Facial Nerve Paralysis and Surgical Management
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Abstract:
The facial nerve coursing through the temporal bone provides a challenge to the otologic surgeon. Advances in surgical instrumentation and refinements of surgical strategies enable the otologist to uncover the entire course of the facial nerve safely from brainstem to its exit from temporal bone. The most common cause of facial nerve paralysis is Bell's palsy, followed by traumatic facial paralysis, herpes zoster oticus, and intratemporal tumous lesion. The surgical approaches to the injured facial nerve depend on its causes. Acute, severe facial nerve paralysis caused by viral infection or trauma can be managed by early use of transmastoid approach, middle cranial approach, or combined approach. In case of intratemporal benign tumor with favorable facial function, great care must be taken not to damage the facial nerve with nerve preservation technique. However, in malignant tumor with favorable facial function, the priority must be placed on the complete resection than to the facial nerve preservation. In consideration of selecting surgical technique of facial nerve paralysis reconstruction, clinician must find out the cause, degree and duration of paralysis for the appropriate technique.Keywords:
Facial paralysis
Geniculate ganglion
Facial paralysis
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Background: Surgical treatment of carcinoma of the external auditory canal (EAC) and temporal bone involves a lateral temporal bone resection (LTBR) or more extensive sub-total or total temporal bone resection with some degree of parotidectomy or parotid margins. Involvement of the parotid gland or parotid nodes results in a higher pathologic staging and likely worse outcomes. In this study, we review all temporal bone carcinoma specimens at our institution over the past three years for parotid gland or parotid node involvement.
Parotidectomy
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Serial evoked electromyography (EEMG) is a reliable, objective, repeatable test of facial nerve function. It is very important in the initial patient evaluation in determining percent degeneration of the facial nerve. A response of 0-20% will usually result in incomplete return of facial function while responses of 60% or better will usually result in normal function. With viral facial paralysis (Bell's palsy, herpes zoster oticus), serial EEMG after several weeks has little value in predicting the final percent recovery of facial function. If there is no EEMG response, the diagnosis of viral facial paralysis is questionable and serial tests should be done until facial function begins to return. If there is no return of facial function or EEMG responses, the diagnosis is probably a tumor and the nerve should be explored. When surgical manipulation of the facial nerve has resulted in partial facial weakness, EEMG helps predict the degree of recovery of facial function. EEMG results of 60% or better will result in normal facial function while EEMG results of 25% or less will result in incomplete return of facial function. Serial testing is not necessary in this group of patients. After transection and repair of the facial nerve, serial EEMG is of value in showing continuity of the repair. Lack of improvement in EEMG over 5-12 months and no return of facial function indicates poor prognosis.
Facial paralysis
Facial muscles
Facial weakness
Facial electromyography
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Congenital malformations
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In another report (this issue) the authors described a method of monitoring intraoperative facial nerve evoked electromyography (IFeEMG) by direct electrical stimulation of the intracranial facial nerve and discussed its usefulness in the identification of the facial nerve during surgery for cerebellopontine angle tumors. This report concerns the usefulness of IFeEMG in making prognoses of postoperative facial nerve function. In 21 patients with acoustic neurinomas the correlation between the results of IFeEMG by stimulation of the morphologically preserved facial nerve and postoperative facial nerve function was determined. Patients with no IFeEMG response at the completion of tumor removal had severe postoperative facial palsy, which did not improve. Patients with a good response had no palsy or, at most, mild palsy. These findings suggest that severe postoperative facial palsy due to neurotmesis can be predicted intraoperatively by IFeEMG monitoring. Early surgical treatment is recommended for patients with morphologically preserved facial nerves but no IFeEMG response.
Facial electromyography
Facial muscles
Facial paralysis
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Quantitative analysis of the facial nerve on the lesion side as well as the normal side, which allowed for more accurate measurement of facial nerve enhancement in patients with facial palsy, showed statistically significant correlation with the initial severity of facial nerve inflammation, although little prognostic significance was shown.This study investigated the clinical significance of quantitative measurement of facial nerve enhancement in patients with Bell's palsy by analyzing the enhancement pattern and correlating MRI findings with initial severity of facial palsy and clinical outcome.Facial nerve enhancement was measured quantitatively by using the region of interest on pre- and postcontrast T1-weighted images in 44 patients diagnosed with Bell's palsy. The signal intensity increase on the lesion side was first compared with that of the contralateral side and then correlated with the initial degree of facial palsy and prognosis.The lesion side showed significantly higher signal intensity increase compared with the normal side in all of the segments except for the mastoid segment. Signal intensity increase at the internal auditory canal and labyrinthine segments showed correlation with the initial degree of facial palsy but no significant difference was found between different prognostic groups.
