Masseteric-Facial Anastomosis: A Report of Three Cases

Intoduction The pathways of the facial nerve are variable, and knowledge of that is essential. The worst impact caused by facial paralysis is related to quality of life, especially regarding the self-esteem and social acceptance on the part of the patients, leading to social isolation and disruption on their mental health. Case Report A 33-year-old female patient, with a stage-T3 acoustic neurinoma, presented with a moderate dysfunction (grades II to III) according to the House- Brackmann (HB) Facial Nerve Grading System. A 43-year-old male patient, with a stage- T4B trigeminal schwannoma, underwent a resective surgery and presented grade-VI dysfunction according to the HB scale. And a female patient with a stage-T4A acoustic neurinoma presented grade-IV dysfunction according to the HB scale. Discussion We performed a literature review of papers related to surgeries for masseteric-facial nerve anastomosis and compiled the results in table; then, we compared these data with those obtained from our cases. Conclusion The masseteric nerve is the one that shows the best prognosis among all the cranial nerves that could be used, but it is also necessary to perform well the surgical technique to access the facial branch and consequently achieve a better masseteric-facial nerve anastomosis.

Hypoglossal-Facial Anastomosis for Facial Nerve Reconstruction: Outcomes using the Side-to-End Surgical Technique

Introduction The side-to-end hypoglossal-facial anastomosis (HFA) technique is an excellent alternative technique to the classic end-terminal anastomosis, because itmay decrease the symptoms resulting from hypoglossal-nerve transection. Methods Patients with facial nerve palsy (House-Brackmann [HB] grade VI) requiring facial reconstruction from 2014 to 2017were retrospectively included in the study. Results In total, 12 cases were identified, with a mean follow-up of 3 years. The causes of facial paralysis were due to resection of posterior-fossa tumors and trauma. There was improvement in 91.6% of the patients (11/12) after the HFA. The rate of improvement according to the HB grade was as follows: HB III - 58.3%; HB IV - 16.6%; and HB II - 16.6%. The first signs of improvement were observed in the patients with the shortest time between the paralysis and the anastomosis surgery (3.5months versus 8.5 months; p » 0.011). The patients with HB II and III had a shorter time between the diagnosis and the anastomosis surgery (mean: 5.22 months), while the patients with HB IV and VI had a longer time of paresis (mean: 9.5 months; p » 0.099). We did not observe lingual atrophy or changes in swallowing. Discussion and Conclusion Hypoglossal-facial anastomosis with the terminolateral technique has good results and low morbidity in relation to tongue motility and swallowing problems. The HB grade and recovery appear to be better in patients operated on with a shorter paralysis time.

Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System / Lesões do nervo facial relacionadas à parotidectomia: proposta de um sistema Sunnybrook de graduação facial modificado

ABSTRACT Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. Objective To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch. Methods We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014. Results The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function. Conclusion The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

RESUMO A lesão do nervo facial é a principal complicação neurológica relacionada às parotidectomias e, em geral, o ramo marginal mandibular é o mais frequentemente acometido. Objetivo Testar um Sistema Sunnybrook de Graduação Facial modificado (mS-FGS) como uma nova ferramenta para avaliar a função do nervo facial após a parotidectomia, enfatizando o ramo marginal mandibular. Métodos Estudo retrospectivo, baseado em prontuários de 73 casos (40 do sexo feminino, 18-84 anos, idade média = 53,2), submetidos à parotidectomia, com preservação do nervo facial. Todos os pacientes apresentavam neoplasias parotídeas ou câncer de pele avançado, e foram tratados pela autora principal entre 2006 e 2014. Resultados Neste estudo, os músculos inervados pelo ramo marginal mandibular foram os mais acometidos (72,6% dos casos), principalmente nos pacientes que realizaram esvaziamento cervical (p = 0,023). Os Escores de Movimento Voluntário obtidos pelo sistema modificado foram inferiores aos obtidos pelo original (p < 0,001). As melhores pontuações foram observadas em pacientes com tumores benignos parotídeos e os piores resultados, naqueles com câncer de pele. Pacientes que necessitaram de esvaziamento cervical e ressecção de outras estruturas, além da parótida, apresentaram escores menores (p = 0,031 e p = 0,021), evidenciados apenas pelo sistema modificado. Os tumores malignos geraram escores significativamente menores, independentemente do instrumento empregado. A análise pós fisioterapia envolveu 50 casos. Os piores resultados, após a intervenção fisioterapêutica, também foram observados nos músculos inervados pelo ramo marginal mandibular. Conclusão A avaliação da disfunção facial pós-parotidectomia, através do Sistema Sunnybrook com a modificação proposta permitiu uma apreciação mais detalhada do ramo marginal mandibular, sem prejuízo à avaliação dos demais ramos.

Ritidoplastia e paralisia facial: como lidar? / Facelift and Facial nerve injury: how to deal with?

Não é novidade para os cirurgiões plásticos, especialmente aos que se dedicam à cirurgia de face, que o nervo facial pode ser lesado virtualmente em qualquer cirurgia de ritidoplastia. Porém, apesar da importância contida nesse tema, não é tarefa simples encontrar na literatura artigos que abordem de forma objetiva a correlação entre lesão do nervo facial e cirurgia facial. Paralisias faciais, sejam elas completas ou não, podem se tornar situações potencialmente conflituosas na relação médicopaciente. Este artigo, portanto, visa propor de forma clara e sucinta, baseada na experiência dos autores, um guia de como evitar, identificar e tratar uma potencial lesão do nervo facial no contexto de uma cirurgia de face, em especial a ritidoplastia.

