Complete Facial Paralysis Caused by Stabbing With a Car Key at the Stylomastoid Foramen

Non-iatrogenic traumatic facial paralysis is most common in intratemporal facial nerve injury caused by temporal bone fracture, followed by intraparotid facial nerve branch injury. Facial paralysis caused by injury to the extratemporal trunk of the facial nerve is extremely rare. We present a case of a 60-year-old man suffering from immediate complete left peripheral facial paralysis due to blunt transection of extratemporal trunk of facial nerve by stabbing with a car key. There was a facial nerve defect about 1 cm in length. The great auricular nerve was grafted to repair the facial nerve. Over 12 months, his facial nerve function improved to a House-Brackmann III/VI.

Ocular-oral synkinesis caused by partial injury of the zygomatic and buccal branches of the facial nerve after mid-face trauma

BACKGROUND

Facial nerve paralysis induced by acute traumatic facial nerve injuries limited to the zygomatic and buccal branches shows unique complications, such as strong co-contractions of the lower facial muscles around the lips during voluntary blinking (ocular-oral synkinesis). We investigated the characteristics of facial complications after facial nerve injury in the mid-face area and reported the treatment results.

METHODS

A total of 21 patients with facial nerve injuries to the zygomatic and/or buccal branches were evaluated for the degree of facial synkinesis and mouth asymmetry. Patients with mild-to-moderate symptoms were treated using physical rehabilitation therapy combined with botulinum toxin (Botox) injection, and patients with severe or uncontrolled symptoms were treated using surgical therapy.

RESULTS

Initial/final mean synkinesis scores and mouth asymmetry degrees were 2.17/1.75 and 0.85/0.66 in the physical therapy group and 3.11/0.78 and 2.41/-0.31 in the surgery group, respectively. Physical therapy with Botox injection alone did not show significant improvements in synkinetic symptoms of the patients with mild-to-moderate synkinesis (p > 0.05), whereas surgical therapy resulted in significant improvements in synkinesis and mouth asymmetry (p < 0.05).

CONCLUSIONS

Surgical treatment is an effective adjustment procedure for the management of facial complications in patients with severe or uncontrolled synkinesis after facial nerve injury to the mid-face area.

Totally endoscopic transcanal facial nerve decompression in patients with traumatic facial nerve paralysis: from geniculate ganglion to mastoid segment

OBJECTIVE

The current study evaluated the effectiveness of endoscopic transcanal facial nerve decompression in patients with post-traumatic facial nerve paralysis.

METHODS

This retrospective study included 10 patients with post-traumatic complete facial nerve paralysis who underwent endoscopic transcanal facial nerve decompression. The surgical technique was explained step by step, and the surgical complications, hearing status and facial nerve function 12 months post-operatively were reported.

RESULTS

Endoscopic transcanal facial nerve decompression allowed exposure of the geniculate ganglion to the mastoid segment. The facial nerve function improved from House-Brackmann grade VI to grades I and II in 8 of 10 (80 per cent) patients, and 2 patients experienced partial recovery (House-Brackmann grades III and IV). No severe complication was reported.

CONCLUSION

Endoscopic transcanal facial nerve decompression, involving the nerve from the geniculate ganglion to the mastoid segment, is a safe and effective approach in patients with post-traumatic facial nerve paralysis.

Long-term outcomes of facial nerve decompression by transmastoid versus middle cranial fossa approach for traumatic facial paralysis

OBJECTIVES

To evaluate and compare the long-term results of patients who underwent facial nerve decompression surgery with either transmastoid-supralabyrinthine (TMSL) or combined transmastoid- middle cranial fossa (MCF) approach for traumatic facial nerve paralysis.

MATERIALS AND METHODS

This is a single-center retrospective case-control study. The medical records of traumatic facial paralysis patients with House Brackmann (HB) Grade 6 who underwent facial nerve decompression surgery at via either TMSL or MCF approach between January 2011 and December 2017 were reviewed. The patients who had otic capsule involvement and total sensorineural hearing loss, therefore underwent translabyrinthine facial nerve decompression, and the patients follow-up period has not yet reached four years were excluded from the study. Postoperative HB score and hearing status were compared.

RESULTS

Eleven patients were operated with MCF approach (group 1), while 9 patients with TMSL approach (group 2). Average age of patients was 20.04 + 15.2 (range:4-47) years. Three (15 %) patients were female, while 17 (85 %) was male. Geniculate ganglion (90 %) was the most affected segment of the facial nerve. Facial nerve edema was observed in all cases, while intraneural hematoma were encountered in 4 (20 %) cases. Statistically significant improvement in median HB scores were reached in both groups, and no significant difference was observed in post-operative HB scores between both techniques. No significant difference in median AC 0,5-4 khZ and BC 0,5-3 kHz thresholds was observed between both techniques.

CONCLUSION

Even middle fossa approach is the best surgical technique to explore geniculate ganglion and labyrinthine segment of facial nerve, the functional results of transmastoid supralabrynthine approach, which is not needed craniotomy with low complication rate are as successful as middle fossa approach in selected patients.

