the facial nerve without the interposition of a nerve graft, with a faster reinnervation. Moreover, the use of the masseteric nerve gives no morbidity to the masticatory functions.

Assessing the Efficacy of Anastomosis between Ansa Cervicalis and Facial Nerve for Patients with Concomitant Facial Palsy and Peripheral Neuropathy

Background: For decades, patients with facial asymmetry have experienced social interaction difficulties, leading them to seek treatment in the hope of restoring facial symmetry and quality of life. Researchers evaluated numerous surgical techniques, but achieving results remains a significant hurdle. Specifically, anastomosis between the ansa cervicalis (AC) and facial nerve (FN) can hinder the patient's physical appearance. Objective: Our study goal was to examine the efficiency of anastomosis between AC and FN for facial motor function recovery even in the presence of peripheral neuropathy. Materials and Methods: Four patients diagnosed with facial palsy grade VI on the House & Brackmann Scale (HB) after vestibular schwannoma (VS) resection (Koos grade IV) via the retrosigmoid approach underwent AC and FN anastomosis. Outcomes were related to tumor grade, previous therapy, and the time between postoperative facial palsy and anastomosis. Images and neurophysiological data were evaluated. Results: After vs. resection, all four patients demonstrated HB grade VI facial palsy for an average of 17 months. During the follow-up program, lasting between 6 and 36 months, two patients were evaluated as having HB grade III facial palsy; the other two patients were diagnosed with grade IV HB facial palsy. None of the patients developed tongue atrophy, speech disorder, or masticatordys function. Conclusions: Anastomosis between the AC and FN is a safe and effective treatment for facial paralysis after cerebellopontine tumor resection. Nerve reanimation may be feasible even for patients with peripheral polyneuropathy. This study also offers a new option for patients with a progression-free status.

Seminal Studies in Facial Reanimation Surgery: Consensus and Controversies in the Top 50 Most Cited Articles

ABSTRACT

Facial paralysis can impair one's ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist.Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.

Microanatomic analyses of extratemporal facial nerve and its branches, hypoglossal nerve, sural nerve, and great auricular nerve

OBJECTIVE

To investigate microanatomic organizations of the extratemporal facial nerve and its branches, hypoglossal nerve, sural nerve, and great auricular nerve.

METHODS

Nerve samples were dissected in 12 postmortem autopsies, and histomorphometric analyses were conducted.

RESULTS

There was no significant difference between the right and left sides of the nerve samples for the nerve area, fascicle area, number of fascicles and average number of axons. The lowest mean fascicle number was found in the hypoglossal nerve (4.9 ± 1.4) while the highest was in great auricular nerve (11.4 ± 6.8). The highest nerve area (3,182,788 ± 838,430 μm²), fascicle area (1,573,181 ± 457,331 μm²) and axon number (14,772 ± 4402) were in hypoglossal nerve (p < 0.05). The number of axons per unit nerve area was higher in the facial nerve, truncus temporofacialis, truncus cervicofacialis and hypoglossal nerve, which are motor nerves, compared to the sural nerve and great auricular nerve, which are sensory nerves (p < 0.05). The number of axons per unit fascicle area was also higher in motor nerves than in sensory nerves (p < 0.05).

CONCLUSION

In the present study, it was observed that each nerve contained a different number of fascicles and these fascicles were different both in size and in the number of axons they contained. All these variables could be the reason why the desired outcomes cannot always be achieved in nerve reconstruction.

Hemihypoglossal-facial nerve anastomosis: results and electromyographic characterization

INTRODUCTION

The facial nerve surgery belongs to the basic procedures during lateral skull base approaches. Its damage has serious medical and psychological consequences, and therefore mastery of reconstruction and correction techniques should belong to the repertoire of skull base surgeons. The goal of this study was to demonstrate usefulness of electromyographic follow-up in facial nerve reconstruction.

