Vascular permeability to sodium fluorescein in the rabbit cranial nerve root: possible correlation with normal cranial nerve enhancement on gadolinium-enhanced magnetic resonance imaging

Vascular permeability in cranial nerve roots was examined after intravenous injection of sodium fluorescein in the adult rabbit. Fluorescence was observed in the distal nerves through the following portions: intracavernous portion of the oculomotor nerve, distal internal auditory camal segment of the facial nerve, and ganglionic portions of the trigeminal, glossopharyngeal and vagus nerves. In the acoustic nerve, the vestibular ganglion showed fluorescence. No fluorescence was observed in the olfactory or optic nerves. During in vivo gadolinium-enhanced magnetic resonance imaging (Gd-MRI) of two separate animals, trigeminal nerve enhancement was observed in the region showing fluorescence. Histologically, intense fluorescence was observed in ganglia and external nerve sheaths of the cranial nerves showing macroscopic fluorescence. A slight fluorescence was also seen in endoneurial connective tissue but not observed within the nerve fibers. The results of this study suggest that the physiological enhancement of human cranial nerves seen on Gd-MRI may correlate with vascular permeability.     

Improved facial nerve identification with novel fluorescently labeled probe

Objectives/Hypothesis:

By phage display, we have developed a novel peptide (NP41) that binds selectively to nerves following systemic administration. We evaluated the pattern of facial nerve labeling with fluorescently‐labeled NP41 (F‐NP41). We also tested whether F‐NP41 highlights facial nerves well enough to identify nerve stumps accurately several weeks after nerve transection.

Study Design:

Forty‐seven wild‐type mice were studied prospectively. One surgeon performed the nerve transection, reanastomoses, and monitoring of functional recovery.

Methods:

Fluorescent labeling: F‐NP41 was administered intravenously (20 mice). Nerve labeling was studied with fluorescence microscopy. Transection and reanastomosis: the right facial nerve was transected (25 mice). Three weeks after transection, F‐NP41 was administered intravenously and fluorescence microscopy was used to identify the nerve stumps and reanastomosis in one group. Nerve identification and renastomosis was performed with white light in another group without F‐NP41. The control group underwent sham surgery. Time to nerve identification was recorded. Functional recovery was monitored for at least 8 weeks.

Results:

We found excellent labeling of intact and transected facial nerves following F‐NP41 administration. Several weeks following nerve transection, F‐NP41 provided accurate identification of the proximal and distal nerve stumps. Following reanastomosis, time to recovery and level of functional recovery was similar in the absence and presence of F‐NP41.

Conclusions:

We show improved visualization of facial nerves with a novel systemically applied fluorescently labeled probe. Use of F‐NP41 resulted in accurate identification of facial nerve stumps several weeks following transection. Functional recovery was similar with and without the use of F‐NP41. Laryngoscope, 2011     

Study on facial motoneuronal death after proximal or distal facial nerve transection

BACKGROUND: Among the cranial nerves, the facial nerve is most liable to be damaged. Pathologic changes in the facial motor nucleus (FMN) after nerve injury are not well recognized, and the optimal time for facial nerve reconstruction after axotomy is controversial. In this study, to clarify the pathologic change in the FMN after axotomy and to determine the best time for surgery, facial motoneuronal death was investigated after facial nerve injury. METHODS: Sixty Wistar rats were divided into proximal and distal groups. In the proximal group, the right facial nerve was transected at the porus of internal acoustic meatus. In the distal group, the nerve was cut at the stylomastoid foramen. The animals were sacrificed from day 3 to day 60 after surgery, and the brainstem was fixed with 4% paraformaldehyde. The FMN were then examined in serial sections stained with Cresyl Violet, and facial motoneurons were counted under a light microscope. RESULTS: The death rate of facial motoneurons in the animals that underwent proximal axotomy was found to be higher and cell death occurred earlier than in the distal axotomy animals at every time point. Moreover, neuron death increased with time and peaked at 15 days after surgery. CONCLUSIONS: The results indicate that the injury site was correlated with facial motoneuronal death, and suggest that reconstructive surgery should be performed as early as possible.     

