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Objective: The incidence and risk factors for facial nerve dysfunction (FND) following CyberKnife® therapy for vestibular schwannoma (VS) remain poorly understood. This study investigates whether differential radiation doses to vulnerable segments of the facial nerve may be associated with FND outcomes., Methods: Patients were identified who underwent CyberKnife® radiosurgery for VS at a single institution. Basic demographics, tumor characteristics, and facial nerve function were collected. Total radiation doses to tumor, internal auditory canal (IAC), and labyrinthine segment of facial nerve (LSFN) were evaluated., Results: Six out of 64 patients experienced FND following CyberKnife® treatment for VS (9.38%, 6/64). Patients with FND were compared to those without FND (control). Of the 64 patients, complete radiation records were obtained for 30 patients (6 FND vs. 24 control). There were no significant differences in demographic or tumor characteristics between control and FND cohorts. More severe FND (HB ≥ 4) had significantly larger tumors (3.74 vs. 1.27 cm 3 , p = 0.037) with directionally decreased time to FND (3.50 vs. 33.5 months, p = 0.106) than patients with HB < 4, respectively. There were directionally, nonsignificant differences between maximum radiation doses to the LSFN (2492.4 vs. 2557.0 cGy, p = 0.121) and IAC (2877.3 vs. 2895.5 cGy, p = 0.824) between the control and FND cohorts, respectively., Conclusions: FND may represent an underrecognized sequelae of CyberKnife® radiosurgery for VS that can occur many months following treatment. Further studies are needed to elucidate the effect of differential radiation exposure to the facial nerve with FND following treatment., Level of Evidence: 3 (Retrospective Cohort Study) Laryngoscope, 134:5080-5086, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

The surgical approach to facial rejuvenation has evolved significantly over the last century. As surgeons have deepened their understanding of facial anatomy over the last half century, so have their surgical approaches to the rhytidectomy, with increasingly extensive manipulation of the underlying soft tissue in the face. While these procedures have become more comprehensive and natural in their approach, the risk of temporary facial palsy also appears to be on the rise. In this text, we review the technique for deep plane facelifts and neck contouring with an emphasis on the facial nerve anatomy and methods to preserve the intricate facial nerve network during tissue dissection and modification. Careful execution of the surgical steps involved, including deep neck contouring, SMAS (superficial musculoaponeurotic system) suspension, and skin management, is essential to achieve the authentic aesthetic outcomes that patients desire while ensuring patient safety., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Surgical resection is standard treatment for pleomorphic adenoma (PA) of the parotid gland. A small number (2-5%) of these tumors recur. Recurrence usually necessitates reoperation, which is technically challenging and puts the facial nerve (FN) at risk. The aim of this study is to characterize the recurrent parotid PA population and compare outcomes after surgery for singly recurrent and multiply recurrent tumors., Methods: This study was a retrospective chart review of patients at a single tertiary care academic medical center who underwent operations for recurrent PA of the parotid gland between 2007 and 2020. Demographic data, details of surgical interventions, pre- and postoperative FN function, and recurrence rates were studied. These factors were compared between patients with singly and multiply recurrent tumors., Results: Thirty-eight patients met criteria: 4 patients presented for primary PA and subsequently recurred, 26 with a first recurrence, 7 with a second recurrence, and 1 with a fourth recurrence. Multiply recurrent PAs were more likely to require at least partial nerve sacrifice at the time of reoperation ( P = 0.0092). Significantly worse long-term FN outcomes were seen following surgery for multiply recurrent PA ( P = 0.008). There was no significant difference between the rate of re-recurrence following first revision surgery vs second-fourth revision surgery. Time to reoperation was significantly shorter between the first and second revision surgery than between the primary surgery and first revision ( P = 0.0017)., Conclusion: Surgery for recurrent PA incurs high risk to the FN, and this risk appears to increase in the setting of multiple recurrences., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study aimed to analyze the effects of anterior descending mandible (ADM) and free superior mesenteric artery (SMAS) folding flaps on post-parotidectomy facial depression., Methods: This retrospective study examined the effects of sex, age, surgical sample size, method, duration, and blood loss on postoperative complications in 65 patients., Results: No significant differences involving sex, age, or sample size for surgical resection were observed between the two groups. The incidence of Frey syndrome (P = 0.175) and the locations of facial nerve injuries and tumors were not significantly different between the two groups. However, a statistically significant difference was observed in postoperative facial depression between the groups (P = 0.045, P < 0.05). No significant difference was found between facial nerve injury and Frey's sign in subgroup analysis of facial depression deformities. Within the facial depression group, tumor locations were significantly different (P = 0.021, P < 0.05). In the cases of facial depression after partial parotid resection, no significant difference was observed between ADM implantation and SMAS flap placement. A significant difference was noted between the ADM implantation and SMAS flap groups in the total parotidectomy group (P = 0.046 and P < 0.05, respectively)., Conclusion: Women are more likely to experience facial depression after parotid surgery. Facial depression is most likely to occur after parotid resection if the tumor is located in the deep lobes of the parotid gland. The use of SMAS flaps can prevent facial depression, and both ADM and SMAS flaps can prevent Frey's syndrome. Partial parotid resection reduces the risk of facial nerve injury and facial depression., Competing Interests: Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the People’s Hospital of Anshun City (Ethical Application Ref: ASSRMYYLLZ2). Consent for publication All participants agreed to participate in the study and provided written informed consent. Consent to publish from patients The inclusion of the patient’s portrait has received the patient’s consent. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Facial nerve baroparesis is a peripheral facial nerve injury resulting from barotrauma during activities such as diving, aviation, and mountain climbing. This condition occurs when increased pressure in the middle ear affects the facial nerve, leading to facial palsy. Despite being documented in otolaryngology literature, facial nerve baroparesis remains underreported and often misunderstood. Enhanced awareness and education about this condition are essential for effectively managing affected patients, helping to mitigate unnecessary panic and procedures during episodes., Case Presentation: We present two cases of facial nerve baroparesis that occurred during flights. The first case involves a 25-year-old Arab male with no significant medical history who experienced a transient, one-time episode of right-sided facial nerve baroparesis during a flight from Kuwait to Syria; he reported nasal congestion and a sore throat prior to the flight, with the episode lasting approximately 30 min before resolving spontaneously. The second case is a 30-year-old Arab female with a history of chronic allergic rhinitis, who has experienced recurrent episodes of left-sided facial nerve baroparesis for the past 2 years, occurring during nearly every flight; each episode lasted around 5 min, caused severe facial pain, and also resolved spontaneously. Both patients exhibited varying degrees of Eustachian tube dysfunction. Treatment for the recurrent case included maneuvers to alleviate ear pressure and the use of nasal decongestants, which improved symptoms and decreased the frequency of episodes., Conclusion: Facial nerve baroparesis is frequently underestimated due to its temporary nature, yet it remains a significant cause of facial nerve palsy, especially after changes in pressure. Although the underlying mechanisms are not completely understood, dysfunction of the Eustachian tube is believed to be a contributing factor. Identifying the characteristic features of baroparesis-such as rapid onset, brief duration, and bilateral involvement of facial muscles-is essential for effective management. This highlights the necessity of educating healthcare professionals and flight personnel about this condition to prevent unnecessary treatments. For recurrent cases, management strategies should focus on alleviating Eustachian tube dysfunction., Competing Interests: Declarations Ethics approval and consent to participate: This is a case report; therefore, it did not require ethical approval from the ethics committee. Consent Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal Competing interests The Author declares no competing interest., (© 2024. The Author(s).)