Is largely known that the facial nerve virtually can be injured in every facial lift. Even though its importance, it is difficult to find in the literature articles related to this theme. Complete or incomplete facial paralysis after a facial procedures, may become a very uncomfortable situation between the patient and the surgeon, that is why we propose in this article a guide which intends to help avoid, identify and manage a facial nerve injury in the event of a face lift. Identifying Facial palsy before the surgery: Intending to make the pre-op facial assessment as simple as possible, we suggest a systematic approach examination. Avoiding facial nerve injury during face lifting: Several technical details are discussed along the text aiming to minimize the risk of nerve damage during the surgical procedure. What to in the event of a post-operative facial palsy: The authors propose a logical approach to the facial palsy, suggesting a planning for diagnosis, classification of the lesion and a rational treatment for the injury. Conclusion: This article presents a guide showing some safe technical options to avoid nerve damage during rythidoplasty, how to identify the lesion and treat it if necessary.

Association between facial nerve second genu angle and facial canal dehiscence in patients with cholesteatoma: evaluation with temporal multidetector computed tomography and surgical findings / Associação entre o ângulo do segundo joelho do nervo facial e deiscência do canal facial em pacientes com colesteatoma: avaliac¸ão do osso temporal por tomografia com multidetectores e pelos achados cirúrgicos

Abstract Introduction: Otitis media, mastoiditis or the pressure effect of tumorous lesions such as cholesteatoma can be the cause of facial canal dehiscence and facial nerve paralysis. The most common segment involved in dehiscence is the tympanic segment and the second most common is the lateral aspect of the facial canal in the oval window area. Objective: To determine the prevalence of the facial canal dehiscence and the relationship between the angle at the second genu of the facial nerve and facial canal dehiscence. Methods: We evaluated the surgical findings in 113 patients who underwent surgery for cholesteatoma. Facial canal dehiscence was detected in 62 of the 113 patients. Patients were divided into two groups: Group 1, with dehiscence of the facial canal and Group 2, without dehiscence of the facial canal. Results: The mean angles at the second genu of the facial nerve in Groups 1 and 2 were 117.8º ± 9.63º and 114º ± 9.9º, respectively. There was a statistically significant difference between the mean angles at the second genu for the two groups (p = 0.04). Conclusion: In patients with dehiscence of the facial canal, the angle at the second genu was found to be wider than those without dehiscence.

Resumo Introdução: Otite média, mastoidite ou a compressão por lesões tumorais como o colesteatoma podem ser a causa da deiscência do canal facial e paralisia do nervo facial. A deiscência ocorre mais frequentemente no segmento timpânico, seguido do aspecto lateral do canal facial na área da janela oval. Objetivo: Determinar a prevalência da deiscência do canal facial e sua relação com o ângulo no segundo joelho do nervo facial. Método: Avaliamos os achados cirúrgicos para detecção de deiscência do canal facial em 113 pacientes submetidos à cirurgia de colesteatoma. A deiscência do canal facial foi observada em 62. Os pacientes foram divididos em dois grupos: Grupo 1, com deiscência do canal facial, e Grupo 2, sem deiscência do canal facial. Resultados: Os ângulos médios no segundo joelho do nervo facial nos grupos 1 e 2 foram 117,8º ± 9,63º e 114º ± 9,9º, respectivamente. Houve diferença estatisticamente significante entre os ângulos médios no segundo joelho para os dois grupos (p = 0,04). Conclusão: Em pacientes com deiscência no canal facial, foi observado que o ângulo do segundo joelho era maior do que naqueles sem deiscência.

Evaluation of the Facial Recess and Cochlea on the Temporal Bone of Stillbirths regarding the Percutaneous Cochlear Implant

Abstract Introduction The literature shows that there are anatomical changes on the temporal bone anatomy during the first four years of life in children. Therefore, we decided to evaluate the temporal bone anatomy regarding the cochlear implant surgery in stillbirths between 32 and 40 weeks of gestational age using computed tomography to simulate the trajectory of the drill to the scala timpani avoiding vital structures. Objectives To measure the distances of the simulated trajectory to the facial recess, cochlea, ossicular chain and tympanic membrane, while performing the minimally invasive cochlear implant technique, using the Improvise imaging software (Vanderbilt University, Nashville, TN, US). Methods An experimental study with 9 stillbirth specimens, with gestational ages ranging between 32 and 40 weeks, undergoing tomographic evaluation with individualization and reconstruction of the labyrinth, facial nerve, ossicular chain, tympanic membrane and cochlea followed by drill path definition to the scala tympani. Improvise was used for the computed tomography (CT) evaluation and for the reconstruction of the structures and trajectory of the drill. Results Range of the distance of the trajectory to the facial nerve: 0.58 to 1.71mm. to the ossicular chain: 0.38 to 1.49 mm; to the tympanic membrane: 0.85 to 1.96 mm; total range of the distance of the trajectory: 5.92 to 12.65 mm. Conclusion The measurements of the relationship between the drill and the anatomical structures of the middle ear and the simulation of the trajectory showed that the middle ear cavity at 32 weeks was big enough for surgical procedures such as cochlear implants. Although cochlear implantation at birth is not an indication yet, this study shows that the technique may be an option in the future.