MATERIAL AND METHODS

A total of 16 patients underwent hemihypoglossal-facial anastomosis between 2005 and 2017. Most of the primary lesions came from vestibular schwannoma surgery. All patients were examined with electromyography and scored according to the House-Brackmann and IOWA grading scales. Function of the tongue has been evaluated.

RESULTS

Ten patients achieved definitive House-Brackmann grade 3 score (62.5%). We did not observe any association with the patient's age, previous irradiation and the etiology of the damage. Electromyography showed pathological spontaneous activity after the first surgery. Incipient regeneration potentials were detected in 4-17 months (average 7.6) and reached maximum in 6.5-18 months (average 16). Electromyographic assessment of the effect of tongue movement showed better mimic voluntary activity by swallowing or by moving the tongue up. There was no relationship between the start of activity and the interval to achieving maximal activity.

CONCLUSION

Hemihypoglossal-facial nerve anastomosis is a safe procedure and it is an optimal solution for cases lacking a proximal stump or in the case of reconstruction in the second stage. Electromyography can predict initial reinnervation activity after reconstructive procedures. During subsequent follow-up it can help to discover insufficiently recovering patients, however clinical characteristics are crucial.

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

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

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

Introduction

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

Presentation of case

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

Conclusion

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

•

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

•

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

•

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of axonal sprouting and motor performance after hypoglossal-facial end-to-side nerve repair: experimental study in rats

Hypoglossal-facial nerve anastomosis (HFA) aims to reanimate denervated mimic muscles with hypoglossal axons when the transected facial nerve is not accessible. The aim of this study was to evaluate the recovery of HFA using a "Y" tube in two variants: (1) the proximal stump of the hypoglossal nerve was entubulated to the "Y" tube (classic "Y" tube HFA) and (2) the "Y" tube was sutured to an epineurial window of a slightly damaged hypoglossal nerve (end-to-side "Y" tube HFA). A total of 48 adult female rats were divided into four groups: intact controls (group 1), sham operated (group 2), classic "Y" tube HFA (group 3) and end-to-side "Y" tube HFA (group 4). The abdominal aorta with both common iliac arteries of isogeneic male rats served as the Y-tube conduit. Animals from group 4 recovered better than those from group 3: the degree of collateral axonal branching (3 ± 1%) was significantly lower than that determined in group 3 (13 ± 1%). The mean deviation of the tongue from the midline was significantly smaller in group 4 (6 ± 4°) than that measured in animals from group 3 (41 ± 6°). In the determination of vibrissal motor function in group 3 and group 4, a decrease in amplitude was found to be - 66% and - 92%, respectively. No differences in the reinnervation pattern of the target muscles were detected. As a result, these surgical models were not determined to be able to improve vibrissal movements. It was concluded that performance of end-to-side "Y" tube HFA diminishes collateral axonal branching at the lesion site, which in turn, promotes better recovery of tongue- and vibrissal-motor performance.

Functional Outcome and Quality of Life After Hypoglossal-Facial Jump Nerve Suture

Background: To evaluate the face-specific quality of life after hypoglossal-facial jump nerve suture for patients with long-term facial paralysis.

Methods: A single-center retrospective cohort study was performed. Forty-one adults (46% women; median age: 55 years) received a hypoglossal-facial jump nerve suture. Sunnybrook and eFACE grading was performed before surgery and at a median time of 42 months after surgery. The Facial Clinimetric Evaluation (FaCE) survey and the Facial Disability Index (FDI) were used to quantify face-specific quality of life after surgery.

Results: Hypoglossal-facial jump nerve suture was successful in all cases without tongue dysfunction. After surgery, the median FaCE Total score was 60 and the median FDI Total score was 76.3. Most Sunnybrook and eFACE grading subscores improved significantly after surgery. Younger age was the only consistent independent predictor for better FaCE outcome. Additional upper eyelid weight loading further improved the FaCE Eye comfort subscore. Sunnybrook grading showed a better correlation to FaCE assessment than the eFACE. Neither Sunnybrook nor eFACE grading correlated to the FDI assessment.