&lt;b&gt;Introduction:&lt;/b&gt; Surgical removal of recurrent parotid gland tumours is the first-line treatment but presents an increased risk of facial nerve injury and a considerable re-recurrence failure rate.&lt;b&gt;Aim:&lt;/b&gt; Identification of individuals exposed to a higher risk of re-procedure, raising awareness in the preoperative setting, and proposing an optimal follow-up.&lt;b&gt;Methods:&lt;/b&gt; The retrospective review included 72 patients treated with revision surgery in a single centre. The demographics, clinicopathologic variables, and operative details were analysed.&lt;b&gt;Results:&lt;/b&gt; Recurrent pleomorphic adenoma (PA) was the main reason for reoperation (66.7%), followed by new monomorphic adenoma (13.9%), resection extension (12.5%), and malignancy recurrence (6.9%). Time to revision surgery was on average 68.6 months and was the shortest for extended resection cases (average 1.9 months). The period was substantially longer in recurrent PA (90.8 months). The final facial nerve function according to the House-Brackmann scale (HBS) decreased in 37% of patients after reoperation. The number of recurrences per patient ranged from one in 61% of cases to eight in a solitary case.&lt;b&gt;Conclusions:&lt;/b&gt; The rate of revision parotid surgery was 8.4%. Negative margins at the first resection were not of protective significance. Recurrent PA was the main cause of revision surgery and over one-third of this cohort had a subsequent relapse. As many as 37% of patients experienced a decrease in facial nerve function following revision surgery.

The removal of vestibular schwannomas carries a risk of facial palsy. This study aims to evaluate the usefulness and technical aspects of intraoperative monitoring (IOM) for the facial nerve. A total of 96 patients who underwent surgery for vestibular schwannoma were retrospectively investigated. The cohort was divided into two groups: those with intraoperative facial nerve monitoring (IOM group) and those without IOM (non-IOM group). Preoperative and postoperative facial nerve functions were assessed using the House-Brackmann (HB) scale immediately after surgery, at discharge, and at the 1-year follow-up. HB grade I and II were classified as satisfactory outcomes, HB grade III and IV as intermediate, and HB grade V and VI as poor. Facial nerve functions were compared between the groups. Additionally, the ratio of satisfactory results was investigated in the IOM group, focusing on whether the root exit zone (REZ) was identified at an early or late stage of surgery. Among the 65 (67%) patients in the IOM group and 31 (32%) patients in the non-IOM group, there were no differences in demographic and tumor characteristics. The extent of resection varied from subtotal to gross total removal, with no statistical differences between the groups. Although facial nerve function was more favorably preserved in the non-IOM group immediately after surgery, this trend reversed at discharge and the 1-year follow-up, showing significant statistical differences. In the IOM group, more patients achieved satisfactory outcomes when the REZ was identified early compared to late during tumor resection. Intraoperative facial nerve monitoring provides more satisfactory outcomes in preserving nerve function in vestibular schwannoma surgery. Early recognition of the REZ may contribute to improved surgical outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

It is well known that the digastric posterior belly is one of the essential landmarks for facial nerve identification during parotid surgery. While there were multiple reports about variations of the digastric anterior belly, only a few anatomical variations of the posterior belly of the digastric muscle have been described.In this article, we describe an anatomical variation of the posterior belly of digastric muscle found during superficial parotidectomy of a patient with pleomorphic adenoma. This anatomical variation also led to an anatomical variation in the position of the facial nerve.To our knowledge, this is the first report of an absent posterior belly of digastric muscle found during live parotid surgery. The knowledge of current anatomical variation may help to avoid facial nerve injury during parotid surgery and preserve the function of muscles of facial expression., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Facial nerve (FN) injury during a face lift is a relatively rare but potentially devastating complication. Despite extensive literature discussing FN anatomy and danger zones, few studies describe detailed management, FN exploration intraoperative findings, and outcome after post-face lift facial paralysis (PFFP). The authors reviewed a 20-year experience in managing iatrogenic PFFP., Methods: Patients with PFFP were retrospectively identified between 2002 and 2022. Demographic data, operative details from the face lift procedure, facial function after face lift, medical and surgical management, intraoperative findings, and long-term outcomes were analyzed., Results: A total of 25 patients who experienced PFFP were referred for evaluation over the past 20 years. Eight patients required FN exploration, 6 of whom underwent nerve repair; all recovered to some degree, with 50% achieving essentially normal facial function. Fourteen patients underwent nonsurgical management, including physical therapy, chemodenervation, and filler therapy. Of these nonsurgical patients who were not lost to follow-up, 50% achieved normal facial function and 42% achieved nearly normal facial function. The single patient who had no spontaneous improvement presented outside the reinnervation window and was not an operative candidate., Conclusions: PFFP outcome depends on injury type and location, accurate assessment, and appropriate treatment; however, the overall prognosis is favorable. FN exploration is warranted when nerve transection is suspected. Observation is suitable for patients demonstrating early signs of recovery. Patients presenting beyond a reasonable reinnervation window will need other facial reanimation techniques. When FN exploration is required, outcomes may be superior in a facial nerve center setting. Adjunctive interventions for symmetry improvement while awaiting recovery are available., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