Outcome of different facial nerve reconstruction techniques / Resultados de diferentes técnicas de reconstrução do nervo facial

Abstract Introduction: There is no technique of facial nerve reconstruction that guarantees facial function recovery up to grade III. Objective: To evaluate the efficacy and safety of different facial nerve reconstruction techniques. Methods: Facial nerve reconstruction was performed in 22 patients (facial nerve interpositional graft in 11 patients and hypoglossal-facial nerve transfer in another 11 patients). All patients had facial function House-Brackmann (HB) grade VI, either caused by trauma or after resection of a tumor. All patients were submitted to a primary nerve reconstruction except 7 patients, where late reconstruction was performed two weeks to four months after the initial surgery. The follow-up period was at least two years. Results: For facial nerve interpositional graft technique, we achieved facial function HB grade III in eight patients and grade IV in three patients. Synkinesis was found in eight patients, and facial contracture with synkinesis was found in two patients. In regards to hypoglossal-facial nerve transfer using different modifications, we achieved facial function HB grade III in nine patients and grade IV in two patients. Facial contracture, synkinesis and tongue atrophy were found in three patients, and synkinesis was found in five patients. However, those who had primary direct facial-hypoglossal end-to-side anastomosis showed the best result without any neurological deficit. Conclusion: Among various reanimation techniques, when indicated, direct end-to-side facial-hypoglossal anastomosis through epineural suturing is the most effective technique with excellent outcomes for facial reanimation and preservation of tongue movement, particularly when performed as a primary technique.

Resumo Introdução: Não existe uma técnica de reconstrução do nervo facial que garanta a recuperação da função facial até o grau III. Objetivo: Avaliar a eficácia e segurança de diferentes técnicas de reconstrução do nervo facial. Método: Ao todo, 22 pacientes foram submetidos a reconstrução do nervo facial (enxerto com interposição do nervo facial em 11 pacientes e com transferência do nervo hipoglosso facial em 11 pacientes). Todos os pacientes apresentavam função facial de grau VI (de acordo com a classificação de House-Brackmann - HB) causada por trauma ou pela ressecção de um tumor. A reconstrução do nervo principal foi efetuada, exceto em sete pacientes, nos quais a reconstrução foi realizada entre duas semanas a quatro meses após a cirurgia inicial. O período de acompanhamento foi de, no mínimo, dois anos. Resultados: Para a técnica de enxerto com interposição de nervo facial, o grau de função facial obtido foi HB III em oito pacientes e HB IV em três pacientes. Sincinesia foi observada em oito pacientes e contratura facial com sincinesia em dois pacientes. Em relação à transferência do nervo hipoglosso facial com o uso de diferentes modificações, obtivemos função facial HB grau III em nove pacientes e HB grau IV em dois pacientes. Contratura facial, sincinesia e atrofia lingual foram observadas em três pacientes e sincinesia observada em cinco pacientes. No entanto, aqueles submetidos a anastomose primária direta hipoglosso-facial término-lateral apresentaram o melhor resultado, sem qualquer déficit neurológico. Conclusão: Entre as várias técnicas de reanimação, sempre que possível, a anastomose direta término-lateral hopoglosso-facial por meio de sutura epineural é a técnica mais eficaz, com excelentes resultados para reanimação facial e preservação do movimento da língua, especialmente quando realizada como técnica primária.

Frontalis muscle flap suspension surgery for the treatment of blepharoptosis based on the anatomical study of the frontal muscle nerve in the third of the eyebrow / Cirugía de suspensión del colgajo muscular frontal en el tratamiento de blefaroptosis basado en el estudio anatómico del nervio del músculo occipitofrontal en el tercio de la ceja

The aim of this study was to investigate the course of the supraorbital nerve and temporal branch of the facial nerve, and to verify the clinical security of cutting the frontalis muscle flap to treat blepharoptosis in one-third of the eyebrow. Twenty cadavers were dissected. The relationship of the supraorbital nerve and the course of the frontotemporal branch of the facial nerve with the head and neck muscles was evaluated. Forty patients underwent clinical frontal muscular flap suspension surgery for the treatment of blepharoptosis. The postoperative curative and complication rates were determined. The courses of the supraorbital nerve and frontotemporal branch of the facial nerve were observed to determine a relatively safe area in one-third of the eyebrow. The average width of the zone was 25.0±3.5 mm. In forty cases, satisfactory results were achieved in correcting blepharoptosis by cutting the frontal muscular flap in the middle of eyebrow within the wide range of 17±2.1 mm. No secondary sensory and motor dysfunctions occurred. One-third of the eyebrow (eyebrow center, within 17±2.1 mm) was a relatively safe area and allowed for the prevention of damage to the temporal branch of the facial nerve inside the supraorbital nerve and supraorbital artery and the outer frontotemporal branch of the facial nerve.

