205 A RECLASSIFICATION OF TEMPORAL BONE FRACTURES AND ITS ASSOCIATION WITH FACIAL NERVE INJURY.
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Abstract:
Background
Historic methods of classifying temporal bone fractures have been shown to poorly correlate with clinical findings. Due to the mechanisms of injury associated with these fractures, complete examination of patients can be difficult. An effective and simple way of correlating radiological findings in temporal bone fractures with complications like facial nerve weakness and paralysis will better guide physicians in treatment of their patients. We hypothesize that a classification system based on the medial extent of a fracture will best predict facial nerve injuries.Study Design and Methods
A retrospective chart review identified 109 patients with 131 temporal bone fractures. Temporal bone CT scans and a record of facial nerve evaluation was available in 115 fractures (99 patients). CT scans were reviewed and fractures were classified by our proposed system and by the traditional system (longitudinal, transverse, and mixed). Our proposed system is as follows: Group A is a lateral fracture involving the mastoid, external auditory canal, and/or temporomandibular joint; Group B involves the tympanic cleft; Group C involves the course of the facial nerve; and Group D involves the otic capsule. A final rating of A-D was given based on the medial most extent of the fracture line. Fractures were grouped according to the classification schemes and correlated with clinical reports of facial nerve dysfunction.Results
In 115 temporal bone fractures, 16 patients with facial nerve weakness or paralysis were identified. Using the new classification scheme, facial nerve injury was present as follows: Group A fractures - 0/20, Group B - 5/55 (9%), Group C - 6/31 (19%), Group D - 5/9 (56%). Using the traditional classification system, facial nerve dysfunction was present as follows: 11/72 (13%) of longitudinal fractures, 4/21 (19%) of transverse fractures, and 3/22 (14%) of mixed fractures.Conclusion
When compared to the traditional classification system for temporal bone fractures, these results demonstrate that the new system appears to have a higher predictive value with facial nerve function. This simple system can help physicians to triage patients and guide treatment even if a complete examination of the patient is not possible.Keywords:
Facial paralysis
Facial weakness
Nerve Injury
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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Developing acoustic neuromas subject the facial nerve to pressure within the internal auditory canal and to displacement around the surface of the enlarging tumor in the cerebellopontine angle. While the acoustic tumor is confined to the internal auditory canal, very few patients have obvious evidence of facial nerve involvement. However, when the tumor extends into the cerebellopontine angle and gradually becomes larger, the stretching of the facial nerve causes obvious facial weakness. In this series of 53 acoustic neuromas, five patients had facial weakness (cases No. 4,16, 24, 30, and 49) and three patients had facial twitching (cases No. 3, 21, and 28). It is our feeling that most patients with acoustic neuroma will ultimately develop gross obvious evidence of facial weakness if the tumor is allowed to progress far enough. Since the facial nerve can become involved in almost all cases, we felt that a quantitation of facial nerve
Facial weakness
Neuroma
Acoustic neuroma
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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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Objectives To determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Data Sources PubMed‐NCBI database from 1970 to 2014. Review Methods A systematic review and meta‐analysis of the literature was conducted. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs control). Primary and secondary end points were defined as immediate postoperative and permanent facial nerve weakness (House‐Brackmann score, ≥2), respectively. Results After a review of 1414 potential publications, 7 articles met inclusion criteria, with a total of 546 patients included in the final meta‐analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared to the unmonitored group (22.5% vs 34.9%; P =. 001). The incidence of permanent weakness was not statistically different in the long term (3.9% vs 7.1%; P =. 18). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 9, given an absolute risk reduction of 11.7% This corresponded to a 47% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.53; 95% CI, 0.35 to 0.79; P =. 002). Conclusion In primary cases of parotidectomy, intraoperative FNM decreases the risk of immediate postoperative facial nerve weakness but does not appear to influence the final outcome of permanent facial nerve weakness.
Facial weakness
Parotidectomy
Facial paralysis
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Congenital malformations
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Objectives: Determine the effectiveness of intraoperative facial nerve monitoring (FNM) in preventing immediate and permanent postoperative facial nerve weakness in patients undergoing primary parotidectomy. Methods: Systematic review and meta‐analysis. A comprehensive literature search was conducted using the PubMed‐NCBI database from 1970 to 2014. Acceptable studies included controlled series that evaluated facial nerve function following primary parotidectomy with or without FNM (intraoperative nerve monitor vs. control). Primary and secondary endpoints were defined as immediate postoperative and permanent facial nerve weakness (≥2 House‐Brackmann score), respectively. Results: A total of 1414 articles were reviewed, resulting in 8 articles that met inclusion criteria. In total, 626 patients were included in the final meta‐analysis. The incidence of immediate postoperative weakness following parotidectomy was significantly lower in the FNM group compared with the unmonitored group (22.4% vs 35.0%, P =. 001). The incidence of permanent weakness was also lower, but this difference was not statistically significant (4.2% vs 7.6%, P =. 10). The number of monitored cases needed to prevent 1 incidence of immediate postoperative facial nerve weakness was 8 given an absolute risk reduction of 12.6%. This corresponded to a 49% decrease in the incidence of immediate facial nerve dysfunction (odds ratio, 0.51; 95% confidence interval, 0.34 to 0.76, P =. 001). Conclusions: In primary cases of parotidectomy, intraoperative facial nerve monitoring decreases the risk of immediate postoperative facial nerve weakness, but does not appear to influence the final outcome of permanent facial nerve weakness.
Facial weakness
Parotidectomy
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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