Facial Reanimation After Peripheral Facial Nerve Paralysis: A Single-institution Surgical Experience

Facial nerve trauma occasionally develops during oral and maxillofacial surgery. This study was aimed at enhancing the available knowledge on facial nerve reanimation correlated to surgery and proposing our surgical algorithm. We retrospectively analyzed medical records of patients who underwent facial reanimation surgery at our hospital. The inclusion criterion was surgery for facial reanimation from January 2004 to June 2021. We included 383 eligible patients who underwent facial reanimation surgery. Trauma or maxillofacial neoplasms were noted in 208 of 383 and 164 of 383 cases, respectively. In 238 of 383 cases, nerve branches were likely more vulnerable. Facial nerve anastomosis was performed in 256 patients. Sixty-eight patients received nerve grafts. In 22 patients, distal facial nerve transfer to the masseteric nerve, sublingual nerve, or contralateral facial nerve was performed. Twenty-five patients received static surgery; in most cases, the temporalis fascia flap (20/25) was used. The nerve function outcomes were HB grade I (n=17), Grade Ⅱ (n=108), Grade Ⅲ (n=118), Grade Ⅳ (n=94), and Grade V (n=46). The mean follow-up time was 4.88 ± 3.93 years. Facial paralysis caused by trauma ( P =0.000), branch injury ( P =0.000), and the primary reconstruction of facial nerve ( P =0.000) were predictive of favorable treatment outcomes. Although facial nerve injury caused by trauma was more likely, cases of interference in facial expression could be limited, and so did the injury to branches. Nerve anastomosis was prioritized if a tension-free suture was possible. Maintaining the integrity of the nerve and shortening the duration of mimetic muscular denervation were crucial.

Neural networks for estimation of facial palsy after vestibular schwannoma surgery

PURPOSE

Facial nerve damage in vestibular schwannoma surgery is associated with A-train patterns in free-running EMG, correlating with the degree of postoperative facial palsy. However, anatomy, preoperative functional status, tumor size and occurrence of A-trains clusters, i.e., sudden A-trains in most channels may further contribute. In the presented study, we examine neural networks to estimate postoperative facial function based on such features.

METHODS

Data from 200 consecutive patients were used to train neural feed-forward networks (NN). Estimated and clinical postoperative House and Brackmann (HB) grades were compared. Different input sets were evaluated.

RESULTS

Networks based on traintime, preoperative HB grade and tumor size achieved good estimation of postoperative HB grades (chi2 = 54.8), compared to using tumor size or mean traintime alone (chi2 = 30.6 and 31.9). Separate intermediate nerve or detection of A-train clusters did not improve performance. Removal of A-train cluster traintime improved results (chi2 = 54.8 vs. 51.3) in patients without separate intermediate nerve.

CONCLUSION

NN based on preoperative HB, traintime and tumor size provide good estimations of postoperative HB. The method is amenable to real-time implementation and supports integration of information from different sources. NN could enable multimodal facial nerve monitoring and improve postoperative outcomes.

Amer's classification of territories of facial nerve injury in early cases and strategies for the management of different territories

Early cases of facial nerve injury are best treated by restoring the neural pathway to the same existing facial muscles. Knowledge of the exact territory of facial nerve injury is required to design a plane for the reconstruction of these injuries and to compare results. The current study aims to design a classification system for territories of facial nerve injury based on the location of nearest healthy fascicles to the site of injury both proximally and distally. Two hundred-one patients with early facial nerve injury were assessed for treatment. According to the results of the exploration, 13 territories of injury were identified. The management strategy was planned according to the territory of injury. The current classification system is a simple, easy and effective method for the classification of territories of facial nerve injury. The classification system accurately describes the nearest possible healthy proximal and distal fascicles and can be employed to easily report cases and implement a management plan. This classification scheme also allows us to more effectively compare results.

Topical insulin in neurotrophic keratopathy after resection of acoustic neuroma

CASE REPORT

A patient with a history of surgical resection of an acoustic neuroma presented with involvement of both the left facial nerve and the left trigeminal nerve. She initially consulted for exposure keratitis, but two weeks later presented with an infectious keratitis. After taking the corneal sample, she presented with persistent epithelial defect, which did not respond to medical management. Topical insulin was indicated, and a decrease in the area of the lesion was seen in the following 5 days. A therapeutic contact lens was also placed at that time and finally, two weeks after the initiation of insulin, the epithelial defect completely closed.

DISCUSSION

This was a complex case due to the confluence of facial paralysis, neurotrophic keratitis, and infectious keratitis, which finally had a successful outcome. Topical insulin can be an effective adjuvant therapy in cases of neurotrophic ulcers that do not respond to standard therapy.

An Experimental Study on the Optimal Timing for the Repair of Incomplete Facial Paralysis by Hypoglossal-facial 'Side'-to-side Neurorrhaphy in Rats

OBJECTIVE

To investigate the optimal timing for the repair of persistent incomplete facial paralysis by hypoglossal-facial 'side'-to-side neurorrhaphy in rats.

METHODS

A total of 30 adult rats with crushed and bulldog-clamped facial nerve injury were randomly divided into 5 groups (n = 6 each) that were subjected to injury without nerve repair or with immediate repair, 2-week-delayed repair, 4-week-delayed repair, or 8-week-delayed repair. Three months later, the effects of repair in each rat were evaluated by facial symmetry assessment, electrophysiological examination, retrograde labeling, and axon regeneration measurement.