El objetivo de este estudio fue investigar el curso del nervio supraorbital y la rama temporal del nervio facial, para verificar la seguridad clínica de cortar el vientre frontal del músculo occipitofrontal (colgajo de músculo frontal) para tratar la blefaroptosis en un tercio de la ceja. Veinte cadáveres fueron disecados. Se evaluó la relación del nervio supraorbital y el curso de la rama temporal del nervio facial con los músculos de la cabeza y cuello. Cuarenta pacientes fueron sometidos a la cirugía de confección del colgajo del músculo frontal para el tratamiento de la ptosis palpebral. Se determinaron las tasas de curación y de complicaciones postoperatorias. Se observaron los cursos del nervio supraorbital y la rama temporal del nervio facial para determinar un área relativamente segura en un tercio de la ceja. El ancho medio de la zona fue 25,0±3,5 mm. En cuarenta casos, se lograron resultados satisfactorios en la corrección de la blefaroptosis con el colgajo del músculo frontal en la mitad de la ceja en un rango de 17±2,1 mm. No se produjeron disfunciones sensoriales o motoras secundarias. El tercio de la ceja (centro del entrecejo, dentro de 17±2,1 mm) es una zona relativamente segura y permite la prevención de daños al ramo temporal del nervio facial ubicada medial al nervio supraorbitario y a la arteria supraorbitaria, además del ramo temporal lateral del nervio facial.

Facial nerve identification with fluorescent dye in rats

PURPOSE The parotidectomy technique still has an elevated paresis and paralysis index, lowering patient life's quality. The correct identification of the facial nerve can prevent nerve damage. Fluorescent dye identifies nerves in experimental studies but only few articles focused its use on facial nerve study in parotidectomies. We aimed to stain the rat facial nerve with fluorescent dye to facilitate visualization and dissection in order to prevent injuries. METHODS Forty adult male Wistar rats were submitted to facial injection of saline solution (Gsf-control group, 10) or fluorescent dye solution (Gdye group, 30) followed by parotidectomy preserving the facial nerve, measuring the time for localization and facility of localization (LocTime and LFN). Nerve function was assessed using the Vibrissae Movements (PMV) and Eyelid Closure Motion (PFP) scores. RESULTS Nerve localization was faster in Gdye group, with 83% Easy LFN rate. The Gdye group presented with low nerve injury degree and better PMV and PFP scores, with high sensitivity and accuracy. CONCLUSIONS This experimental method of facial nerve fluorescence was effective for intraoperative nerve visualization, identification and preservation. The technique may be used in future facial nerve studies, translated to humans, contributing to the optimization of parotid surgery in the near future.

Schwannoma del nervio facial y sus ramas en el oído medio: reporte de 3 casos y revisión de literatura / Schwannoma of the facial nerve and its branches in the middle ear: a report of 3 cases and literature review

El schwannoma del nervio facial (SNF) es un tumor infrecuente, sin embargo es el tumor más frecuente del nervio facial. Son tumores benignos de crecimiento lento que producen sintomatología otológica no específica y pueden asociar parálisis facial. No existen exámenes preoperatorios que nos permitan diagnosticar con certeza el SNF. El estudio de elección se realiza con TC de alta resolución y RM con gadolinio. El diagnóstico definitivo es histopatológico pero se puede hacer diagnóstico presuntivo si la clínica, imágenes y hallazgo intraoperatorios son concordantes. El objetivo del tratamiento debe intentar preservar la función del nervio facial por el mayor tiempo posible. En casos de pacientes asintomáticos, o sin compromiso del nervio facial, se prefiere la observación. Se presentan en este artículo casos de schwannomas del facial intratimpánico y de cuerda del tímpano.

The facial nerve schwannoma (SNF) is a rare tumor, however it is the most common tumor of the facial nerve. They are slow-growing benign tumors that produce non-specific otologic symptoms and may be associated facial paralysis. There are no preoperative tests that allow us to accurately diagnose the SNF. The study of choice is made with high resolution CT and MRI with gadolinium. Definitive diagnosis is histopathological but the physician may make a presumptive diagnosis if clinical images and intraoperative findings are consistent. The goal of treatment should try to preserve facial nerve function for as long as possible. In cases of asymptomatic patients, without facial nerve involvement, observation is prefered. Cases of schwannomas of intratympanic facial and chorda tympani are presented in this article.

Alterações nervosas na ritidoplastia: uma revisão sistemática / Nerve alterations in rhytidoplasty: a systematic literature review

INTRODUÇÃO: A ritidoplastia se tornou uma das cirurgias estéticas mais realizadas por cirurgiões plásticos ao redor do mundo. Junto com o aumento do número de cirurgias, a quantidade de complicações associadas ao procedimento também aumentou, sendo que as alterações nervosas são uma das que despertam maiores preocupações. O presente estudo visa a identificar, por meio de uma revisão sistemática, as principais estruturas nervosas lesadas durante uma ritidoplastia, tanto por técnicas convencionais como endoscópicas. MÉTODOS: Uma revisão sistemática da literatura foi realizada nas principais bases de dados utilizadas atualmente. Artigos que preencheram os critérios de inclusão foram analisados na íntegra e suas referências, verificadas. Ao final, 20 estudos foram incluídos. RESULTADOS: Nestes 20 artigos, no total, foram avaliados 3.347 pacientes, sendo encontradas 142 lesões nervosas: 79 do nervo facial; 55 do nervo trigêmeo, e oito do nervo auricular magno. Destas, apenas duas foram definitivas. As lesões, proporcionalmente, foram mais comuns nas técnicas videoassistidas (81%), quando comparadas com as convencionais (19%). CONCLUSÃO: Encontramos que as lesões dos ramos temporal e bucal são mais frequentes no facelift e as do nervo auricular magno, na ritidoplastia cervical. Apesar de as lesões nervosas serem pouco frequentes na literatura, faltam estudos bem desenhados que busquem conhecer melhor estas complicações.