Conclusion: The hypoglossal-facial jump nerve suture is a good option for nerve transfer to reanimate the facial muscles to improve facial motor function and face-specific quality of life.

Surgical Outcomes of Intratemporal Facial Nerve Schwannomas According to Facial Nerve Manipulation

OBJECTIVES

The aim of this study was to evaluate the preoperative and postoperative facial nerve (FN) function in patients with FN schwannoma (FNS) and analyze the duration of preoperative facial palsy according to the preoperative and postoperative facial function.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 29 patients with FNS who underwent surgery. We evaluated the FN function according to the type of FN manipulation and location of the anastomoses in the cable nerve graft, and we also analyzed the duration of facial palsy according to the facial function before and after surgery.

RESULTS

All 4 patients who underwent nerve-stripping surgery had the House-Brackmann (H-B) Grade III, 12 of 21 who underwent a cable nerve graft had the H-B Grade III or better postoperatively, and all 4 who underwent a hypoglossal facial crossover had the H-B Grade IV. Patients who underwent cable nerve grafting were more likely to have better FN function when the proximal anastomosis site was located in the internal auditory canal, geniculate ganglion, tympanic segment of FN, and distal end in the mastoid segment of FN. The duration of preoperative facial palsy was statistically shorter in patients with better postoperative facial function.

CONCLUSION

Surgery can be considered in patients with FNS who have the H-B Grade III or worse. A shorter duration of facial palsy prior to surgery resulted in better postoperative facial function.

Hypoglossal Facial Nerve Anastomosis for Post-Operative and Post-Traumatic Complete Facial Nerve Paralysis

AIM:

This study aims to evaluate the outcome of patients with complete facial paralysis following surgery to cerebellopontine angle tumours or following traumatic petrous bone fractures after reanimation by hypoglossal-facial anastomosis as regards clinical improvement of facial asymmetry and facial muscle contractility as well as complications associated with hypoglossal-facial reanimation procedure.

METHODS:

This thesis included a prospective study to be carried out on 15 patients with unilateral complete lower motor neuron facial paralysis (11 patients after cerebellopontine angle tumour resection and 4 patients after traumatic transverse petrous bone fracture) operated upon by end to end hypoglossal-facial nerve anastomosis in Cairo university hospitals in the period between June 2015 and January 2017.

RESULTS:

At one year follow up the improvement of facial nerve functions were as follows: Three cases (20%) had improved to House Hrackmann grade II, eleven cases (73.33%) had improved to grade III, and one patient (6.66%) had improved to House Brackmann grade IV.

CONCLUSION:

Despite the various techniques in facial reanimation following facial nerve paralysis, the end to end hypoglossal-facial nerve anastomosis remains the gold standard procedure with satisfying results in cases of the viable distal facial stump and non-atrophic muscles. Early hypoglossal-facial anastomotic repair after acute facial nerve injury is associated with better long-term facial function outcomes and should be considered in the management algorithm.

Eyelid reanimation using crossface nerve graft: Relationship between surgical outcome and preoperative paralysis duration

BACKGROUND

To reanimate the mimetic muscles, crossface nerve graft (CFNG) is an effective surgical option. However, muscle atrophy after facial paralysis may influence the surgical result. We analyzed the relationship between surgical result and preoperative paralysis duration.

METHODS

We performed CFNG on 15 patients. The sural nerve was transferred between the affected and nonaffected sides of the zygomatic branch. Eyelid function and eyelid lid were evaluated using the modified House-Brackmann scale. The effects of age, sex, cause of facial paralysis, graft nerve length, and preoperative paralysis duration were evaluated.