The purpose of this retrospective study was to identify risks of postoperative facial nerve injury (FNI) in mandibular condylar fractures. A total of 59 consecutive cases of condyle fracture or plate removal with a retromandibular transparotid approach (RMTA) were divided into FNI and non-FNI groups that were evaluated for associations with age, sex, laterality, fracture type, height, weight, body mass index (BMI), and maxillofacial bone height and width diameters on computed tomography (CT). FNI occurred in 11 of 59 patients (18.64%), all of them female (p = 0.0011). Other statistically significant factors on univariate analysis for FNI included a short height (156.95 ± 8.16 cm vs. 164.29 ± 9.89 cm, p = 0.04), low weight (46.08 ± 8.03 kg vs. 58.94 ± 11.79 kg, p = 0.003), low BMI (18.64 ± 2.63 kg/m 2 21.68 ± 3.02 kg/m 2 , p = 0.007), short condylion-anterior fracture distance (19.34 ± 3.15 mm vs. 22.26 ± 3.96 mm, p = 0.04) and short condylion-posterior fracture distance (20.12 ± 3.98 mm vs. 25.45 ± 5.02 mm, p = 0.009). Our retrospective study suggested that FNI with RMTA surgery occurs particularly in female patients and may occur more frequently in patients who are short, lean or have high condyle fractures., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Facial nerve (FN) dysfunction is a potential complication during open reduction of mandibular condylar fractures., Purpose: The purpose of this study was to measure and compare the postoperative FN function following transparotid (TP) and transmasseteric anterior parotid (TMAP) operative approaches in open reduction and internal fixation of condylar fractures using electromyogram., Study Design, Setting, Sample: A randomized controlled clinical trial was designed. The study was conducted in a single tertiary-care hospital in the inpatient setting. Patients aged above 18 years with unilateral condylar fracture of the jaw or bilateral condylar fractures undergoing surgery on only 1 side were included. Patients were excluded if they had fractures of the head, bilateral condylar fractures with surgery planned on both sides, a previous history of surgery in the retromandibular area, existing lacerations to approach condyle, preoperative signs of FN weakness, or a history of parotid surgery., Predictor Variable: The predictor variable was the operative approach and the subjects were allocated randomly to TMAP and TP., Main Outcome Variable(s): The primary outcome variable was postoperative FN function in the surgical approach employed using the House-Brackmann scale and electromyography (EMG) to record any subtle weakness in nerve function. The FN function is recorded at 3 time intervals postoperatively 1 week (T1), 1 month (T2), and 3 months (T3). The secondary outcomes studied were operating time and any other complications recorded., Covariates: Age, sex, fracture pattern with classification of condylar fractures into condylar neck or base fractures according to Loukata et al. 4 Any associated fracture of mandible describing the anatomical location viz symphysis and parasymphysis (anterior mandible), body, contralateral condyle or greater than 1 associated fracture were recorded. Similarly, the presence or absence of any associated midface fracture was also recorded to suggest that the study participants were homogenous in all aspects., Analyses: Analytical statistics included χ 2 test, t-test, and repeated measures ANOVA followed by post hoc test to compare EMG data (mean power and mean amplitude) between 2 operative approaches (TP vs TMAP) for facial muscles including frontalis, oculi, and buccinator at different time intervals (T0, T1, T2, T3). Patients within each group were also analyzed to check for nerve recovery occurring during the follow-up period. The level of significance was set at P < .05., Results: The study sample was composed of 22 patients with a mean age of 32.82 ± 11.21 years in TMAP and 27.82 ± 8.54 years in the TP group respectively (P = .26); male predominance of 81.8 and 90.9% in TMAP and TP group respectively (P = .53) was noted. The FN deficit as assessed by the House-Brackmann scale clinically, was at 54% (T1), 36.4% (T2), and 9.1% (T3) for the TP group and 27% (T1),9% (T2), and 0% (T3) for TMAP group; however, the results were statistically insignificant (P = .31). In surface EMG evaluation, the mean power for the frontalis muscle was significantly higher in the TMAP approach at the T3 time (105.03 ± 9.7 vs 89.56 ± 10; 95% confidence interval -24.28 to -6.65 with P value = .002). TP approach was faster with a mean exposure time of 9.9 minutes., Conclusion and Relevance: The results show that both approaches give comparable long-term results with the TMAP group showing better frontalis muscle activity., (Copyright © 2024 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: To present the current literature on management of facial nerve disorder secondary to trauma, with a focus on the utility of electrodiagnostic testing in this setting., Recent Findings: Patients with facial palsy related to temporal bone fractures should be started on high-dose corticosteroids as early as possible. Recent literature on the benefit of surgical intervention in the setting of temporal bone fracture is mixed. Some studies support early surgical decompression whereas others have found no benefit compared with conservative treatment., Summary: The management of facial nerve trauma is based on location and extent of injury. Extratemporal trauma and transected nerve should be treated with surgical exploration and tension-free coaptation ideally within 72 h. There are no guidelines for intratemporal facial nerve trauma. Surgical decompression compared with medical management is debated in the literature without consensus and more large studies are needed., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We aim to report a rare case of a herniated mastoid segment of the facial nerve that was accidently discovered during cochlear implantation surgery and how altering the surgery plan could achieve the implantation while preserving the nerve., Case Presentation: A four-year-old girl presented with profound bilateral sensorineural hearing loss that did not completely resolve after 2 years of using hearing aids was scheduled for cochlear implantation surgery in the right ear. During surgery, a herniated mastoid segment of the facial nerve took an anterior course and obstructed the access to the round window., Conclusion: When a traditional posterior tympanotomy approach in cochlear implantation surgery is limited in cases of a herniated facial nerve, a tunnel created near the inferior part of the posterior wall of the auditory canal provided safe insertion of the electrode. It also permitted placement of a piece of fascia between the electrode and the facial nerve, therefore, protecting the facial nerve from electrical stimuli., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The ideal goal of treatment for medium to large vestibular schwannoma is complete tumor removal with preservation of all cranial nerves. However, despite the advancements in microsurgery and intraoperative monitoring, the risk of facial nerve dysfunction following total resection varies between 31% and 57%. Currently, the goal of treatment for large tumors is shifting from total excision to facial nerve preservation., Objective: To evaluate the facial nerve outcome in patients who underwent subtotal excision with or without subsequent gamma knife radiosurgery for large vestibular schwannomas in our institute., Methods and Material: All patients who underwent primary surgery for large vestibular schwannomas between January 2012 and December 2016 were analyzed retrospectively. Cases where total excision was not done and a residue was left behind to prevent facial nerve injury during surgery were included in the study., Results: A total of 52 patients who met the inclusion criteria were analyzed. At final follow-up, 70% of patients had good facial nerve function (H-B grade 1 and 2). In patients with normal facial nerve function preoperatively, 81% (25/31) of them had good facial nerve outcomes (H-B grade 1 and 2), whereas in patients with preexisting facial nerve deficits, nearly 62% (13/21) of them either maintained or had improvement in their facial nerve grades., Conclusion: Good facial nerve outcomes and tumor control rate is obtained by subtotal excision of VS followed by upfront or delayed GKRS; however, there is a need for long-term follow-up to detect recurrences in these slow-growing tumors., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Objectives: Iatrogenic facial nerve palsy following otological surgery is a devastating complication that results in adverse aesthetic and functional outcomes. This study aims to review studies that have reported cases of immediate facial nerve palsy to learn why and where injuries occurred and to assess outcomes following management., Databases Reviewed: MEDLINE, Embase, Cochrane CENTRAL, and Pubmed up to June 20, 2023., Methods: Clinical studies of immediate facial nerve palsies following middle ear and cochlear implantation surgery were included. Risk of bias was examined using the Brazzelli risk of bias tool. Due to the inconsistency in reporting of outcomes, we were unable to perform a meta-analysis., Results: Of 234 studies identified, 11 met the inclusion criteria. The most common causes of injury were excessive drilling, use of sharp hooks to remove disease, or disorientation of the surgeon secondary to bleeding or inflammation. Variable usage of preoperative computed tomography (CT) imaging and intraoperative facial nerve monitoring was reported. The tympanic segment was the most common site of injury. A variety of surgical techniques were employed to approach the facial nerve injury including facial nerve decompression, direct closure, and repair using an autologous nerve graft., Conclusions: Otological surgeons should consider utilizing preoperative CT imaging to establish a three-dimensional mental image of key landmarks and anatomical variations before embarking on surgery. Intraoperative FN monitoring enables safe practice. Despite these measures, complex disease processes and hostile intraoperative conditions can present difficulty. Multiple treatment options are available to treat the underlying injury., Competing Interests: Conflict of Interest: Nil., (Copyright © 2024, Otology & Neurotology, Inc.)

The purpose of this study was to assess the effects of protecting the facial nerve with a modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint which allows an excellent operative field of visualization, multiple surgical procedures of the temporomandibular joint, and general care which improves the immediate postoperative period, making this a less morbid surgery. This study included 33 patients (39 sides) who underwent surgical treatment for disorders of the temporomandibular joint from the years 2021 to 2023 at the maxillofacial department of the clinic "Colsanitas" located in Bogota, Colombia. Therapeutic results were evaluated by postoperative facial nerve injury, with the House-Brackman scale; every patient was examined for adequate facial musculature function immediately after surgery. Notably, zero patients presented facial nerve injury. These results imply that the modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint reduces the incidence of facial nerve injuries, improves operative site exposure, and lowers the frequency of complications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Vestibular schwannomas (VS) are the most common tumor of the skull base with available treatment options that carry a risk of iatrogenic injury to the facial nerve, which can significantly impact patients' quality of life. As facial nerve outcomes remain challenging to prognosticate, we endeavored to utilize machine learning to decipher predictive factors relevant to facial nerve outcomes following microsurgical resection of VS. A database of patient-, tumor- and surgery-specific features was constructed via retrospective chart review of 242 consecutive patients who underwent microsurgical resection of VS over a 7-year study period. This database was then used to train non-linear supervised machine learning classifiers to predict facial nerve preservation, defined as House-Brackmann (HB) I vs. facial nerve injury, defined as HB II-VI, as determined at 6-month outpatient follow-up. A random forest algorithm demonstrated 90.5% accuracy, 90% sensitivity and 90% specificity in facial nerve injury prognostication. A random variable (rv) was generated by randomly sampling a Gaussian distribution and used as a benchmark to compare the predictiveness of other features. This analysis revealed age, body mass index (BMI), case length and the tumor dimension representing tumor growth towards the brainstem as prognosticators of facial nerve injury. When validated via prospective assessment of facial nerve injury risk, this model demonstrated 84% accuracy. Here, we describe the development of a machine learning algorithm to predict the likelihood of facial nerve injury following microsurgical resection of VS. In addition to serving as a clinically applicable tool, this highlights the potential of machine learning to reveal non-linear relationships between variables which may have clinical value in prognostication of outcomes for high-risk surgical procedures., (© 2024. The Author(s).)