INTRODUCTION: Rhytidoplasty has become one of the most common aesthetic surgeries performed by plastic surgeons worldwide. Along with the increase in the number of surgeries performed, the number of procedure-related complications has also increased. In particular, nerve injuries are the major concern. By conducting a systematic review, the present study aimed to identify the main nerve structures injured during rhytidoplasty, by either the conventional or endoscopic technique. METHODS: A systematic literature review was performed in the main databases currently used. Articles that met the inclusion criteria were analyzed in their entirety, and their references were checked. Finally, 20 studies were included. RESULTS: In these 20 articles, 3,347 patients were evaluated and 142 nerve injuries found, of which 79 were of the facial nerve, 55 were of the trigeminal nerve, and eight were of the great auricular nerve. Of these, only two were definitive. The lesions were more prevalent (81%) with the video-assisted techniques than with the conventional techniques (19%). CONCLUSION: We found that the injuries of the temporal and buccal branches were more frequent during facelifts; and those of the great auricular nerve, during cervical rhytidoplasty. Although nerve injuries are infrequent in the literature, well-designed studies that aim to better understand these complications are lacking.

Reparo do nervo facial com sutura epineural térmico-terminal e coaptação com adesivo de fibrina em ratos associado ou não a laserterapia / Repair of facial nerve with epineural end-to-end suture and coaptation with fibrin adhesive in rats associated or not laser therapy

As lesões que envolvem nervos periféricos, especialmente os traumatismos facias, são muito comuns e decorrentes principalmente de acidentes com veículos motorizados, lesões acidentais e quedas, que levam a fraturas do osso temporal ou lacerações da face e consequentemente lesões do nervo facial. A principal meta no estudo da regeneração nervosa é descobrir uma técnica adequada de reparo em lesões de nervos periféricos que traga como resultado a recuperação funcional das estruturas por eles inervadas. A sutura epineural é um método muito utilizado para recuperação de lesões nervosas, assim como o uso do adesivo de fibrina, que requer menor destreza do cirurgião. O adesivo derivado do veneno de serpente (CEVAP/UNESP, Botucatu-SP) é um selante biológico e biodegradável, pois não produz reações adversas, não contém sangue humano, apresenta uma boa capacidade adesiva, não transmite doenças infecciosas, e pode ser utilizado como coadjuvante em procedimentos de sutura convencional. Sendo assim, o objetivo deste trabalho foi comparar duas técnicas de recuperação de nervos periféricos lesionados: a sutura epineural término-terminal e o adesivo de fibrina derivado do veneno de serpente, e observar se o uso da laserterapia de baixa potência influencia esse processo de regeneração. Para isso, foram utilizados 42 ratos machos (Rattus norvegicus, Wistar), com 60 dias de vida, separados aleatoriamente em um Grupo Controle e quatro Grupos Experimentais, assim formados: Grupo Controle (GC, n=10), em que foi coletado o nervo facial íntegro aos 95 e 135 dias de vida; Grupo Experimental Sutura (GES, n=16) e Grupo Experimental Adesivo de Fibrina (GEF, n=16), onde no lado direito da face o ramo bucal do nervo facial foi seccionado e realizado a sutura epineural término-terminal e, no lado esquerdo da face, o ramo bucal do nervo facial foi seccionado e utilizado o adesivo de fibrina para coaptação das extremidades; Grupo Experimental Sutura e Laserterapia (GESL, n=16)...

The injuries involving peripheral nerves, especially facial traumatisms are very common and serious and longstanding facial paralysis lead to significant deterioration in the quality of the individuals life. The main goal in the study of nerve regeneration is finding a suitable repair technique for peripheral nerve injuries that bring results in the functional recovery of the structures innervated by them. Therefore, the aim of this study was to compare two techniques for recovery of injured peripheral nerves: the end-to-end epineural suture and fibrin adhesive derived from snake venom (CEVAP / UNESP, Botucatu-SP), and observeif the use of low-level laser therapy influences this regeneration process. For this purpose, 42 male rats (Rattus norvegicus, Wistar) were used , with 60 days of life, were randomly separated into a control group and four experimental groups, which were formed this way: Control Group (CG , n = 10), in which the intact facial nerve was collected at 95 and 135 days of life; Experimental Suture Group (ESG, n = 16 ) and Experimental Fibrin Adhesive Group (EFG, n = 16), where the right side of the face the buccal branch of the facial nerve was transectioned and the epineural end-to-end suture was performed and the left side of the face, the buccal branch of the facial nerve was transectioned and the fibrin glue was used for coaptation of the edges; Experimental Suture Laser Therapy Group (ESLG, n = 16) and Experimental Fibrin Adhesive Laser Therapy Group (EFLG, n = 16) underwent the same procedures of ESG and EFG , included the application of Laser Gallium- Aluminum-Arsenide (GaAlAs) by an 830 nm wavelength pulse continuous, 6 J/cm2, for 24 seconds, three times a week during five weeks at three points of the operated areas. The animals in the experimental groups were euthanized at 95 days (five weeks post-surgery) and 135 days (ten weeks post-surgery). The collected samples were...