Bell Palsy
Clinical Significance
Intensity
Facial Nerve Palsy
Facial paralysis
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To explore the clinical features, pathologic characteristics and treatments of the facial paralysis caused by temporal bone tumors.Retrospective analyzed the 23 clinical data of peripheral facial paralysis caused by temporal bone tumors, including 11 cases of facial nerve tumor: facial nerve neurilemmoma in 8 cases, facial nerve neurofibroma in 3 cases; 12 cases of temporal bone malignant tumor: temporal bone squamous cell carcinoma in 9 cases, chondrosarcoma in 1 case, rhabdomyosarcoma in 2 cases. All the patients accepted the CT scan examination and MRI examination. Twenty-three cases were surgically treated: facial nerve tumor resection were performed in 11 cases, among those, through mastoid approach in 7 cases, combined mastoid with middle cranial fossa approach in 3 cases, combined mastoid with parotid approach in 2 cases. Eight cases underwent facial nerve graft following the surgical removal of tumors. Twelve cases were temporal bone malignant tumor resection: among those, extended mastoidotympanectomy in 5 cases, subtotal temporal bone resection in 6 cases, total temporal bone resection in 1 case, all were treated by radiotherapies after surgeries.Whether the tumors go along the facial nerve in imaging is the major identification method to identify the facial nerve tumors or no-facial nerve tumors. During the 3-8 years follow-up, 10 patients who were totally removed the facial nerve tumor were no recurrence, 1 patient had tumors present. The recurrence rate of temporal bone malignancy was 41. 7% (5/12), 5 cases of Stell stage T2 and 5 cases of stage T3. The 5-year survival rate was 66.7% (8/12).Most of facial nerve tumors that cause the facial palsy are benign, and no-facial nerve tumors are most common among the malignant tumors. CT and MRI films are valuable for the diagnosis. Operation is the major treatment, the manner of the operation bases on the type and the extent of the tumors. Facial nerve grafting can improve the facial neurological function after the tumor excision. Malignancy should be treated by combination of operation and radiotherapy, etc.
Facial paralysis
Middle cranial fossa
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The present retrospective study of 6,200 subjects with temporal bone pathology allowed for the identification of a group of 12 patients aged between 12 and 59 years in whom the presence of facial nerve neurinoma diagnosed by computed tomography was confirmed during surgical intervention and by histological methods. The patients were allocated to three groups depending on the localization of neurinoma. Patients of group 1 (n=8) had neurinoma of the mastoidal segment, those of group 2 presented with neurinoma of the tympanic segment, and patients of group 3 showed combined lesions of the tympanic and labyrinthine segments. Clinical and CT characteristics of each group are presented. CT of the temporal bone is shown to provide a tool of high informative value for the diagnosis of facial nerve neurinoma. It is suggested that CT should be used to examine patients with facial nerve paresis or conductive and mixed hearing loss of unspecified etiology for the early diagnosis of facial nerve neurinoma.
Paresis
Etiology
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Anatomical landmark
Oval window
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Objcetive To report results of facianervdecompression for peripheral facial palscaused by different facianever diseases.Methods Etiologies in this group included trauma(n=9), Bell's palsy(n=3) and cholesteatoma in middle ear(n=3).All patients were treated with facial nerve decompression via transmastoid, subtemporal or supralabyrinthine approach.es.The House-Brackmann facial nerve grade was assessed during the 0.5 to 2 years follow up.Results Among the 9 traumat.ic facial palsy patients caused by temporal bone fracture, 5 received surgery within 2 to 4 weeks and achieved grade I(n=4) or II(n=1) facial function; 3 received surgery within 5 to 8 weeks and achieved grade Ⅱ(n=2) or Ⅲ(n=1) facial function; and 1received the operation within 9 to 12 weeks after the injury and achieved only grade Ⅳ facial function.Two patients with Bell's palsy were operated on within 9 to12 weeks and achieved grade I or II facial function. One Bell's palsy patient achieved gradeⅢ facial function after receiving surgery 12 weeks after disease onset. The 3 cases of middle ear cholesteatoma were oper.ated upon in 1 to 2 weeks and all achieved grade I facial function. Conclusions Appropriate timing and facial nerve decom.pression operations based on the etiologies can lead to good facial function results.
Facial paralysis
Etiology
Facial canal
Microvascular Decompression
Cranial nerve disease
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