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., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Mandibular fractures are common facial fractures, and contemporary management of mandibular condylar fractures is controversial. The purpose of this study was to compare the outcomes of patients who sustained a mandibular condylar fracture between 2016 and 2020, who were managed by either open or closed techniques. The outcomes of this study were: post-operative facial nerve function, occlusion, and maximal mouth opening., Methods: This study is a retrospective multicentre cohort study which assessed clinical records for 246 patients with mandibular condyle fractures in three hospitals in Perth, Western Australia. The primary outcome measure was changes in post-operative facial nerve function., Results: One hundred and thirty-two patients underwent open reduction and internal fixation (ORIF), and 114 patients had closed management. The overall rate of temporary facial nerve injury following ORIF was 3.28%. The overall rate of permanent facial nerve injury was 0.82%. Sialocoele occurred in 2.46% of all patients who underwent ORIF. 6.14% of patients had persisting malocclusion across both groups. There was a statistically significant association between the degree of fragment shortening and facial nerve injury (P = 0.0063), with more facial nerve changes in the group with 5 mm or greater of fragment shortening., Conclusions: There is still significant debate over the management of mandibular condylar injuries. This study demonstrates a similar rate of temporary and permanent facial nerve injury as previously described, as well as a similar rate of sialocoele occurrence. Further prospective studies may provide clarity about important characteristics that will help guide decision making for mandibular condylar fractures., (© 2023 Royal Australasian College of Surgeons.)

Background and Objectives: The emergence of machine learning models has significantly improved the accuracy of surgical outcome predictions. This study aims to develop and validate an artificial neural network (ANN) model for predicting facial nerve (FN) outcomes after vestibular schwannoma (VS) surgery using the proximal-to-distal amplitude ratio (P/D) along with clinical variables., Methods: This retrospective study included 71 patients who underwent VS resection between 2018 and 2022. At the end of surgery, the FN was stimulated at the brainstem (proximal) and internal acoustic meatus (distal) and the P/D was calculated. Postoperative FN function was assessed using the House-Brackmann grading system at discharge (short-term) and after 9-12 months (long-term). House-Brackmann grades I-II were considered good outcome, whereas grades III-VI were considered fair/poor. An ANN model was constructed, and the performance of the model was evaluated using the area under the ROC curve for internal validation and accuracy, sensitivity, specificity, and positive and negative predictive values for external validation., Results: The short-term FN outcome was grades I-II in 57.7% and grades III-VI in 42.3% of patients. Initially, a model using P/D had an area under the curve of 0.906 (internal validation) and an accuracy of 89.1% (95% CI: 68.3%-98.8%) (external validation) for predicting good vs fair/poor short-term FN outcomes. The model was then refined to include only muscles with a P/D with a proximal latency between 6 and 8 ms. This improved the accuracy to 100% (95% CI: 79%-100%). Integrating clinical variables (patient's age, tumor size, and preoperative HB grade) in addition to P/D into the model did not significantly improve the predative value. A model was then created to predict the long-term FN outcome using P/D with latencies between 6 and 8 ms and had an accuracy of 90.9% (95% CI: 58.7%-99.8%)., Conclusion: ANN models incorporating P/D can be a valuable tool for predicting FN outcomes after VS surgery. Refining the model to include P/D with latencies between 6 and 8 ms further improves the model's prediction. A user-friendly interface is provided to facilitate the implementation of this model., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Condylar fracture treatment is a debated topic among maxillofacial surgeons. Various surgical techniques are used today, each one with advantages and disadvantages. The aim of this study is to present and evaluate our technique adopted for treatment of any type of extracapsular condylar fractures. Between 2020 and 2022, 16 condylar fractures were treated. In two patients with bilateral condylar fractures, the present technique was compared to the mini-retromandibular approach. All the patients were checked for clinical and radiological outcomes, facial nerve injury, scar visibility and presence of salivary complications. Dental occlusion was always restored, and facial nerve damage or salivary disorders were not observed. The skin incision, limited to the caudal two-thirds of the auricle, made the scar almost invisible and greatly improved the surgical field in the condylar neck area, facilitating the treatment. The proposed technique provides easier internal fixation for both neck and base condylar fractures with good cosmetic results, ensuring better protection of the facial nerve and parotid gland. The surgical technique described has not shown disadvantages in terms of operational difficulty, results, and complications. This novel surgical technique could represent a new choice in the treatment of extracapsular condylar fractures, although further studies are needed to support this new proposal., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Delayed facial palsy (DFP) is a common and unique complication after resection of vestibular schwannoma (VS). Few studies have focused on the clinical question of whether patients with DFP can be expected to have the same long-term prognosis in terms of facial nerve function as those without DFP based on their facial nerve function immediately postoperatively. This study aimed to clarify the clinical impact of DFP on the long-term functional status of the facial nerve after VS resection., Methods: The authors retrospectively reviewed patients with sporadic VS who were treated surgically via a retrosigmoid approach between January 2002 and March 2020. DFP was defined as de novo deterioration of facial nerve function by a House-Brackmann (HB) grade ≥ I more than 72 hours postoperatively. The incidence of DFP after VS resection and its impact on long-term facial nerve function were analyzed., Results: DFP developed in 38 (14.3%) of 266 patients who met the inclusion criteria. The median latency until DFP onset postoperatively was 8.5 days. When facial nerve function was normal immediately postoperatively, the rate of preservation of favorable facial nerve function (HB grade I or II) at 24 months postoperatively was 100% for all patients regardless of whether they developed DFP. In contrast, when facial nerve dysfunction was present immediately postoperatively, the rate of preservation of favorable facial nerve function at 24 months postoperatively was significantly lower in patients with DFP than in those without DFP (77.8% vs 100% in patients with HB grade II immediately postoperatively, p = 0.001; 50.0% vs 90.3% in those with HB grade III immediately postoperatively, p = 0.042). DFP development had a significantly negative impact on the long-term functional status of the facial nerve postoperatively when age, tumor size, and HB grade immediately postoperatively were taken into account (OR 0.04, 95% CI 0.01-0.20; p < 0.001)., Conclusions: DFP can be a minor complication when normal facial nerve function is observed immediately after surgery. However, when facial nerve dysfunction is present immediately after surgery, even if mild, the long-term prognosis for facial nerve function is significantly worse in patients with DFP than in those without DFP.

Background/aim: Mandibular condylar fractures represent 25%-35% of all mandibular fractures. Despite profound research, there is still a controverse debate about treating these fractures conservatively or by open reduction and internal fixation (ORIF). The aim of this study is to analyse the outcome after open and closed treatment of extracapsular mandibular condyle fractures regarding general characteristics, post-treatment malocclusion, facial nerve palsy (FNP), maximum mouth opening (MMO) and parotid complications., Methods: A retrospective cohort of 377 fractures (350 open, 27 closed treatment) was reviewed by reference to clinical and radiological pre- and postoperative documentation. Follow-up period was 12 months. Pearsons' chi-square-test, correlations, Kruskal-Wallis test and t-test were carried out for statistical analysis., Results: The dominant type of fracture was type II in Spiessl and Schroll classification (50.1%). In the open treated fractures, the most common approach was retromandibular transparotid (91.7%). Post-treatment malocclusion occurred in 18.0% and was significantly increased in bilateral fractures (p = .039), in luxation fractures (p = .016) and in patients with full dentition (p = .004). After open reduction and internal fixation (ORIF), temporary FNP was documented in 7.1% whereas a permanent paresis occurred in 1.7%. FNP was significantly associated with high fractures (p = .001), comminution (p = .028) and increased duration of surgery (p = .040). Parotid complications were significantly associated with revision surgery (p = .009). Post-treatment reduction of MMO mainly occurred in female patients (p < .001) as well as in patients with bilateral fractures (p < .001), high fractures (p = .030) and concomitant mandibular (p = .001) and midfacial fractures (p = .009)., Conclusion: Malocclusion seems to be the most frequent long-term complication after open reduction and osteosynthesis of extracapsular mandibular condyle fractures. We suggest ORIF by a transparotid approach to be an appropriate treatment with a low complication rate regarding especially FNP for extracapsular fractures of the mandibular condyle., (© 2023 The Authors. Dental Traumatology published by John Wiley & Sons Ltd.)