Neurophysiologic intraoperative monitoring: II. Facial nerve function

Intraoperative facial nerve monitoring provides a potentially useful adjunct to recent surgical advances in neurotology and neurosurgery. These measures further aid the surgeon in preserving facial nerve function by enhancing visual identification with electrical monitoring of mechanically evoked facial muscle activation. Facial nerve monitoring in neurotologic surgery may achieve the following goals: (1) early recognition of surgical trauma to the facial nerve, with immediate feedback made available to the surgeon through monitoring of mechanical activation; (2) assistance in distinguishing the facial nerve from regional cranial nerves and from adjacent soft tissue and tumor with selective electrical stimulation; (3) facilitation of tumor excision by electrical mapping of portions of tumor that are remote from the facial nerve; (4) confirmation of nerve stimulability at the completion of surgery; and (5) identification of the site and degree of neural dysfunction in patients undergoing nerve exploration for suspected facial nerve neoplasm or undergoing decompression in acute facial palsy. This paper provides an overview of intraoperative facial nerve monitoring principles and methodology and reports a recent clinical investigation that demonstrates the utility of facial nerve monitoring in translabyrinthine acoustic neuroma surgery.     

Facial nerve monitoring in middle ear and mastoid surgery

HYPOTHESIS: Intraoperative electromyographic facial nerve monitoring, long accepted as the standard of care in surgery for acoustic neuroma and other cerebellopontine angle tumors, may be of aid in middle ear and mastoid surgery. STUDY DESIGN: Retrospective series of 262 cases of middle ear/mastoid surgery in which monitoring was performed by a neurophysiologist. METHODS: Neurophysiological monitoring events were classified as mechanical or electrical. The voltages producing facial nerve stimulation were compiled and compared with observed facial nerve dehiscence. RESULTS: The most common use of monitoring was localization of the facial nerve by electrical stimulation (60%) or identification of mechanically evoked activity (39%). In 57 cases (36%), the first electrical stimulation event evoked a facial nerve response at less than 1 V threshold, indicating little or no bony covering. The minimum stimulation threshold throughout each of these cases was less than 1 V in 88 of the 159 cases (55%) in which stimulation was attempted. In contrast, the facial nerve was visibly dehiscent in only 35 cases (13%). Neurophysiological monitoring confirmed aberrant facial nerve course through the temporal bone in four cases resulting in cancellation of surgical treatment in two cases. Postoperative facial nerve function was preserved in all cases when present preoperatively. CONCLUSIONS: An electrical stimulation threshold of less than 1 V is a more useful criterion of dehiscence than observation under the operating microscope. The absence of monitoring events allows safe dissection. Monitoring can help locate the facial nerve, guide the dissection and drilling, and confirm its integrity, thereby allowing more definitive surgical treatment while preserving neural function.     

Experimental study on facial nerve regeneration with or without geniculate ganglionectomy

OBJECTIVE: To investigate regeneration of the distal facial nerve following nerve grafting within the tympanic segment with geniculate ganglion preservation or dissection. DESIGN: Randomized controlled trial. SUBJECTS: Twenty-three adult New Zealand albino rabbits were used in this study. INTERVENTIONS: A 2-mm tympanic segment of the facial nerve was removed, and the greater auricular nerve was harvested for grafting in all animals. In group 1 (10 rabbits), the geniculate ganglion was preserved. In group 2 (13 rabbits), the geniculate ganglion was dissected. Mastoidal and extratemporal segments of the facial nerve were harvested 3 months postoperatively for histological examination by electron microscopy. RESULTS: The number of myelinated axons in normal facial nerves was 1819.6 +/- 535.6. In group 1, the number of myelinated axons was 123.6 +/- 31.1, and, compared with normal facial nerves, the diameter of the regenerative axons was decreased and the sheath thickness in the regenerative fiber was diminished. In group 2, the number of myelinated axons was 515.1 +/- 103.1, while the myelin sheath thickness was proportionate to axon diameter. (Data are given as mean +/- SD.) CONCLUSION: Geniculate ganglionectomy may improve motor axon regeneration.     