RESULTS

The mean follow up period was 9.3 ± 3.3 (range 4-14) years. Eyelid closure was excellent in four patients, good in six, fair in one, and poor in four. Statistically, no significant difference was observed between those patients with excellent or good outcomes and fair or poor outcomes regarding age (40.9 ± 11.0 years vs. 22.6 ± 20.8; P = .067), sex (male/female = 2/8 vs. 3/2; P = .250), cause (tumor/trauma = 10/0 vs. 3/2; P = .095), and length of nerve graft (14.4 ± 0.8 cm vs. 13.8 ± 1.6 cm; P = .375). The average preoperative paralysis duration in the excellent/good patients was significantly shorter than that in the fair/poor patients (P = .005). All eight cases with preoperative paralysis of less than 6 months showed a marked excellent/good result. Two of the seven patients with preoperative paralysis was 6 months or longer marked fair/poor result. (P = .007).

CONCLUSIONS

To achieve successful results with CFNG, surgery should be performed within 6 months of the onset of paralysis.

Transposition of the Intratemporal Facial to Hypoglossal Nerve for Reanimation of the Paralyzed Face: The VII to XII TranspositionTechnique

IMPORTANCE

The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation.

OBJECTIVES

To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation.

DESIGN, SETTINGS, AND PARTICIPANTS

A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center.

MAIN OUTCOMES AND MEASURES

Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis.

METHODS

Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system.

RESULTS

All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction.

CONCLUSIONS AND RELEVENCE

Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites.

LEVEL OF EVIDENCE

4.

Facial reanimation using hypoglossal-facial nerve anastomosis after schwannoma removal

CONCLUSION

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

OBJECTIVE

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

METHOD

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

RESULTS

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

Hypoglossal-Facial Nerve Anastomosis: A Meta-Analytic Study

Objectives:

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

Methods:

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

Results:

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

Conclusions:

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

Atrophy of the tongue following complete versus partial hypoglossal nerve transection in a canine model

OBJECTIVES/HYPOTHESIS

The hypoglossal nerve (XII) has been used as a donor nerve in facial and laryngeal reinnervation. The purpose of this study was to investigate the neuromuscular changes that occur within the tongue following partial or complete transection of XII using a canine model.

STUDY DESIGN

Histopathological comparison of tongue denervation following two types of XII resection in a canine model.

METHODS

Ten adult canines underwent complete unilateral resection of XII or resection of only the medial terminal branch of the hypoglossal nerve (mXII). After 6 months of recovery, tongue specimens were analyzed histopathologically using whole cross-sections. Routine histologic sections were assessed by two neuropathologists blinded to the type of denervation. The cross-sectional area was calculated of both sides of the tongue, and the amount of myosin was quantified morphometrically using immunohistochemistry for myosin (antimyosin heavy chain, fast isotype). Statistical comparison between partial and complete denervation was performed using the Student t test.

RESULTS

Six months following XII transection, quantitative measures of the cross-sectional area of the tongue and content of myosin demonstrated severe muscle atrophy on the operated side of the tongue for both groups, compared to the nonoperated side. For partial transection involving only mXII, the degree of atrophy was less severe (P < .05).

CONCLUSIONS

This study provides new histological information demonstrating that partial resection of the hypoglossal nerve, sacrificing only the proximal medial branch of the hypoglossal nerve (mXII), results in less severe atrophy of the tongue than complete transection of the entire hypoglossal nerve.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:2689-2693, 2016.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Facial reanimations: part I--recent paralyses