The accurate identification and preservation of the facial nerve (FN) during vestibular schwannoma (VS) surgery is crucial for maintaining facial function. Investigating the application of diffusion tensor imaging (DTI) in preoperative planning for large VS surgery is provided. PubMed, Cochrane Library, Science Direct, ISI Web of Science, Embase, and additional sources were searched to identify cohort studies about the preoperative DTI usage for the FN tracking before large VS (≥ 2.5 cm) surgery published between 1990 and 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed; the Newcastle-Ottawa Scale was used to assess the risk of bias and to evaluate limitations based on selection/outcome biases. A total of 8 publications yielding 149 VS (mean size 3.66 ± 0.81 cm) were included. Surgical concordance with preoperative DTI FN tracking was 91.67% (range 85-100%). Overall DTI reliability was 88.89% (range 81.81-95.83%). Larger tumor size predicted either DTI inaccurate finding or complete DTI failure (p = 0.001). VS size above > 3.5 cm was associated with a higher risk of DTI failure (p = 0.022), with a higher risk of inaccurate DTI finding preoperatively (p = 0.033), and with a higher House-Brackman score postoperatively (p = 0.007). Application of DTI in larger VS surgery is a valuable FN identification along with electrophysiological monitoring and neuronavigation, therefore also in its preservation and in lowering risk of complications. DTI represents a valuable adjunct to electrophysiological monitoring and neuronavigation in FN identification, applicable not only for smaller, but also larger VS., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Parotid pleomorphic adenoma (PA) patients present significant diagnostic and surgical challenges rendering them high risk for facial nerve injury. Recurrent PA patients often present with history of facial nerve injury or previous reanimations making salvage of the facial nerve or previous reanimations significantly more complex. The study aim is to share our experience with this high risk for facial nerve injury population and review the literature., Methods: Adult patients with recurrent PA and history of facial nerve injury with at least 3 months of follow-up were analyzed for demographics, facial palsy history, previous head and neck surgeries, previous facial paralysis reconstruction, preoperative imaging, surgical approach, and postoperative outcomes., Results: Four female patients were identified with an average age of 62 years. All patients underwent an initial protective dissection of the facial nerve or previous reanimation reconstruction by the facial nerve reconstructive team followed by the extirpative team. The average number of previous head and neck surgeries was 5, the number of recurrences was 2, and follow-up was 20 months. Half had prior dynamic facial reanimation. Two patients underwent complete preextirpative dissection of the facial nerve resulting in neuropraxia, which recovered completely after an average of 143 days. A third patient presented with 2 recurrences, both during and after reanimation with a dually innervated free functional muscle transfer. The reconstruction was salvaged, and motion was achieved. A fourth patient presented with benign preoperative findings, but intraoperative findings confirmed malignancy, necessitating facial nerve sacrifice, followed by immediate intratemporal grafting of the facial nerve and masseteric nerve transfer. Motion appeared 139 days postoperatively., Conclusions: A multidisciplinary effort should be implemented in this high risk for facial nerve injury population with the primary goal of protecting the facial nerve or any previous reanimation procedures, yet with preparedness to apply any reconstructive strategy based on intraoperative findings., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The paper summarizes the academic thought and clinical experience of professor LI De-hua in treatment of facial nerve injury after total parotidectomy with blade needle based on jingjin (muscle region of meridian, sinew/fascia) theory. This disease is located at muscle regions of hand-/foot-three yang meridians; and the sinew/fascia adhesion is its basic pathogenesis, manifested by "transversely-distributed collaterals" and "knotted tendons". In treatment, the knotted tendons are taken as the points. Using the relaxation technique of blade needle, the lesions of sinews/fascia are dissected and removed to release the stimulation or compression to the nerves and vessels so that the normal function of sinews/fascia can be restored.

Objectives: To investigate a method for predicting postoperative facial nerve paralysis (POFNP) during parotid surgery using intraoperative nerve monitoring (IONM)., Methods: We assessed prediction for POFNP by using IONM, comparing between stimulation in the facial nerve trunk and each branch by using facial nerve monitoring. The amplitude response ratio (ARR) was calculated for the trunk/periphery. In addition, we then examined the correlation between ARR and time to recovery of paralyzed branches., Results: 372 branches of 93 patients did not develop POFNP and were classified as group A. Among 20 patients who developed POFNP, 51 branches without POFNP were classified as group B, and 29 branches with POFNP were classified as group C. The ARR was approximately 1 in group A and B. but less than 0.5 in all branches in Group C. When the cut off value of ARR was set at 0.55, the sensitivity, specificity, and accuracy of POFNP diagnosis by ARR were 96.5%, 93.1%, and 96.8%, respectively., Conclusion: Using IONM during parotid surgery enables easy prediction of POFNP., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Koos grade 4 vestibular schwannoma (KG4VS) is a large tumor that causes brainstem displacement and is generally considered a candidate for surgery. Few studies have examined the relationship between morphological differences in KG4VS other than tumor size and postoperative facial nerve function. The authors have developed a landmark-based subclassification of KG4VS that provides insights into the morphology of this tumor and can predict the risk of facial nerve injury during microsurgery. The aims of this study were to morphologically verify the validity of this subclassification and to clarify the relationship of the position of the center of the vestibular schwannoma within the cerebellopontine angle (CPA) cistern on preoperative MR images to postoperative facial nerve function in patients who underwent microsurgical resection of a vestibular schwannoma., Methods: In this paper, the authors classified KG4VSs into two subtypes according to the position of the center of the KG4VS within the CPA cistern relative to the perpendicular bisector of the porus acusticus internus, which was the landmark for the subclassification. KG4VSs with ventral centers to the landmark were classified as type 4V, and those with dorsal centers as type 4D. The clinical impact of this subclassification on short- and long-term postoperative facial nerve function was analyzed., Results: In this study, the authors retrospectively reviewed patients with vestibular schwannoma who were treated surgically via a retrosigmoid approach between January 2010 and March 2020. Of the 107 patients with KG4VS who met the inclusion criteria, 45 (42.1%) were classified as having type 4V (KG4VSs with centers ventral to the perpendicular bisector of the porous acusticus internus) and 62 (57.9%) as having type 4D (those with centers dorsal to the perpendicular bisector). Ventral extension to the perpendicular bisector of the porus acusticus internus was significantly greater in the type 4V group than in the type 4D group (p < 0.001), although there was no significant difference in the maximal ventrodorsal diameter. The rate of preservation of favorable facial nerve function (House-Brackmann grades I and II) was significantly lower in the type 4V group than in the type 4D group in terms of both short-term (46.7% vs 85.5%, p < 0.001) and long-term (82.9% vs 96.7%, p = 0.001) outcomes. Type 4V had a significantly negative impact on short-term (OR 7.67, 95% CI 2.90-20.3; p < 0.001) and long-term (OR 6.05, 95% CI 1.04-35.0; p = 0.045) facial nerve function after surgery when age, tumor size, and presence of a fundal fluid cap were taken into account., Conclusions: The authors have delineated two different morphological subtypes of KG4VS. This subclassification could predict short- and long-term facial nerve function after microsurgical resection of KG4VS via the retrosigmoid approach. The risk of postoperative facial palsy when attempting total resection is greater for type 4V than for type 4D. This classification into types 4V and 4D could help to predict the risk of facial nerve injury and generate more individualized surgical strategies for KG4VSs with better facial nerve outcomes.