RESULTS

At 3 months after injury, the alpha angle significantly increased in the group of rats with 4-week-delayed repair compared with the other four groups. Upon stimulation of the facial nerve or Pre degenerated nerve, the muscle action potentials MAPs were recorded in the whisker pad muscle, and the MAP amplitude and area under the curve in the 4-week-delayed repair group were significantly augmented at 3 months post-injury. Similarly, the number of retrograde-labeled motor neurons in the facial and hypoglossal nuclei was quantified to be significantly greater in the 4-week-delayed repair group than in the other groups, and a large number of regenerated axons was also observed.

CONCLUSION

The results of this study demonstrated that hemiHN-FN neurorrhaphy performed 4 weeks after facial nerve injury was most effective in terms of the functional recovery of axonal regeneration and activation of facial muscles.

Reliability of temporal bone high-resolution CT in patients with facial paralysis in temporal bone fracture

OBJECTIVE

This study aimed to investigate the reliability of temporal bone high-resolution CT (HRCT) in patients with traumatic facial paralysis.

METHODS

HRCT with cross-sectional scanning and multi-planar reformation (MPR) was performed on 26 cases with traumatic facial paralysis, and the preoperative imaging manifestations were compared with surgical findings.

RESULTS

Preoperative HRCT revealed fallopian canal damage at the posterior genu in 1 case, geniculate ganglion in 22 cases, labyrinthine segment in 4 cases, tympanic segment in 13 cases and mastoid segment in 0 case, while surgical findings confirmed fallopian canal damage at the posterior genu in 7 cases, geniculate ganglion in 23 cases, labyrinthine segment in 4 cases, tympanic segment in 17 cases and mastoid segment in 7 cases. The accuracy of temporal bone HRCT in revealing damage at those segments of fallopian canal was 14.3%, 95.7%, 100%, 76.5, and 0%, respectively.

CONCLUSION

Temporal bone HRCT can generally estimate the extent of damage and provide important information for traumatic facial paralysis before surgery. However, it is unreliable in revealing the damage of fallopian canal at the posterior genu and mastoid segment.

Facial Nerve Paresis: Case Report of Blunt Facial Nerve Injury

Facial nerve paresis is an uncommon but concerning condition in the pediatric population. The function and anatomy of the facial nerve is complex, and injuries to this structure may be associated with devastating physiological and psychological implications for the affected child and family. The purpose of this paper was to report a case involving a six-year-old Caucasian female who suffered a blunt traumatic injury to the orofacial region resulting in partial paralysis of the seventh cranial nerve. Following the injury, the child was unable to fully elevate the corner of her mouth. The deficit occurred immediately, and she experienced a prolonged course of recovery.

The histopathological and electrophysiological effects of thymoquinone and methylprednisolone in a rabbit traumatic facial nerve paralysis model

OBJECTIVE

We aimed to determine the effects of methylprednisolone and thymoquinone on nerve healing in a traumatic facial nerve paralysis animal model.

SUBJECTS AND METHODS

Twenty-four rabbits were randomly divided into 4 groups: group I: control group received no medication and no trauma; group II: sham group received no medication after facial nerve trauma group III: 5mg/kg/day thymoquinone administered; group IV: 1mg/kg/day methylprednisolone administered. An initial electrophysiological assessment was performed in all the animals. The buccal branch of the facial nerve was then clipped to form a traumatic facial paralysis model. The drugs were administered for two weeks once a day. At the end of the second month, the electrophysiological assessments were performed and the distal part of the traumatic facial nerve were dissected and examined under light microscopy.

RESULTS

Best nerve regeneration was observed in the control and the thymoquinone groups, respectively, whereas the weakest regeneration was determined in the sham group. Thymoquinone and methylprednisolone significantly increased nerve recovery, as measured by histopathological scores and electrophysiological assessment. In the thymoquinone group, due to postoperative amplitude, axon diameter and thickness of myelin sheath values were significantly further increased nerve regeneration compared to that of the methylprednisolone group and these values were close to those of the values of the control group.

CONCLUSION

Thymoquinone was slightly better than methylprednisolone for functional nerve recovery. The neuroprotective effect of thymoquinone was attributed to its antioxidant and anti-inflammatory effects. Thymoquinone can have a new treatment option to ameliorate the nerve injury.

[Differences in clinical features between cholesteatoma in external auditory meatus and middle ear]

OBJECTIVE

Differences in clinical features, especially facial nerve canal leision between cholesteatoma in external auditory meatus and middle ear were compaired.

METHOD

A retrospective clinical analysis was made. Clinical data included 125 cases of middle ear cholesteatoma with facial nerve canal leision and 28 cases of cholesteatoma occurred in external auditory canal from 2003-01-2014-08 in our hospital.