Unilateral facial paralysis is a common condition: 1 in every 60 people will experience Bell's palsy during the course of their life, and the residual deficits are particularly problematic for those who do not spontaneously recover the function of the facial nerve. Functionally the most relevant defect is lack of corneal lubrication because of inability to close the eyelid or blink. Morphologically, this presents as obvious ptosis caused by absence of the muscle tone at rest. "Restitutio ad integrum" of a paralysed face by operation is currently impossible, but realistic targets are improvement of facial symmetry and partial recovery of closure of the eyelids and smiling. Movements of the forehead and lower lip tend to be neglected targets for intervention because they are of less functional importance. Recent paralyses are those in which the mimetic musculature may be reactivated by provision of neural input, and the time limit is generally 18-24 months. Electromyography helps to detect it by assessing the presence of muscular fibrillations. If those are not detectable paralyses are considered to be long-standing, and new musculature must be transferred into the face, generally by transplantation of a muscular free flap or of the temporalis muscle in several different ways. When the facial nerve has been severed by trauma or during operation, immediate reconstruction must be considered and the simplest and most efficient is direct neurorrhaphy. If an appreciable part of the nerve is missing and the proximal and distal nerve stumps do not meet, an interpositional nerve graft must be placed to guarantee neural continuity. When reconstruction of the total extracranial branch of the facial nerve is required, the thoracodorsal nerve has proved to be highly effective. In case immediate reconstruction cannot be accomplished and the trunk of the facial nerve is not available as a donor nerve, mimetic musculature may be reactivated by provision of new neural input. Strong inputs from the masseteric or hypoglossus nerves may be mixed with those that arise from branches of the contralateral facial nerve after 2 cross-face nerve grafts have been placed, and good functional recovery is generally obtained. Several ancillary procedures are required to improve the end results in most cases.

Comparison of Direct Side-to-End and End-to-End Hypoglossal-Facial Anastomosis for Facial Nerve Repair

BACKGROUND

The hypoglossal facial anastomosis (HFA) is the gold standard for facial reanimation in patients with severe facial nerve palsy. The major drawbacks of the classic HFA technique are lingual morbidities due to hypoglossal nerve transection. The side-to-end HFA is a modification of the classic technique with fewer tongue-related morbidities.

OBJECTIVES

In this study we compared the outcome of the classic end-to-end and the direct side-to-end HFA surgeries performed at our center in regards to the facial reanimation success rate and tongue-related morbidities.

METHODS

Twenty-six successive cases of HFA were enrolled. In 9 of them end-to-end anastomoses were performed, and 17 had direct side-to-end anastomoses. The House-Brackmann (HB) and Pitty and Tator (PT) scales were used to document surgical outcome. The hemiglossal atrophy, swallowing, and hypoglossal nerve function were assessed at follow-up.

RESULTS

The original pathology was vestibular schwannoma in 15, meningioma in 4, brain stem glioma in 4, and other pathologies in 3. The mean interval between facial palsy and HFA was 18 months (range: 0-60). The median follow-up period was 20 months. The PT grade at follow-up was worse in patients with a longer interval from facial palsy and HFA (P value: 0.041). The lesion type was the only other factor that affected PT grade (the best results in vestibular schwannoma and the worst in the other pathologies group, P value: 0.038). The recovery period for facial tonicity was longer in patients with radiation therapy before HFA (13.5 vs. 8.5 months) and those with a longer than 2-year interval from facial palsy to HFA (13.5 vs. 8.5 months). Although no significant difference between the side-to-end and the end-to-end groups was seen in terms of facial nerve functional recovery, patients from the side-to-end group had a significantly lower rate of lingual morbidities (tongue hemiatrophy: 100% vs. 5.8%, swallowing difficulty: 55% vs. 11.7%, speech disorder 33% vs. 0%).

CONCLUSION

With the side-to-end HFA technique the functional restoration outcome is at least as good as that following the classic end-to-end HFA, but the complications related to the complete hypoglossal nerve transection can be avoided. Best results are achieved if this procedure is performed within the first 2 years after facial nerve injury. Patients with facial palsy of longer duration also have the chance for good functional restoration after HFA.

Facial nerve trauma: evaluation and considerations in management

The management of facial paralysis continues to evolve. Understanding the facial nerve anatomy and the different methods of evaluating the degree of facial nerve injury are crucial for successful management. When the facial nerve is transected, direct coaptation leads to the best outcome, followed by interpositional nerve grafting. In cases where motor end plates are still intact but a primary repair or graft is not feasible, a nerve transfer should be employed. When complete muscle atrophy has occurred, regional muscle transfer or free flap reconstruction is an option. When dynamic reanimation cannot be undertaken, static procedures offer some benefit. Adjunctive tools such as botulinum toxin injection and biofeedback can be helpful. Several new treatment modalities lie on the horizon which hold potential to alter the current treatment algorithm.

