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.

Outcome of different facial nerve reconstruction techniques.

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.

Giant Cell Tumor of the Temporal Bone Invading into the Pterygoid Muscle through the Temporomandibular Joint.

We report a case of giant cell tumor of the temporal bone invading into the pterygoid muscle through the temporomandibular joint. The patient was a 43-year-old woman who developed left ear fullness 2 years earlier with a mass in the external auditory canal. Radiologic evaluation revealed extension into the infratemporal fossa and confirmed that the tumor was invading into pterygoid muscle. A middle cranial fossa approach along with tympanoplasty was used for total resection of the tumor. Once a tumor invades into muscle tissue, meticulous care is required to remove it because identification of tumor tissue becomes extremely difficult.

Large middle ear schwannoma of the Jacobson's nerve with intracranial extension.

The patient is a 64-year-old woman who developed a sensation of right ear fullness and hearing loss in early November 2010. Physical examination revealed a painless reddish granular lesion filling in the right external auditory canal. Her right ear was deaf, and no facial palsy was noted. Computed tomography, magnetic resonance imaging and positron emission tomography revealed a middle ear mass extending to the external auditory canal with intracranial invasion causing temporal lobe retraction and inferiorly extending just anterior to the jugular bulb as well. A combination of transmastoid and middle cranial fossa approach along with anterior rerouting of the facial nerve was employed for a near-total removal of the tumor. Based upon the operative findings, it was deemed that the tumor could have arisen from the Jacobson's nerve.