RESULT

Clinical course of cholesteatoma in external auditory canal was 4.97 ± 7.51 years, course of middle ear cholesteatoma was 16.60 ± 14.42 years (P < 0.01). 21 cases (75%) of external auditory canal cholesteatoma were manifested as pneumatic mastoid and 110 cases (88%) of middle ear cholesteatoma were manifested as diploic mastoid respectively. 22 cases (78.6%) of facial nerve canal damage-in mastoid segment in cholesteatoma of external auditory meatus and 76 cases (60.8%) of facial nerve canal damage in tympanic segment in cholesteatoma of middle ear were observed (P < 0.01). The incidence rate of ossicular errosion in middle ear chol-esteatoma was significantly higher than that in external auditory meatus (P < 0.01). The incidence of semicircular canal defects in middle ear cholesteatoma (30.4%), was significantly higher when comparing to the incidence (10.7%) in cholesteatoma of external auditory meatus (P < 0.05).

CONCLUSION

The site of facial nerve canal lesion in middle ear cholesteatoma and cholesteatoma of external auditory meatus were different. More attention should be paid before and during operation to avoid facial nerve injury, including physical examinations, especial otologic exams, radiological reading and careful operation.

Isolated marginal facial nerve paresis after TMJ discopexy: a case report

Isolated marginal facial nerve paresis after TMJ discopexy: a case report. This is the first report of a transient, isolated marginal facial nerve paresis after temporomandibular joint arthrotomy. The paresis seems to have resulted from a crush lesion by Backhaus forceps, placed transcutaneously during the operation to distract the intra-articular space.

Postparotidectomy facial nerve paralysis: peripheral versus proximal identification

OBJECTIVES

Facial nerve palsy is a distressing complication of parotid surgery. We determined to analyse parotid surgery outcomes in a district general hospital in order to identify our own risk factors leading to increased incidence of facial nerve palsy. Primarily, we aimed to determine the efficacy of peripheral versus proximal facial nerve identification in preventing facial nerve damage.

METHODS

This was a retrospective study of hospital records. The records of sixty-four patients aged between 32 and 84 years who had attended our Otolaryngology department over a six-year period were analysed, with notes made of operative procedure, identification of the facial nerve and post-operative facial nerve palsy. The Neurosign400 facial nerve monitor was used and the degree of facial nerve paralysis was assessed using the House Brackmann (HB) classification of facial nerve paralysis.

RESULTS

Sixty-four patients underwent parotidectomy. Thirty-two patients had the peripheral branch of the facial nerve identified while another thirty-two patients had proximal nerve identification. Six patients had HB 2 facial nerve palsy, but all completely recovered within six months. Four out of the six patients had peripheral identification of the facial nerve.

CONCLUSIONS

Although peripheral versus proximal identification of the facial nerve was associated with greater incidence of temporary facial nerve paralysis, all the patients recovered within six months. This study may indicate that exposing a peripheral branch of the facial nerve with the help of Neurosign400 is a useful way of performing parotidectomy where proximal identification of a nerve is not possible.

Immunodeficiency impairs re-injury induced reversal of neuronal atrophy: relation to T cell subsets and microglia

Following facial nerve resection in the mouse, a substantial number of neurons reside in an atrophied state (characterized by cell shrinkage and decreased ability to uptake Nissl stain), which can be reversed by re-injury. The mechanisms mediating the reversal of neuronal atrophy remain unclear. Although T cells have been shown to prevent neuronal loss following peripheral nerve injury, it was unknown whether T cells play a role in mediating the reversal of axotomy-induced neuronal atrophy. Thus, we used a facial nerve re-injury model to test the hypothesis that the reversal of neuronal atrophy would be impaired in recombinase activating gene-2 knockout (RAG-2 KO) mice, which lack functional T and B cells. Measures of neuronal survival were compared in the injured facial motor nucleus (FMN) of RAG-2 KO and wild-type (WT) mice that received a resection of the right facial nerve followed by re-injury of the same nerve 10 weeks later ("chronic resection+re-injury") or a resection of the right facial nerve followed by sham re-injury of the same nerve 10 weeks later ("chronic resection+sham"). We recently demonstrated that prior exposure to neuronal injury elicited a marked increase in T cell trafficking indicative of a T cell memory response when the contralateral FMN was injured later in adulthood. We examined if such a T cell memory response would also occur in the current re-injury model. RAG-2 KO mice showed no reversal of neuronal atrophy whereas WT mice showed a robust response. The reversal of atrophy in WT mice was not accompanied by a T cell memory response. Although the number of CD4(+) and CD8(+) T cells in the injured FMN did not differ from each other, double-negative T cells appear to be recruited in response to neuronal injury. Re-injury did not result in increased expression of MHC2 by microglia. Our findings suggest that T cells may be involved in reversing the axotomy-induced atrophy of injured neurons.

The role of botulinum toxin in the management of head and neck cancer patients

PURPOSE OF REVIEW

In this review article different relevant applications of botulinum toxin type A are demonstrated in patients with head and neck cancer.

RECENT FINDINGS

Patients with head and neck cancers of different etiologies often suffer from disorders concerning their musculature (for example, synkinesis in mimic muscles) or gland secretion in the head and neck region. This leads to many problems and reduces their quality of life. The application of botulinum toxin type A can improve movement disorders like synkinesis following reconstructive surgery in patients with cancers of the parotid gland, spasms of the pharyngo-esophageal musculature following laryngectomies and disorders of the autonomous nerve system like hypersalivation, hyperlacrimation and pathological sweating.