Purpose: To explore a minimally invasive trans-canal endoscopic facial nerve decompression for traumatic facial nerve palsy and compare it with microscopic facial nerve decompression., Methods: 35 and 38 patients underwent endoscopic and microscopic facial nerve decompression, respectively, for traumatic facial nerve palsy. Onset of symptoms, type of temporal bone fracture, day of surgical intervention following trauma, ossicular chain status and nature of insult to facial nerve were observed. Time period for recovery (House Brackmann grade ≤ 3), long term recovery rates, pre- and post-operative hearing status, surgical time and post-operative pain were compared between groups., Results: Maximum patients in endoscopic and microscopic groups (77.1% and 76.3%, respectively) had acute onset of symptoms. 57.1% (20/35) had longitudinal, 17.1% (6/35) had transverse and 25.7% (9/35) had mixed fractures in endoscopic group. In the microscopic group, 57.9% (22/38) had longitudinal, 18.4% (7/38) had transverse and 23.7% (9/38) had mixed fractures. The mean (± S.D.) post-operative air-bone gap in endoscopic and microscopic group were 16.47 ± 4.5 dB and 19.4 ± 5.2 dB, respectively, which was statistically significant. The mean (± S.D.) time period for recovery of endoscopic and microscopic groups were 14.4 ± 5 days and 22.5 ± 7 days, respectively (p value < 0.05). The difference in post-operative pain between the two groups was also statistically significant. The difference in long term recovery rates was not statistically significant (p > 0.05)., Conclusions: Endoscopic facial nerve decompression results in early recovery, less post-operative pain and better post-operative air-bone gap closure when compared to conventional microscopic technique., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Facial nerve decompression surgery is performed on patients with immediate, complete traumatic facial palsy. However, the clinical advantage of the surgical treatment has weak evidence because of lack of control groups in previous studies. Therefore, this study compared facial function outcomes between the patients who underwent surgery and those who did not. Furthermore, in cases of bilateral traumatic facial palsy, the outcomes of the surgical and nonsurgical sides were also discussed., Methods: A retrospective medical chart review of immediate and severe (House-Brackman [HB] grade V and VI) traumatic facial palsy was conducted. Twenty-five ears from the surgical group and eight ears from the conservative treatment group were enrolled. Among the patients, three with immediate and severe bilateral facial palsy underwent unilateral surgery., Results: The average HB grade after 1-year follow-up was 1.7 in the surgical group and 1.5 in the nonsurgical group. Four patients who have definite facial canal disruption in the imaging study have recovered to HB grades I-III without surgical intervention. In patients with bilateral facial palsy, the nonsurgical side showed the same or better facial functions than the surgical side., Conclusions: Compared with nonsurgical conservative treatment, facial nerve decompression surgery did not show superior outcomes in immediate HB grade V-VI traumatic facial palsy. The clinical advantage of facial nerve decompression is questionable and should be re-evaluated in a prospectively designed study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Electrophysiological monitoring of the facial nerve during parotidectomy has been reported as an adjunctive method to prevent facial nerve injury. Classically, a needle electrode is used to obtain electromyographic (EMG) signals from facial muscles during facial nerve monitoring (FNM) of parotid surgery, likewise adhesive surface electrodes. This study aimed to investigate the feasibility of performing FNM with surface electrodes during parotid surgery and to compare EMG values with needle electrodes., Methods: Thirty patients who underwent parotidectomy under FNM using adhesive surface and needle electrodes were included. Two pairs of adhesive surface electrodes and needle electrodes were used for FNM during parotid surgery. Mean amplitudes were collected after electrical facial nerve stimulation at 1 mA after specimen removal., Results: The mean amplitude of the adhesive surface electrodes was 226.50 ± 118.44 μV (orbicularis oculi muscle) and 469.6 ± 306.06 μV (orbicularis oris muscle), respectively. The mean amplitude of the needle electrodes was 449.85 ± 248.10 μV (orbicularis oculi muscle) and 654.66 ± 395.71 μV (orbicularis oris muscle), respectively. The mean amplitude of the orbicularis oris muscle was significantly greater than that of the orbicularis oculi. The amplitude values measured in the orbicularis oculi muscle showed significant differences between the needle and skin electrodes., Conclusions: Facial nerve monitoring (FNM) using adhesive surface electrodes is feasible in parotid surgery. Although the mean amplitude value of the surface electrode was relatively lower than that of the needle electrode, the surface electrode is considered a feasible and safe EMG recording device for FNM in parotid surgery., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Facial nerve dysfunction (FND) is a frequent and serious parotidectomy outcome. Intraoperative facial nerve monitoring (IFNM) is an increasingly used technique to identify the facial nerve (FN) and minimize its injury. This study aimed to evaluate the determinant factors in the presence and severity of FND after parotidectomy, including IFNM., Study Design, Setting and Methods: A total of 48 patients consecutively submitted to parotidectomy between 2005 and 2020 in a tertiary hospital were retrospectively analyzed. The House-Brackmann Scale (HBS) was used to assess the severity of FND., Results: There was a mean age of 54.2 ± 17.8 years, 50% were male. Pleomorphic adenoma (41.7%) and Warthin's tumor (25.0%) were most common. From the 23 patients (47.9%) who developed some degree of FND (HBS score of 3.41 ± 1.53), 19 (82.6%) showed facial movement recovery, with a mean recovery time of 4.78 ± 2.53 months. IFNM was performed in 39.6% of the surgeries. The use of IFNM (p = 0.514), the type of surgery-partial or total parotidectomy-(p = 0.853) and the type of histology-benign or malignant lesion-(p = 0.852) did not significantly influence the presence of FND in the postoperative period. However, in the subgroup of patients who developed FND, the HBS value was significantly lower in cases of benign pathology (p = 0.002) and in patients who underwent IFNM (p = 0.017), denoting a significantly lower severity., Conclusion: In the present study, IFNM and the existence of a benign lesion have been shown to be associated with lower severity of FND., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