Enxertos e anastomoses do nervo facial na orelha média: caixa do tímpano e mastoide / Facial nerve grafting and end-to-end anastomosis in the middle ear: tympanic cavity and mastoid

O nervo facial, quando seccionado, pode ser reparado em seu tronco por enxerto ou anastomose. OBJETIVO: Discutir as técnicas em questão e mostrar o que podemos esperar das mesmas. MÉTODO: Foram operados sete pacientes com secção do nervo facial. As cirurgias foram quatro enxertos e três anastomoses. Cinco paralisias foram iatrogênicas e duas por projéteis de arma de fogo. A avaliação da recuperação motora foi feita pela tabela de Janssen. RESULTADOS: Obtivemos 72,5% em média de recuperação motora nos casos de enxerto e 73,3% nos casos de anastomose. CONCLUSÃO: 1. Enxertos e anastomoses são soluções adequadas para reparar o nervo facial seccionado, mas nunca permitem uma recuperação facial completa, podendo ocorrer sincinesias. 2. Em princípio, o nosso objetivo é fazer a anastomose, mas quando existe tração mínima nos cotos do facial, preferimos os enxertos. 3. Em ambas as técnicas, conseguimos acima de 70% de recuperação motora em média (72,5% nos enxertos e 73,3% nas anastomoses).

Sectioned facial nerves can be repaired with grafting or end-to-end anastomosis. OBJECTIVE: To discuss these repair procedures and what can be expected of them. METHOD: Seven patients with sectioned facial nerves were included in the study. Four underwent grafting and three were offered end-to-end anastomosis. Facial nerve palsy was iatrogenic in five patients and was caused by bullet wounds in two. Assessment of motor function recovery was based on Janssen's scale. RESULTS: Mean motor recovery was rated at 72.5% for subjects offered grafting and 73.3% for patients submitted to anastomosis. CONCLUSION: 1. Grafting and anastomosis are proper solutions to repair sectioned facial nerves; complete recovery is never attained; synkinesis may occur. 2. In principle anastomosis is the procedure of choice, but when there is minimal traction in the facial nerve stump grafting is preferred. 3. Both procedures yielded mean motor recovery rates above 70% (72.5% for grafting and 73.3% for anastomosis).

Facial Nerve Paralysis due to Chronic Otitis Media: Prognosis in Restoration of Facial Function after Surgical Intervention

PURPOSE: Facial paralysis is an uncommon but significant complication of chronic otitis media (COM). Surgical eradication of the disease is the most viable way to overcome facial paralysis therefrom. In an effort to guide treatment of this rare complication, we analyzed the prognosis of facial function after surgical treatment. MATERIALS AND METHODS: A total of 3435 patients with COM, who underwent various otologic surgeries throughout a period of 20 years, were analyzed retrospectively. Forty six patients (1.33%) had facial nerve paralysis caused by COM. We analyzed prognostic factors including delay of surgery, the extent of disease, presence or absence of cholesteatoma and the type of surgery affecting surgical outcomes. RESULTS: Surgical intervention had a good effect on the restoration of facial function in cases of shorter duration of onset of facial paralysis to surgery and cases of sudden onset, without cholesteatoma. No previous ear surgery and healthy bony labyrinth indicated a good postoperative prognosis. CONCLUSION: COM causing facial paralysis is most frequently due to cholesteatoma and the presence of cholesteatoma decreased the effectiveness of surgical treatment and indicated a poor prognosis after surgery. In our experience, early surgical intervention can be crucial to recovery of facial function. To prevent recurrent cholesteatoma, which leads to local destruction of the facial nerve, complete eradication of the disease in one procedure cannot be overemphasized for the treatment of patients with COM.

Paralisia facial: análise epidemiológica em hospital de reabilitação / Facial paralysis: epidemiological analysis in a rehabilitation hospital

INTRODUÇÃO: A paralisia facial é a perda temporária ou permanente dos movimentos da mímica facial em decorrência do acometimento do nervo facial. São vários os fatores que influenciam a evolução das lesões do nervo facial. Este estudo teve como objetivo avaliar os aspectos epidemiológicos e a frequência de sequelas após paralisia facial em um serviço de reabilitação. MÉTODO: Estudo retrospectivo dos pacientes com paralisia facial atendidos em hospital de reabilitação no período de janeiro de 2001 a janeiro de 2005. As sequelas foram avaliadas quanto a sexo, idade, etiologia, graduação funcional conforme a escala de House-Brackmann, tempo de evolução, seguimento e intervenções cirúrgicas. Para realização da análise estatística utilizou-se o programa Epi-Info versão 3.2.2. RESULTADOS: Foram admitidos para programa de reabilitação 285 pacientes portadores de paralisia facial, sendo 157 do sexo masculino e 128 do feminino. Todos os pacientes se submeteram a programa de reabilitação e 29 (10,2 por cento), a cirurgia. Dentre os pacientes analisados, 80 por cento foram admitidos a partir da terceira semana do surgimento da paralisia, e 121 (42,5 por cento) tiveram recuperação gradual em 3 meses, espontaneamente, com tratamento clínico ou fisioterápico. Por outro lado, 119 (41,8 por cento) pacientes permaneceram com paralisia facial parcial ou completa e irreversível. CONCLUSÕES: Os casos admitidos foram mais frequentes em pacientes com menos de 20 anos de idade, com causas diversas e quando admitidos em graus menores segundo a escala de House-Brackmann, pois muitos deles se associavam a déficits neurológicos consequentes a paralisia facial de origem central ou congênita.