SUMMARY

The application of botulinum toxin type A is a helpful and minimally invasive treatment option in different functional disorders improving the quality of life in patients with head and neck cancers of different etiologies. Side effects are rare.

Mechanical stimulation of paralyzed vibrissal muscles following facial nerve injury in adult rat promotes full recovery of whisking

Many patients suffer lifelong disabilities after peripheral nerve injury. Insufficient recovery has been attributed to excessive axonal branching, axonal regrowth to improper targets and polyneuronal reinnervation of motor endplates. We used the rat facial nerve transection/suture model to quantify the effects of mechanical stimulation on the paralyzed whisker musculature. "Manual" stimulation involved briskly stroking the whiskers by hand in a manner that specifically mimicked normal whisker movement. "Environmental" stimulation involved enhanced whisker use as rats encountered objects in an enriched environment. Manual and environmental stimulation were also combined. Video-based motion analysis of vibrissal motor performance showed that daily manual, but not environmental, stimulation for 2 months resulted in full recovery of whisking. Polyneuronal reinnervation of motor endplates was reduced but not misdirected axonal regrowth. Our findings indicate the potential of use-specific training to enhance appropriate functional outcome after peripheral nerve injury and may be useful in a clinical rehabilitation setting.

Revision Facial Nerve Surgery

Transection of the facial nerve can result from blunt or penetrating trauma to the face or temporal bone. It can also occur accidentally during surgery, or as a planned surgical procedure carried out in the interest of eradicating disease. If transection is recognized at surgery, direct anastomosis or cable grafting is the procedure of choice. This article presents two cases with neither clinical nor electrical evidence of recovery. The authors review current understanding of the changes that occur in the neuron, axon, and muscle after injury to the nerve and the underlying pathology that led to graft failure in these cases. They also evaluate surgical options and diagnostic test results that help in selecting appropriate surgical procedures.

Differential effects of hypoglossal and facial nerve injuries on survival and growth of rats at different developmental stages

The hypoglossal (XII) nerve is made up of functionally different nerve branches: the medial branch related to protrusion of the tongue and the lateral branch related to its retraction. The present study was performed to determine the effects of facial (VII) and XII nerve injuries on the survival and growth of rats in which the unilateral or bilateral VII and XII nerve components (main trunk, XII-trunk; medial branch, XII-med; lateral branch, XII-lat) had been resected at different developmental stages. In the suckling period, unilateral as well as bilateral injuries in the XII-trunk or XII-med nerve produced disturbed milk intake, lower survival rates and growth retardation in the nerve-injured rats. In the transition and mastication periods, only bilateral injury in the XII-trunk or XII-med nerve produced disturbed food intake followed by lower survival rates and growth retardation in those animals. The unilateral XII-lat nerve injury did not have significant effects on milk and food intake, whereas the bilateral injury caused disturbance in milk intake especially at the early neonatal stage. The unilateral VII nerve injury at the early neonatal stage caused deteriorating effects on food intake resulting in lower survival rate and severe growth retardation in the nerve-injured rats. The results indicate that the survival and growth of XII and VII nerve-resected rats differ considerably depending on the nerves injured and the developmental ages of the animals at the time of nerve insult.

Motor neuronal and glial apoptosis in the adult facial nucleus after intracranial nerve transection

Object

Intracranial lesions affecting the facial nerve are usually associated with significant morbidity and poor functional restitution, despite the fact that a peripheral nerve injury normally recovers well. Mechanistic explanations are needed to direct future therapies. Although neonatal motor neurons are known to die as a result of apoptosis after axotomy, this cell death mechanism has not been explicitly demonstrated after peripheral cranial nerve transection in adult mammals.

Methods

The authors induced substantial retrograde neuronal death in the adult rodent by transecting the facial nerve during its intracranial course. Neuronal apoptosis was demonstrated as shrunken facial motor neurons, retrogradely labeled with fluorogold and with nuclei positively labeled by terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick–end labeling (TUNEL). Glial apoptosis was demonstrated by double labeling with respect to cell type.

On postinjury Days 7 and 14, the intracranial axotomy led to neuronal apoptosis, corresponding to a neuronal loss that was observed quantitatively in cresyl violet–stained tissue sections obtained using a stereological method. In contrast, no neuronal apoptosis was observed after creating a distal lesion of the facial nerve, which causes less neuronal loss. In addition, glial apoptosis was seen in the facial nucleus after both distal and proximal axotomy. Whereas the proximal intracranial axotomy led to TUNEL-positive nuclei in cells showing markers for oligodendrocytes and microglia, only the latter glial cell population was double labeled with TUNEL-positive nuclei after distal lesioning.

Conclusions

These findings may ultimately lead to new therapeutic strategies in patients suffering from facial nerve palsy due to an intracranial lesion.

[Peripheral paralysis of facial nerve in children]

Peripheral facial paresis is one of the most common diagnosed neuropathies in adults and also in children. Many factors can trigger facial paresis and most frequent are infectious, carcinoma and demyelinisation diseases. Very important and interesting problem is an idiopathic facial paresis (Bell's palsy). Actually the main target of scientific research is to assess the etiology (infectious, genetic, immunologic) and to find the most appropriate treatment.