It was the aim of the systematic review to evaluate the incidence of facial palsy following orthognathic surgery, and to assess the possible mechanisms of injury, subsequent management, and eventual outcomes. The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews. A thorough search of PubMed, Scopus, Cochrane Library, and CINAHL databases up to April 2022 was conducted. In total, 34 articles were selected for this review, including 54 facial palsies in 53 patients. The incidence of facial palsy was estimated to range from 0.04% to 0.77%. Most of the possible etiologies proposed involved intraoperative nerve compression or postoperative edema. Physical therapy and steroid administration were the most frequently employed management approaches. Surgical exploration for the facial nerve was executed in one patient. Forty-three facial palsies (79.6%) attained complete recovery with conservative management, whereas 11 facial palsies (20.4%) continued to show incomplete recovery during the follow-up period. Earlier facial palsy onset (timing after surgery) was related to a higher risk of continuing palsy (p = 0.018). Within the limitations of this review it seems that facial palsy following orthognathic surgery should be treated conservatively whenever appropriate., Competing Interests: Declaration of competing interest All authors declare no conflicting relationships., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Papaverine, a vasodilator approved for use by the U.S. Food and Drug Administration, has shown efficacy in treating vasospasm in cardiology, urology, and nephrology. The vasodilatory effect of papaverine is also hoped to protect the facial nerve from ischemic damage and nerve manipulation during vestibular schwannoma surgery. Our institution uses intracisternal papaverine irrigation during vestibular schwannoma resection to protect the facial nerve in patients with neuromonitoring changes. Our objective was to investigate the safety and facial nerve outcomes of intracisternal papaverine irrigation during vestibular schwannoma resection., Methods: We retrospectively reviewed patients who underwent resection of vestibular schwannoma at our institution between 2008 and 2021. Patients received papaverine if the intraoperative facial nerve stimulation threshold increased above 0.05 mA. Postoperative outcomes were compared with control patients who did not receive papaverine., Results: A total of 283 cases were included in our analysis. Patients who received papaverine (n = 60) had lower immediate postoperative House-Brackmann (HB) grades than did control individuals (mean, 1.54 vs. 1.95; P = 0.029) and a lower likelihood of immediate postoperative HB grade >1 (odds ratio, 0.514; P = 0.039). At long-term follow-up, there was no significant difference in HB grade. Papaverine use was not associated with increased rates of perioperative complications (P = 0.24)., Conclusions: The off-label use of intracisternal papaverine irrigation during vestibular schwannoma resection can certainly be used safely for select cases. It is associated with improved immediate postoperative facial nerve outcomes, similar long-term facial nerve outcomes, and no significant increase in complications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In this case report, a 17-year-old female underwent microsurgical exploration and neurorrhaphy after a glass pane accident resulting in traumatic lesion of the right temporal facial nerve branch. Nine months after reconstruction she had regained function of the frontalis muscle. When patients with traumatic facial nerve injuries are admitted to hospital, it is crucial to consult with a microsurgical center to ensure that reconstruction is completed within 24-72 hours from the time of accident to regain mimetic function.

This review summarises the current knowledge of treatment strategies in traumatic extracranial facial nerve injuries. Facial nerve injuries cause significant psychologic and functional morbidity. We present a guideline for the clinical management including physical examination and surgical treatment. To regain mimetic function after facial nerve injuries it is crucial to ensure that microsurgical reconstruction is completed preferably within 24 hours, and no later than 72 hours from the time of accident.

Background: Intraoperative neuromonitoring is crucial for facial nerve preservation in cerebellopontine angle (CPA) surgery. Among the available techniques, the role of intraoperative corticobulbar facial motor evoked potentials (FMEPs) is unclear., Objective: To evaluate the significance of intraoperative FMEPs as indicators for early and late postoperative facial nerve function (FNF) in CPA tumor resection and the feasibility of their integration with standard monitoring techniques., Methods: An institutional series of 83 patients who underwent surgery under intraoperative monitoring for CPA extra-axial tumor resection was reported. A pair of needle electrodes was used to record FMEP from orbicularis oculi (OOc) and orbicularis oris (OOr) muscles at baseline, at the end of surgery and minimum values recorded. From FMEP amplitudes, minimum-to-baseline amplitude ratio (MBR), final-to-baseline amplitude ratio (FBR), and recovery value, intended as FBR minus MBR, were calculated. These indices were correlated with early and late postoperative FNF., Results: Our analysis demonstrated that higher FBR (both from OOc and OOr) and MBR (from OOr only) were associated with a good early and late FNF; a higher MBR from OOc was significantly associated with a good late FNF. The most accurate index in predicting early FNF was FBR measured from OOr with a cutoff of 35.56%, whereas the most accurate index in predicting late FNF was FBR as measured from OOc with a cutoff of 14.29%., Conclusion: Our study confirmed that FMEPs are reliable predictors of early and late postoperative FNF in CPA surgery and could be easily integrated with standard intraoperative neuromonitoring techniques., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Introduction: Despite the different pathophysiological mechanisms underlying Bell's palsy, in assessing severe traumatic facial paralysis, many surgeons rely on electrophysiological criteria to determine whether facial nerve exploration is warranted. To assess the value of preoperative electroneurography (ENoG) and the time of surgery, we analyzed data from three tertiary medical centers., Materials and Methods: The records of 517 patients with a degenerative ratio (DR) greater than 80% on ENoG were collected, and two groups were defined: group A (90% DR ≤ ENoG) and group B (80% DR ≤ ENoG < 90% DR). The difference in effectiveness of surgery versus conservative treatment was analyzed based on the postoperative outcome determined by the House-Brackmann grading system. The independent-samples t test was used to compare surgery with conservative treatment for each day of surgical exploration., Result: In groups A and B, the average recovery time from facial paralysis was better in patients who had undergone surgical exploration than in those who had been treated conservatively. In group A, the difference was significant only for patients who underwent surgery within 8 days. In group B, a significant difference was found for patients who underwent surgery within 16 days but also for surgery performed 20 and 30 days after the onset of facial paralysis., Discussion: In the surgical treatment of facial paralysis, the criteria for trauma patients should be distinguished from those of patients with Bell's palsy. In traumatic facial paralysis, some axons are more vulnerable to external collapse, and the degree of Wallerian degeneration of the peripheral nervous system will vary depending on the type of injury. The results of this study will help to identify those patients with traumatic facial paralysis who should be treated surgically and when they should be treated., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Background: Reoperative face lift can be technically more demanding than primary face lift because of altered anatomy and scarred tissue plane. This study was carried out to analyze the outcome of reoperative face lift using sub-superficial musculoaponeurotic system (SMAS) techniques, including facial nerve injury., Methods: Seventy reoperative face lifts using sub-SMAS techniques were studied. Data analysis includes the patients' demographic information, the interval between the previous face lift and the reoperative face lift, intraoperative findings of the SMAS-platysma anatomy, complications, and rate of revision. A separate group of 180 primary face lifts using sub-SMAS techniques during the same period was analyzed for the incidence of facial nerve injury only., Results: Intraoperative findings in the reoperative group consist of anatomical changes in the SMAS-platysma in 82.9 percent of the cases, including increased fibrosis, changes in thickness, limited movement, and increased adhesion on the undersurface. Sub-SMAS dissection was completed in 137 hemifaces. Complication consists of seroma (1.4 percent), delayed healing (1.4 percent), and temporary facial nerve injury (7.1 percent), which was not correlated with increased fibrosis or adhesion under the SMAS-platysma. The rate of revision within 18 months was 11.4 percent. There was a 2.2 percent incidence of temporary facial nerve injury in the primary face-lift group., Conclusions: Sub-SMAS techniques, with few exceptions, were successfully used in a series of reoperative face lifts. Temporary facial nerve injury was the most frequent complication. Satisfactory outcome was obtained in all the cases. The incidence of facial nerve injury was higher than in primary face lift using sub-SMAS techniques., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: To evaluate iatrogenic facial nerve injury in mastoidectomy and its paralysis improvement result after nerve injury management., Methods: A retrospective review of medical records of 21 patients with iatrogenic facial nerve injury following mastoidectomy who underwent nerve injury management in a tertiary referral center., Results: There were nine males and 12 females, with a mean age of 40.4 ± 15.1 years. Cholesteatoma was the most common primary pathology (76.2%). Mastoidectomy was canal wall up in 8 patients and canal wall down in 13. Nerve injury was due to drilling in 10 patients and sharp tools in 11. The tympanic segment of the facial nerve was the most common injured site (50.0%). Decompression was the most common nerve injury management method (52.4%). Other injury management methods were end-to-end anastomosis (14.3%), great auricular nerve graft (23.8%), and facial-hypoglossal nerve transfer (9.5%). No statistically significant correlation was found between facial nerve function 3-6 months after injury management and the following factors: age, gender, primary pathology, type of mastoidectomy, surgeon's experience, nerve injury site, mechanism of trauma, and nerve injury management method and timing., Conclusion: Regardless of the surgeon's experience or technique applied, a meticulous approach may be more valuable in decreasing the chance of iatrogenic facial nerve injury., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To investigate the effectiveness of facial nerve-sublingual nerve parallel bridge anastomosis for facial nerve injury resulting from closed temporal bone fractures., Methods: Between January 2017 and December 2019, 9 patients with facial nerve injury resulting from closed temporal bone fracture caused by head and face trauma were treated. Among them, 5 patients were treated with facial nerve-sublingual nerve parallel bridge anastomosis (operation group), and 4 patients were treated with neurotrophic drugs combined with rehabilitation exercise (conservative group). There was no significant difference in gender, age, side, cause of injury, duration of facial nerve injury before surgery, House-brackmann grading (hereinafter referred to as HB grading) of facial nerve injury, and other general information between 2 groups ( P >0.05). HB grading was used to evaluate the improvement of facial nerve function before and after treatment. At the same time, facial nerve neuroelectrophysiological test was performed to evaluate the electrical activity of facial muscles before and after treatment. Tongue function, atrophy, and tongue deviation were evaluated after nerve anastomosis according to the tongue function scale proposed by Martins et al ., Results: Patients in both groups were followed up 12-30 months, with an average of 25 months. None of the 5 patients in the operation group showed symptoms such as tongue muscle atrophy, tongue extension deviation, hypoglossal nerve dysfunction (mainly including slurred speech, choking with water), postoperative infection, bleeding, lower limb muscle atrophy or lower limb motor dysfunction after sural nerve injury. Postoperative skin sensory disturbance in lateral malleolus area was found, but gradually recovered to normal. During the follow-up, facial nerve and sublingual motor neurons were innervated to paralyzed facial muscle in the operation group. At last follow-up, the HB grading of 5 patients in the operation group improved from preoperative grade Ⅴ in 2 cases, grade Ⅵ in 3 cases to grade Ⅱ in 3 cases, grade Ⅲ in 1 case, and grade Ⅳ in 1 case. And in the conservative group, there were 1 patient with grade Ⅴ and 3 patients with grade Ⅵ before operation, facial asymmetry continued during follow-up, and only 2 patients improved from grade Ⅵ to grade Ⅴ at last follow-up. There was significant difference in prognosis HB grading between the two groups ( t =5.693, P =0.001). In the operation group, the amplitude and frequency of F wave were gradually improved, and obvious action potential could be collected when the facial muscle was vigorously contracted. On the contrary, there was no significant difference in neuroelectrophysiological results before and after treatment in the conservative group., Conclusion: Facial nerve-sublingual nerve parallel bridge anastomosis can effectively retain the integrity of the facial nerve, while introducing the double innervation of the sublingual nerve opposite nerve, which is suitable for the treatment of severe incomplete facial nerve injury caused by closed fracture.