BACKGROUND: Facial paralysis is characterized by permanent or temporary loss of facial expression due to facial nerve injury. Several factors influence the development of facial nerve lesions. The purpose of this study was to evaluate the epidemiological aspects and incidence of sequelae after facial paralysis at a rehabilitation institution. METHODS: We performed a retrospective study of facial paralysis patients admitted to a rehabilitation hospital between January 2001 and January 2005. Sequelae were analyzed according to gender, age, etiology, functional status as measured by the House-Brackmann scale, evaluation time, follow-up, and surgical procedures. Statistical analyses were performed with Epi-info 3.2.2 software. RESULTS: A total of 285 facial paralysis patients, 157 male and 128 female, were admitted for a rehabilitation program. All subjects followed a rehabilitation program, and 29 (10.2 percent) underwent surgery; 80 percent were admitted during the 3rd week of the paralysis or later, and 121 (42.5 percent) showed gradual recovery after 3 months, either spontaneously or after clinical or physical therapies. Nevertheless, 119 (41.8 percent) sustained irreversible partial or complete facial paralysis. CONCLUSIONS: The prevalence of facial paralysis was greater among patients younger than 20 years. Among these patients, paralysis had different causes, and these patients were admitted with lower House-Brackmann grades. Most cases were associated with neurological deficits leading to facial paralysis of central or congenital origin.

Intraparotid facial nerve neurofibroma: an uncommon neoplasm / Neurofibroma intraparotídeo del nervio facial: una neoplasia poco frecuente

Intraparotid facial nerve neurofibromas are a rare entity, and are grossly and histopathologically distinct from the comparatively more prevalent schwannomas. We report a rare case of an intraparotid facial nerve neurofibroma with intratemporal extension in a 48-year-old female. The tumor was surgically excised with cable grafting of the facial nerve. Electroneurography may eventually assist in the preoperative diagnosis. Facial nerve resection should be more readily contemplated in a patient with neurofibroma than in a patient with schwannoma; however, facial nerve preservation with serial follow-up electroneurography and computerized tomography remains a viable option in patients with small facial nerve neurofibromas when electrical testing reveals minimal evidence of progressive neural degeneration. Close monitoring, especially in neurofibromas associated with Von Recklinghausen's disease, is mandatory because of an increased risk of sarcomatous degeneration.

Los neurofibromas intraparotídeos del nervio facial son una entidad poco frecuente, macroscópicamente e histopatológicamente diferentes de los comparativamente más frecuentes schwannomas. Se presenta un caso raro de un neurofibroma del nervio facial con extensión intraparotídea intratemporal en una mujer de 48 años de edad. El tumor se extirpó quirúrgicamente con injerto del nervio facial. La electroneurografía puede llegar a ayudar en el diagnóstico preoperatorio. La resección del nervio facial debe ser realizada con mayor facilidad en un paciente con neurofibroma que en un paciente con schwannoma, sin embargo, la preservación del nervio facial con electroneurografía de seguimiento y tomografía computarizada sigue siendo una opción viable en pacientes con pequeños neurofibromas del nervio facial, cuando las pruebas eléctricas revelan mínima evidencia de degeneración neuronal progresiva. Una estrecha vigilancia, especialmente en los neurofibromas asociados con la enfermedad de Von Recklinghausen es fundamental debido al aumento del riesgo de degeneración sarcomatosa.

Schwanoma del facial gigante: preservación auditiva y facial mediante decompresión nerviosa / Giant facial shwannoma: hearing and facial function preservation with nerve decompression

Se reporta el caso de un schwanoma del nervio facial que compromete el nervio desde la porción laberíntica hasta la intraparotídea, con erosión de la cápsula ótica a nivel de la cóclea y función facial normal. Mediante decompresión nerviosa se logró preservación de las funciones facial y auditiva y a los 20 meses posoperatorios no hay evidencia de crecimiento tumoral. Se discuten las diferentes alternativas terapéuticas para aquellos casos con función facial y coclear normales.

This report describes a patient with a large facial nerve schwannoma, which involves the facial nerve from its labyrinthine portion until its intra parotid portion with normal facial function. There was also a mild erosion of the otic capsule. It was treated with nerve decompression with facial function andhearing preservation after two years of follow up.

A survey of facial nerve dessection techniques in benign parotid surgery among maxillofacial and ear, nose, and throat surgeons in Nigeria

Objective: The aim of the present study is to identify the facial nerve dissection technique routinely used during parotidectomy for benign parotid tumors by Nigerian Oral and Maxillofacial (OMF) and Ear; Nose; and Throat (ENT) Surgeons. Materials and Methods: A questionnaire-based study was conducted among Oral and Maxillofacial and Ear; Nose; and Throat Surgeons in Nigeria; on their experience with antegrade and retrograde facial nerve dissection techniques in parotid surgery. The respondents were asked to indicate their choice of dissection techniques in revision parotidectomy; limited superficial parotidectomy; and in obese patients with large tumors. They were also asked to indicate if they routinely used perioperative facial nerve monitoring devices in parotid surgery for benign tumors. Result: About half (47.5) of them routinely used the antegrade technique; while only a few (12.5) used the retrograde technique. A large number of them (40); however; used a combination of antegrade and retrograde routinely. Technical ease was the main reason for the choice of technique. The antegrade technique was the technique of choice by most respondents for revision parotidectomy (60) and limited superficial parotidectomy (62). However; the retrograde approach was the technique of choice by most of them (47) in case of parotidectomy in obese patients with large tumors. The routine use of perioperative facial nerve monitoring devices is an uncommon practice among OMF and ENT surgeons in Nigeria. Conclusions: The antegrade approach for facial nerve dissection is the most common technique used in parotid surgery by Nigerian OMF and ENT surgeons. Nigerian surgeons need to consider the retrograde approach in selected cases of parotid surgery especially for localized tumors that are amenable to limited superficial parotidectomy. Inclusion of perioperative facial nerve monitoring devices is also advocated