Temporalis Fascia in the Management of Gold Eyelid Weight Extrusion

A patient with a traumatic facial nerve palsy and resulting paralytic lagophthalmos underwent surgical implantation of a gold weight load, which extruded 4 weeks after surgery. Cicatricial contraction of the anterior lamella developed, and a full-thickness skin graft was used to correct the cicatrix. A second gold weight loading procedure was then undertaken with a temporalis fascia drape added to reduce the risk of extrusion. One year after surgery, there is no sign of migration or extrusion. Gold weight loading has emerged as the standard in management of paralytic lagophthalmos, with extrusion cited as the most serious complication. We propose temporalis fascia draping as an adjuvant procedure in the reimplantation of an extruded gold weight.

[Accuracy of the prognostic diagnosis in acute peripheral facial palsy]

The important factors in the prognostic diagnosis of acute peripheral facial palsy are (1) the causal disease, (2) the site of injury and (3) the degree of injury, although the age of the patient, complication, treatment method and initial day of treatment are also important. Among these 3 factors, the degree of injury is most strongly related to the prognosis. However, the diagnosis of etiology is the most important for the selection of the treatment method. Above all, the differential diagnosis between Bell's palsy and zoster sine herpete (Ramsay Hunt syndrome), is the most significant. However, it is impossible to diagnose all patients with complete accuracy within 3 days after the onset of palsy, even using molecular biological examination including polymerase chain reaction analysis. The diagnosis of the site of injury does not contribute to the prediction of prognosis or the selection of treatment method, except for the determination of the approaching route of the facial nerve decompression for traumatic facial palsy. The scoring system of facial movement (40-point method), nerve excitability test (NET), electroneurography (ENoG), transcranial magnetic stimulation (TMS) and stapedial reflex (SR) are commonly used to estimate the degree of injury. To estimate the accuracy of these examinations, sensitivity and specificity of the tests were calculated according to the findings within 3 days after the onset of palsy and the outcome of 116 patients with Bell's palsy and 31 with Ramsay Hunt syndrome. According to the results, none of these tests seem to be a perfect diagnostic examination for the completely precise prediction of prognosis. However, a patient is predicted to have a good prognosis, if the following 3 findings are observed: (1) more than 10 points in the 40-point scoring system of facial movement, (2) a positive response to TMS and (3) a positive response to SR. An antidromic facial nerve response probably contributes to a precise prediction of prognosis within 3 days after the onset of facial palsy.

Dental perspectives on neuropathic origin

The most common cause of intraoral pain is odontogenic and rarely presents a diagnostic challenge. Pain in a tooth site area that is not dental or periodontal in origin may be difficult to diagnose and treat. Successful management of non-odontogenic pain complaints is inherently dependent on taking a detailed 'pain history'. Treatments that are irreversible and potentially harmful to the underlying dentoalveolar structures must be avoided when the diagnosis is uncertain. Information gleaned from the pain history usually provides a provisional or working diagnosis, and this diagnosis must later be confirmed by specific testing (based on response to medication trials, imaging, laboratory tests, etc.). Patients who suffer from chronic pain conditions are likely to show comorbidity with other pain problems (e.g., neuropathic pain with background muscle discomfort or temporomandibular disorders and headache problems). Thus, in more complex patients, the various elements that comprise the chronic pain condition must be identified and managed, for adequate resolution of the symptoms.

Motoneuron degeneration after facial nerve avulsion is exacerbated in presymptomatic transgenic rats expressing human mutant Cu/Zn superoxide dismutase

We investigated motoneuron degeneration after proximal nerve injury in presymptomatic transgenic (tg) rats expressing human mutant Cu/Zn superoxide dismutase (SOD1). The right facial nerves of presymptomatic tg rats expressing human H46R or G93A SOD1 and their non-tg littermates were avulsed, and facial nuclei were examined at 2 weeks postoperation. Nissl-stained cell counts revealed that facial motoneuron loss after avulsion was exacerbated in H46R- and G93A-tg rats compared with their non-tg littermates. The loss of motoneurons in G93A-tg rats after avulsion was significantly greater than that in H46R-tg rats. Intense cytoplasmic immunolabeling for SOD1 in injured motoneurons after avulsion was demonstrated in H46R- and G93A-tg rats but not in their littermates. Facial axotomy did not induce significant motoneuron loss nor enhance SOD1 immunoreactivity in these tg rats and non-tg littermates at 2 weeks postoperation, although both axotomy and avulsion elicited intense immunolabeling for activating transcription factor-3, phosphorylated c-Jun, and phosphorylated heat shock protein 27 in injured motoneurons of all these animals. The present data indicate the increased vulnerability of injured motoneurons after avulsion in the presymptomatic mutant SOD1-tg rats.

A Comparison of Temporalis Transfer and Free Latissimus Dorsi Transfer in Lower Facial Reanimation Following Unilateral Longstanding Facial Palsy

The ultimate goal in the treatment of facial palsy is the restoration of voluntary and spontaneous movement to the paralyzed side of the face, symmetrical to the normal side. We report our experience treating 40 patients with established facial palsy over a 4-year period. All patients underwent either temporalis transfer or free latissimus dorsi transfer as a single stage to improve lower facial symmetry. We believe that both techniques reliably achieve an increase of movement in facial reanimation after oncological, traumatic, or congenital facial palsy.