Objective: Retromandibular approaches have been known to reduce the risk of facial nerve palsy and improve the management of condylar fractures. As such, it is necessary to identify the best approach with the least complications. This review was conducted to obtain a comprehensive estimate for the risk of complications following both the transparotid and the anteroparotid approach for patients with mandibular condylar fractures., Materials and Methods: A comprehensive search was conducted using PubMed Central, EMBASE, MEDLINE, and Cochrane library, ScienceDirect and Google Scholar from January 1964 until October 2021. The Newcastle Ottawa scale and Cochrane risk of bias tool were used to assess the quality of the included studies. A meta-analysis was carried out using a random-effects model and reported pooled incidence with 95% confidence intervals (CIs). A funnel plot was used to assess possible publication biases., Results: In total, 40 studies with 2,096 participants were assessed and the majority of the included studies (29 out of 40 studies) had a high risk of bias. The pooled incidence of facial nerve palsy following the transparotid approach was 13% (95% CI: 10%-17%; I2=66.8%), and 2% (95% CI: 1%-5%; I2=57.8%) following the anteroparotid approach. The pooled incidence of sialocele following the transparotid approach was 2% (95% CI: 0%-4%; I2=45.8%), and 2% (95% CI: 1%-5%; I2=67.2%) following the anteroparotid approach. The pooled incidence of postoperative infection following the transparotid approach was 1% (95% CI: 0%-4%; I2=63.1%), and 1% (95% CI: 0%-3%; I2=0%) following the anteroparotid approach., Conclusions: The incidence of facial nerve palsy was higher among patients undergoing the transparotid approach when compared to patients undergoing the anteroparotid approach. Further trials comparing both of these approaches are required to identify the best methodology with the lowest complication rate.

Introduction: Iatrogenic facial nerve palsy is distressing to the patient and clinician. The deformity is aesthetically displeasing, and can be functionality problematic for oral competence, dental lip trauma and speech. Furthermore such injuries have litigation implications. Marginal mandibular nerve (MMN) palsy causes an obvious asymmetrical smile. MMN is at particular risk during procedures such as rhytidoplasties, mandibular fracture, tumour resection and neck dissections. Cited causes for the high incidence are large anatomical variations, unreliable landmarks, an exposed neural course and tumour grade or nodal involvement dictating requisite nerve sacrifice. An alternative cause for post-operative asymmetry is damage to the cervical branch of the facial nerve or platysmal dysfunction due to its division. The later tends to have a transient course and recovers. Distinction between MMN palsy and palsy of the cervical branch of the facial nerve or platysma division should therefore be made. In 1979 Ellenbogen differentiated between MMN palsy and "Pseudo-paralysis of the mandibular branch of the facial nerve". Despite this, there is paucity in the literature & confusion amongst clinicians in distinguishing between these palsies, and there is little regarding these post-operative sequelae and neck dissections., Method: This article reflects on the surgical anatomy of the MMN and cervical nerve in relation to danger zones during lymphadenectomy. The authors review the anatomy of the smile. Finally, case studies are utilised to evaluate the differences between MMN palsy and its pseudo-palsy to allow clinical differentiation., Conclusion: Here we present a simple method for clinical differentiation between these two prognostically different injuries, allowing appropriate reassurance, ongoing therapy & management., (Copyright © 2021. Published by Elsevier Inc.)

Objectives/hypothesis: To determine immediate postoperative and long-term facial nerve dysfunction after parotid cancer surgery, risk factors, and the role of facial reanimation surgery., Study Design: Population-based long-term analysis for all new primary parotid carcinoma cases in Thuringia from 1996 to 2019., Methods: Data of the cancer registries of Thuringia, a federal state in Germany, were analyzed in combination with hospital-based data on facial function., Results: About 477 patients (42.3% women; median age: 68 years) were included. It was observed that 6.7% had a preoperative facial nerve dysfunction, 11.7% received a radical parotidectomy, that is, that 5% had a normal preoperative facial function but needed radical surgery because of intraoperative detection of tumor infiltration into the facial nerve. About 10.2% received facial nerve reconstruction surgery. Immediate postoperative facial nerve dysfunction in the other patients was observed in 34.4% of the patients. Advanced T classification (odds ratio [OR] = 2.140; confidence interval [CI] = 1.268-3.611; P = .004) and neck dissection (OR = 2.012; CI = 1.027-3.940; P = .041) were independent risk factors for immediate postoperative facial nerve dysfunction. In addition, 22.0% showed no recovery during follow-up. Advanced T classification (OR = 2.177; CI = 1.147-4.133; P = .017) and postoperative radiotherapy (OR = 2.695; CI = 1.244-5.841; P = .012) were independent risk factors for permanent postoperative facial nerve dysfunction., Conclusion: Patients with primary parotid cancer are at high risk for long-term facial nerve dysfunction. It seems that the possibilities of facial reanimation surgery needs to be utilized even more effectively., Level of Evidence: 3 Laryngoscope, 131:2694-2700, 2021., (© 2021 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)