Anatomia aplicada do ramo temporal do nervo facial: estudo do risco potencial de lesão durante a cirurgia do rejuvenescimento facial / Applied anatomy of the branch of the facial nerve: study of the potential risk of injury during facial rejuvenation surgery

Introdução: O ramo temporal do nervo facial é um dos nervos mais comumente lesados, devido à pouca tela subcutânea que o protege a partir da sua saída da glândula parótida. Método: Vinte e cinco hemifaces de cadáveres foram dissecadas e analisadas as relações entre o ramo temporal e glândula parótida, arco zigomático, SMAS, artéria temporal superficial e músculo frontal. Resultados: Doze ramos temporais dissecados perderam a proteção da glândula parótida a uma distância de 1,7 cm anterior ao trago. O cruzamentodo arco zigomático por dois ramos temporais foi o mais frequente. A passagem pelo arco zigomático ocorreu entre 3,2 e 3,9 cm posteriores à borda lateral da órbita. O curso do ramo temporal junto às faces profundas do SMAS e da fáscia temporoparietal, e acima da lâmina superficial da fáscia temporal profunda foi constante. O ramo frontal da artéria temporal superficial foi superior e sua trajetória paralela ao ramo temporal em 92% das dissecções. Conclusão: O ramo temporal do nervo facial segue um plano constante ao longo da face profunda da fáscia temporoparietal e está muito superficial quando cruza o arco zigomático.

Background: The temporal branch of the facial nerve is one of the nerves more commonly injured due to the scarce subcutaneous tissue that protects it from its exit at the parotid gland. Method: Twenty five cadaveric hemifaces were dissected allowing a analysis of the temporal branch and: parotid gland, zygomatic arch, SMAS, superficial temporal artery and frontal muscle. Results: Twelve temporal branches exposed at a distance 1.7cm anterior to the trago. Two temporal branches crossing the zygomatic arc was the most frequent finding. This passage occurred between 3.2 to 3.9 cm posterior to the lateral border of the orbit. The trajectory of the temporal branch near the deep side of the SMAS and temporofacial fascia and above the superficial layer of the deep temporal fascia was constant. The frontal branch of the superficial temporal artery was superior and parallel to the nerve trajectory in 92% of the dissections Conclusion: The temporal branch follow a constant plane along the under surface of the temporoparietal fascia and is quite superficial as it cross the zygomatic arch.

Simulador cirúrgico para treinamento de dissecção do osso temporal / Surgical simulator for temporal bone dissection training

A dissecção em ossos temporais tem papel fundamental na formação de cirurgiões e sua obtenção esbarra em diversas dificuldades. OBJETIVO: Desenvolver uma réplica sintética do osso temporal para treinamento de dissecção. FORMA DE ESTUDO: Experimental. MATERIAIS E MÉTODOS: Foi desenvolvida uma réplica de resina acrílica termopolimerizante através de técnicas de moldagem com silicone. Para a avaliação do método, foram selecionados cinco cirurgiões otológicos para dissecção do modelo em laboratório de cirurgia experimental. Foi preenchido questionário, levando em consideração a aparência externa, a simulação de procedimentos (colocação de tubo de ventilação, mastoidectomia, descompressão do nervo facial e acesso translabiríntico ao meato acústico interno) e a impressão final. RESULTADOS: A avaliação apontou satisfação na utilização do modelo (80 por cento), sendo mais evidente no que se referiu à dissecção do segmento mastoide do nervo facial e ao acesso translabiríntico ao meato acústico interno. A colocação de tubo de ventilação foi razoável para 60 por cento e satisfatória para 40 por cento deles. A mastoidectomia foi totalmente satisfatória para 40 por cento. CONCLUSÃO: A dissecção neste simulador otológico não substitui o treinamento em ossos temporais de cadáveres, porém, dada a crescente dificuldade na obtenção destes, o desenvolvimento de novas ferramentas de ensino deve ser encorajado para o contínuo aprimoramento de cirurgiões.

Temporal bone dissection plays an important role in the training of surgeons; however, they are difficult to obtain. AIM: To develop a synthetic replica of the temporal bone for dissection training. STUDY DESIGN: Experimental. MATERIALS AND METHODS: An acrylic synthetic resin replica was obtained from a human temporal bone. For the evaluation of the method, we selected five ear surgeons to dissect the model in a laboratory of experimental surgery. A questionnaire was filled, assessing external appearance, the simulation of procedures (placement of ventilation tube, mastoidectomy, decompression of the facial nerve and translabyrinthine access to the internal auditory canal) and their final conclusion. RESULTS: The evaluation indicated satisfaction in using the model (80 percent), being more evident concerning the dissection of the mastoid segment of the facial nerve and translabyrinthine access to the internal auditory canal. The placement of a ventilation tube was reasonable for 60 percent and satisfactory for 40 percent of them. Mastoidectomy was satisfactory for 60 percent and fully satisfactory for 40 percent. CONCLUSION: Dissection in this simulator does not replace otologic training in cadaveric temporal bones. However, given the increasing difficulty in obtaining the latter, the development of new teaching tools should be encouraged to continuously improve surgeons.