Gunshot Wounds to the Facial Nerve

OBJECTIVE

This paper presents our experience with gunshot wounds to the temporal bone and discusses facial nerve lesions, surgical indication, surgical timing, and other findings.

STUDY DESIGN

We performed a retrospective review of patients treated for facial nerve lesion after gunshot injury to the temporal bone.

SETTING

The study was performed in the Otolaryngology Department of the University of Sao Paulo Medical School, Sao Paulo, Brazil.

PATIENTS

Ninety-eight patients treated between 1988 and 1999 were analyzed.

INTERVENTION

Facial nerve lesions, bullet locations, and surgical techniques were analyzed. Patients were monitored for 2 years.

RESULTS

Gunshot trauma to the temporal bone presented considerable tissue loss resulting from the abrasion effect and severity of the impact. The third segment of the facial nerve was most affected, and the bullet was typically found lodged in the mastoid tip. Postoperative infection was common. Such cases required revision surgery, resulting in worse cosmetic outcomes than in cases of closed trauma.

CONCLUSIONS

Surgical exploration of the facial nerve should be performed as soon as possible, since long delays increase the chance of traumatic neuroma and more pronounced scarring around the facial nerve. Open mastoidectomy with meatoplasty is the surgical technique recommended for repairing the mastoid and the facial nerve. In the majority of cases, a cable graft is necessary. Since nerve lesion in proximity to the stylomastoid foramen and extratemporal facial nerve is common, these areas must be explored carefully.

Botulinum toxin type A: fine-tuning treatment of facial nerve injury

Treatment of patients following facial nerve injury can be daunting. A multitude of procedures have been developed to treat the paralyzed face. As patients recover from facial nerve injuries, a variety of asymmetries from nerve hypofunction (paresis or paralysis) or hyperfunction (synkinesis or spasm) often persist. Careful use of botulinum toxin type A can be very useful in improving symmetry in acute or chronic facial nerve abnormality by treating the relatively hyperfunctional side.

[Peripheral facial palsy in middle ear surgery: case report and review of literature]

We present a case of a patient who experienced right facial palsy after being operated for otosclerosis. Seventeen years before our patient had yet undergone the same operation on the contralateral ear and had presented a facial palsy. We also report another case of facial palsy and middle ear damage after an operation for otosclerosis. Facial palsy is a rare complication of middle ear surgery. It is probably caused by a viral relapse and it recedes after few weeks if a proper therapy is administrated to the patient. Thus we deem it is useless to perform immediately advanced, invasive and expensive tests. On the contrary we believe that it is useful, in those cases in which an otosclerotic patient has a history of herpes simplex virus infection, to administer a preventive antiviral therapy before the operation.

Secondary end-to-end repair of extensive facial nerve defects: Surgical technique and postoperative functional results

BACKGROUND

Repair of the transected facial nerve is imperative for restoration of muscle function, including the ability to produce appropriate facial expressions. Injury might involve the main trunk and its several branches. Restoration of function presupposes meticulous repair of all injured nerve branches.

METHODS

Here we report three cases of secondary tension-free end-to-end coaptation of a transected trunk and branches of the facial nerve by removal of the superficial part of the parotid gland.

RESULTS

Facial tone and symmetry at rest and motion were achieved. In two patients, a slight residual synkinesis is observed under stress.

CONCLUSIONS

Direct end-to-end coaptation of the facial nerve and its branches by the technique described should be considered before deciding on grafts or rerouting procedures to deal with gaps of up to 15 mm. This technique is not recommended in the presence of infection and nerve defects. Intensive postoperative physiotherapy is required for optimal results.

[Treatment of facial nerve paralysis using static suspension methods]

After the injury of facial nerve, facial muscles are subjected to complex series of biochemical and histological changes, which lead to muscular atrophy if reinnervation is not restored. Facial palsy is very difficult to manage completely. Regardless this fact, the plan of correction has to be directed towards the following: restoration of normal function, normal facial appearance at rest, symmetry in voluntary movements as well as symmetry in involuntary and emotional movements. Static suspension methods were used in our study. All patients had unilateral complete facial nerve palsy but one female patient who experienced the palsy of frontal branch of n.facialis. This method was successfully used to lift the eyebrow, the lid and to improve lagophthalmus on the paralytic side, then the angle and paralytic part of the lip, to reinforce buccal wall of oral cavity as well as to reconstruct new nasolabial fold. The results were satisfactory and permanent.

[Reconstructive surgery of facial nerve injuries]

The facial nerve is main motor nerve of the face and its injury leads to total ipsilateral paralysis. There are several surgical procedures in reconstruction of the facial nerve, and the most frequent one is hypoglosso-facial anastomosis. In this study were analysed a series of 69 patients operated on Institute of neurosurgery from 1981 to 2000 year. The most frequent cause of injury was the operation of cerebellopontine angle tumors, as well as the skull base fractures. Hypoglosso-facial anastomosis was done in 57 patients, in 5 cases we performed nerve grafting in the cerebellopontine angle, and in 7 patients the facial nerve was operated peripherally. Results were analyzed in 27 of 57 patients with hipoglosso-facial nerve anastomosis. Functional recovery was achived in 22 (81.4%) patients.