[Facial paralysis surgery. Current concepts]

Facial palsy is a relatively common condition, from which most cases recover spontaneously. However, each year, there are 127,000 new cases of irreversible facial paralysis. This condition causes aesthetic, functional and psychologically devastating effects in the patients who suffer it. Various reconstructive techniques have been described, but there is no consensus regarding their indication. While these techniques provide results that are not perfect, many of them give a very good aesthetic and functional result, promoting the psychological, social and labour reintegration of these patients. The aim of this article is to describe the indications for which each technique is used, their results and the ideal time when each one should be applied.

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

Object

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

Methods

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

Results

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

Conclusions

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

Motoneurons innervating facial muscles after hypoglossal and hemihypoglossal-facial nerve anastomosis in rats

Hypoglossal-facial nerve anastomosis (HFA) is the most popular surgical procedure to reinnervate facial muscles after injury of the facial nerve. Section of the hypoglossus causes paralysis and atrophy of the hemi-tongue. In the attempt to overcome this consequence, the hemihypoglossal-facial nerve anastomosis (HHFA) has been proposed and only a half of the main trunk of the hypoglossus is connected to the distal stump of the facial nerve. In the rat, we have studied experimentally the anatomical nuclear changes after HFA and HHFA with the aim of establishing the quantitative motoneuron innervation of facial muscles obtained with each one of the two operative options. Horseradish peroxidase (HRP) injected in both types of anastomosis labeled not only hypoglossal motoneurons, but also facial motoneurons. HFA appeared to offer a significant quantitative motoneuron innervation higher than HHFA and then a higher probable better functional recovery. Both HFA and HHFA performed immediately after section of the facial nerve in rats did not result in a phenomenon of motor hyperinnervation. In our experimental model, the proximal facial nerve stump was coagulated at the stylomastoid foramen to avoid regeneration. Then, the labeled motoneurons into the facial nucleus could really be the expression of axonal projections from facial motoneurons to the hypoglossus nerve and facial muscles. No labeled motoneurons were seen contralaterally as we observed previously after section and repair of several nerves.

Hemihypoglossal nerve transfer for acute facial paralysis

Object

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

Methods

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

Results

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

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

Conclusions

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

Isolated hypoglossal schwannoma in a 9-year-old child

The authors report a case of an isolated schwannoma of left hypoglossal nerve in a 9-year-old girl. To the authors' knowledge, this is the first case report of hypoglossal nerve schwannoma in the pediatric population in the absence of neurofibromatosis Type 2. The patient presented with a 2-month history of morning nausea and vomiting with occasional daytime headaches. Magnetic resonance imaging and subsequent CT scanning revealed a dumbbell tumor with a belly in the lower third of the posterior fossa and head underneath the left jugular foramen. Its neck protruded through an expanded hypoglossal canal. Although the lesion bore radiological characteristics of a hypoglossal schwannoma, the absence of hypoglossal palsy and the apparent lack of such tumors in the pediatric population the preoperative diagnosis was not certain. The tumor was approached via a midline suboccipital craniotomy, and gross-total resection was achieved. Pathological examination confirmed the diagnosis of schwannoma. Blood and tumor tests for mutations in the NF2 gene were negative. Postoperative mild hypoglossal palsy recovered by the 3-month follow-up, and an MRI study obtained at 1 year did not show recurrence.

Bell's palsy and partial hypoglossal to facial nerve transfer: Case presentation and literature review

Background:

Idiopathic facial nerve palsy (Bell's palsy) is a very common condition that affects active population. Despite its generally benign course, a minority of patients can remain with permanent and severe sequelae, including facial palsy or dyskinesia. Hypoglossal to facial nerve anastomosis is rarely used to reinnervate the mimic muscle in these patients. In this paper, we present a case where a direct partial hypoglossal to facial nerve transfer was used to reinnervate the upper and lower face. We also discuss the indications of this procedure.