Surgical intervention in traumatic facial nerve paralysis

A four years review from June 1998 to June 2002 of traumatic facial nerve paralysis from temporal bone fractures that required surgical intervention is presented. The aim of this clinical presentation was to determine the current pattern of cases with traumatic facial paralysis which required surgical intervention at our center. There were six cases, of which four (66%) were longitudinal fractures, one each (17%) had transverse fracture and fracture over the lateral wall of mastoid. Hearing loss (83%) was the commonest associated clinical symptom. All cases underwent decompression via the transmastoid surgical approach. Intraoperative findings revealed oedema of facial nerve involving vertical segment and horizontal segment in three cases each respectively. Two cases had concomitant bony impingement. The facial nerve functions in four cases (66%) and one case recovered to House Brackmann grade 2 and 4, 12 months and 3 months respectively postsurgery. The case with transverse fracture remained as House Brackmann grade 5 after two years.

Local injection of botulinum toxin type A for hemifacial spasm

The preliminary experience of botulinum toxin treatment for hemifacial spasm is reported in this study. Five patients were treated with 10 injections of botulinum toxin in total. Botulinum toxin had a good to excellent effect in all cases. Improvement was observed 2 weeks to 1 month after the injection. The duration of improvement was 0-9 months (mean 4.2 months). The peak rank tended to decrease and the duration of improvement increased after several treatments. Hemifacial spasm caused by the anterior inferior cerebellar artery tended to subside easily. In contrast, compression by the vertebral artery was more refractory. Continuous facial spasm caused by operative trauma subsided after the injection, but paroxysmal spasm still occurred when eating or laughing. Spasm caused by trauma disappeared 4.5 months after the injection. The complications, which were facial nerve paresis in two cases (3 injections, 30%) and diplopia in one case (1 injection, 10%), were transient and subsided in 2 weeks.

Otic capsule fracture with preservation of hearing and delayed-onset facial paralysis

The unusual occurrence of an otic capsule fracture with preservation of hearing is presented. In addition, the patient suffered facial paralysis beginning 6 days after the injury that rapidly recovered. Fifteen-month follow-up reveals stable hearing thresholds. The course of a fracture through the inner ear could be an important factor in determining the potential for hearing preservation.

[Treatment of residual acoustic neurinomas]

Generally the main objective of acoustic neurinoma (AN) surgery is to totally remove the tumor associated with minimum morbidity. Nevertheless, in some cases residual tumor fragments are intentionally or accidentally left in place. These residues can lead to new growth. The present study provides a retrospective analysis of 14 cases of residual AN have undergone surgery at the Otology Group in Piacenza from 1987 to 1999. All these patients had previously undergone at least one retrosigmoidal exeresis although only one had been performed at the Otology Group. All patients except 1 were affected by anacusia at the time of surgery. The list of post-operative deficits included 2 hemipareses, 3 irreversible facial paralysis with consequent corneal opacity in 2 cases, 1 dysmetria and 1 paralysis of the abducent nerve. The patients had also undergone the following additional treatments: 1 emergency revision to drain a cerebellar hematoma, 3 ventricle-peritoneal derivations, 1 double application of stereotactic radiotherapy and 2 surgical procedures for facial plasty. Ten cases underwent the revision surgery at the Otologic Group using a translabyrinthine approach and 4 using a transcochlear approach. Tumor removal was deemed complete in all cases. The sole post-operative complications were a subcutaneous hematoma at the point where abdominal fat was removed and a temporary paralysis of the abducent nerve. Post-operative hospitalization was an average of 6.9 days. Analysis of the results showed that AN must be operated at selected centers in order to reduce the post-operative neurological deficit and the percentage of residual tumor. It also indicated that the retrosigmoid approach has a higher risk of accidentally leaving tumor residues than the other approaches. Finally, in the presence of a residual AN, the translabyrinthine approach offers the greatest advantages.

Surgical management of the paralyzed eye

Blindness is the most dreaded complication of an untreated paralyzed eyelid following injury to the facial nerve. Injuries to the facial nerve are mainly postsurgical. Assessment of neural injury using serial testing is important to be able to differentiate between temporary and permanent paralysis. In the former case, medical management could be sufficient and, in the latter case, a surgical procedure is required. The physician has the choice among several procedures to repair upper eyelid paralysis with the gold standard being the gold weight implant. Lower eyelid ectropion can be repaired using a lateral or medial canthal tightening procedure. If the lower eyelid ectropion is severe, a cartilage implant may be required.

[Chronic facial pain due to nerve injury. Deafferentation pain]

Patients presenting chronic facial pain are very common. After profound examination a significant cause for this pain often cannot be found. Some patients are suffering from this pain due to injury of a sensible nerve and then it is called deafferentation pain. This somatic disorder can give different complaints. Pain can develop as a result of formation of neuromas 'cross-talking' of nerves and alterations in the central nerve system. It seems to be difficult to make clinical features to diagnose deafferentation pain and differentiate it from pain disorders where the psychic suffering seems to be very important. The treatment is based mainly on the reduction of the conducting of abnormal pulses by the damaged or changed nerves.