Case Description:

A 53-year-old woman presenting a spontaneous complete (House and Brackmann grade 6) facial palsy on her left side showed no improvement after 13 months of conservative treatment. Electromyography (EMG) showed complete denervation of the mimic muscles. A direct partial hypoglossal to facial nerve anastomosis was performed, including dissection of the facial nerve at the fallopian canal. One year after the procedure, the patient showed House and Brackmann grade 3 function in her affected face.

Conclusions:

Partial hypoglossal–facial anastomosis with intratemporal drilling of the facial nerve is a viable technique in the rare cases in which severe Bell's palsy does not recover spontaneously. Only carefully selected patients can really benefit from this technique.

Morphometric study of hypoglossal nerve and facial nerve on the submandibular region in korean

OBJECTIVE

This study was performed to determine the anatomical landmarks and optimal dissection points of the facial nerve (FN) and the hypoglossal nerve (HGN) in the submandibular region to provide guidance for hypoglossal-facial nerve anastomosis (HFNA).

METHODS

Twenty-nine specimens were obtained from 15 formalin-fixed adult cadavers. Distances were measured based on the mastoid process tip (MPT), common carotid artery bifurcation (CCAB), and the digastric muscle posterior belly (DMPB).

RESULTS

The shortest distance from the MPT to the stylomastoid foramen was 14.1±2.9 mm. The distance from the MPT to the FN origin was 8.6±2.8 mm anteriorly and 5.9±2.8 mm superiorly. The distance from the CCAB to the crossing point of the HGN and the internal carotid artery was 18.5±6.7 mm, and that to the crossing point of the HGN and the external carotid artery was 15.1±5.7 mm. The distance from the CCAB to the HGN bifurcation was 26.6±7.5 mm. The distance from the digastric groove to the HGN, which was found under the DMPB, was about 35.8±5.7 mm. The distance from the digastric groove to the HGN, which was found under the DMPB, corresponded to about 65.5% of the whole length of the DMPB.

CONCLUSION

This study provides useful information regarding the morphometric anatomy of the submandibular region, and the presented morphological data on the nerves and surrounding structures will aid in understanding the anatomical structures more accurately to prevent complications of HFNA.

Facial nerve damage following surgery for cerebellopontine angle tumours. Prevention and comprehensive treatment

Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20-70% of patients. Facial nerve paresis is observed in 10-40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.

Hemihypoglossal-facial nerve anastomosis for facial nerve palsy

BACKGROUND AND PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Split hypoglossal-facial nerve neurorrhaphy for treatment of the paralyzed face

BACKGROUND

Several methods of neural rehabilitation for facial paralysis using 12-7 transfers have been described. The purpose of this study is to report on a series for dynamic reinnervation of the paralyzed face by using a split 12-7 nerve transposition. The goals of this procedure are to minimize tongue morbidity and to provide good facial reinnervation.

METHODS

Prospective case series. Melolabial crease discursion, overall facial movement, and degree of tongue atrophy and mobility were recorded.

RESULTS

Thirteen patients underwent facial reanimation using a split hypoglossal-facial nerve transfer with postoperative follow-up to 58 months (range, 6-58 months). All patients achieved excellent rest symmetry and facial tone. Of 13 patients, 10 had measurable coordinated movement and discursion of their melolabial crease. Of 13 patients, 12 had mild to moderate ipsilateral tongue atrophy. The mean time to onset of visible reinnervation was 3 months.

CONCLUSION

Split hypoglossal-facial nerve transposition provides good rehabilitation of facial nerve paralysis with reduced lingual morbidity. Long-term rest symmetry and potential learned movement can be achieved. This technique may provide a favorable alternative to the traditional method of complete hypoglossal sacrifice or jump grafting.

Direct Facial-to-Hypoglossal Neurorrhaphy with Parotid Release

OBJECTIVE

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

DESIGN

Prospective cohort.

SETTING

Academic tertiary care referral center.

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Reanimation following facial palsy: present and future directions

BACKGROUND

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

METHODS

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

RESULTS AND CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rehabilitation after cranial base surgery

Recent advancements in skull base surgery to remove or diminish the size of cranial base tumors allow more to be done than ever before to preserve life for patients who have tumors in anatomic locations once considered unreachable without causing massive functional impairment or death. Nonetheless, the resulting outcome has a direct and serious impact on the quality of life of the patient. In this article on palliation, the authors focus on the rehabilitative techniques used in patients who have undergone extensive cranial base resection. These techniques can also be used to improve the life of patients who have not undergone surgery but suffer from poor quality of life because of the natural growth of the tumor.

Surgical results of the Hypoglossal-Facial nerve Jump Graft technique

BACKGROUND

The Hypoglossal-Facial nerve crossover has appeared as a surgical option for those scenarios where the facial nerve is injured in its intracranial course, but the conventional technique unequivocally leads to twelfth cranial nerve deficit. In recent years a number of different surgical approaches have been introduced with a view to avoiding the complete section of the hypoglossal nerve, such as the Jump Graft technique. This paper aims to present the results of the Hypoglossal-Facial nerve Jump Graft technique in relation to facial musculature reanimation capability and hemitongue function preservation.

METHODS

A retrospective analysis of the records of eight patients submitted to Hypoglossal-Facial nerve Jump Graft technique was performed. The surgical approach was characterised by the interposition of a short graft sutured to the distal stump of the transected facial nerve and sutured end-to-side to the hypoglossi, with cutting of only a third of the diameter of the latter.

FINDINGS

The facial nerve injuries were secondary to temporal bone trauma in five cases and to cerebellopontine angle tumour surgery in three. Grafts were harvested from the greater auricular nerve in six patients and from the sural nerve in two. The results of facial reanimation demonstrated facial symmetry and improvement in the facial tone in all cases, and classified as House-Brackmann grade IV in three (37.5%) and grade III in five (62.5%) patients. There was no incidence of definitive hemitongue atrophy and no patient complaint of swallowing or speech difficulty.

CONCLUSIONS

The modification of the conventional technique of Hypoglossal-Facial nerve anastomosis by means of sectioning one third of the hypoglossal nerve area does not lead to dysfunction of this nerve and the surgical results in terms of facial reanimation are satisfactory.

Facial reanimation by means of the hypoglossal nerve: anatomic comparison of different techniques

OBJECTIVE

The goal of this study was to determine the various anatomical and surgical relationships between the facial and hypoglossal nerves to define the required length of each for a nerve transfer, either by means of a classical hypoglossal-facial nerve anastomosis or combined with any of its variants developed to reduce tongue morbidities.

METHODS

Five adult cadaver heads were bilaterally dissected in the parotid and submaxillary regions. Two clinical cases are described for illustration.

RESULTS

The prebifurcation extracranial facial nerve is found 4.82 +/- 0.88 mm from the external auditory meatus, 5.31 +/- 1.50 mm from the mastoid tip, 15.65 +/- 0.85 mm from the lateral end of C1, 17.19 +/- 1.64 mm from the border of the mandible condyle, and 4.86 +/- 1.29 mm from the digastric muscle. The average lengths of the mastoid segment of the facial nerve and the prebifurcation extracranial facial nerve are 16.35 +/- 1.21 mm and 18.93 +/- 1.41 mm, respectively. The average distance from the bifurcation of the facial nerve to the hypoglossal nerve turn is 31.56 +/- 2.53 mm. For a direct hypoglossal-facial nerve anastomosis, a length of approximately 19 mm of the hypoglossal nerve is required. For the interposition nerve graft technique, a 35 mm-long graft is required. For the technique using a longitudinally dissected hypoglossal nerve, an average length of 31.56 mm is required. Exposure of the facial nerve within the mastoid process drilling technique requires 16.35 mm of drilling.

CONCLUSION

This study attempts to establish the exact graft, dissection within the hypoglossal nerve, and mastoid drilling requirements for hypoglossal to facial nerve transfer.