Induction of regional collateral sprouting following muscle denervation

OBJECTIVES/HYPOTHESIS: Anecdotal clinical findings suggest that denervated muscle may regain modest functional recovery via spontaneous collateral sprouts from intact adjacent nerve fibers. The current study evaluates the conditions needed for the denervated masseter muscle to induce axonal sprouting from the facial nerve. We hypothesize that epineurial injury is required to induce collateral sprouting toward a neighboring denervated muscle. STUDY DESIGN: Twelve thy1-yellow fluorescent protein-16 (thy1-YFP-16) transgenic mice whose axons express yellow fluorescent protein were allocated into six groups, with four degrees of facial nerve injury (intact, crush, transection, removed segment) with or without masseter denervation. METHODS: Animals underwent serial in vivo imaging analyses under the fluorescent microscope weekly for 5 or 7 weeks and were subsequently perfused for analysis. Masseter muscle acetylcholine receptors (AChRs) were stained with Alexa Fluor 594 conjugated alpha-bungarotoxin, and whole mounts were imaged with confocal microscopy. RESULTS: In groups with intact or crushed facial nerves, no evidence of collateral sprouting was demonstrated. Mice with transected facial nerve branches or removed segments demonstrated sprouting from the proximal stump into the denervated masseter. Staining of the AChRs confirmed that new neuromuscular junctions were established between the facial nerve and the denervated masseter. CONCLUSIONS: This study suggests that epineurial injury is required to stimulate axonal sprouting into adjacent denervated muscle. Nerves with compromised epineurium may be useful in promoting neo-neurotization after muscle denervation.     

Transcranial magnetic stimulation in acute facial nerve injury

OBJECTIVE/HYPOTHESIS: Available electrodiagnostic tests that are used to evaluate facial nerve injury examine the nerve distal to the stylomastoid foramen; because most facial nerve injuries are within the temporal bone, the tests cannot evaluate the nerve at or across the injury site. The interpretation of these tests depends on the predictability (or unpredictability) of distal degenerative process. Transcranial magnetic stimulation may be able to stimulate the nerve proximal to the injury site. The hypothesis of the present study is that in cases of mild traumatic facial nerve injury where axonal integrity is maintained, proximal stimulation of the nerve using higher than normal stimulus intensities to "overcome" the block at the injury site result in recordable facial nerve activity. STUDY DESIGN: A prospective controlled animal study comparing response to transcranial magnetic stimulation of the facial nerve in the following groups: mild injury, severe injury/transection, and control. METHODS: We studied 44 facial nerves in 22 cats. Fifteen nerves were subjected to mild trauma. Five nerves were severely crushed, 2 nerves were completely transected, and 22 nerves were not traumatized. All nerves were examined with the transcranial magnetic stimulation system before the trauma, immediately after the trauma, and at 3, 8, and 12 weeks after trauma. RESULTS: All nerves in the mild and severe trauma groups showed complete clinical paralysis immediately after trauma. The nerves in the mild trauma group showed significant increase in threshold as well as significant increase in latency for recordable facial muscle response to transcranial magnetic stimulation. Thresholds and latencies decreased gradually within 3 to 12 weeks and returned almost to preinjury levels. This paralleled the return of clinical facial muscle movement. In the severe trauma/transection group, the nerves had no facial muscle response to transcranial magnetic stimulation after trauma. Neither facial muscle response to transcranial magnetic stimulation nor facial muscle movements recovered. CONCLUSIONS: In cats transcranial magnetic stimulation can assess the integrity of the facial nerve after trauma and predict its potential for regeneration. This technique can excite the nerve proximal to the injury site and may play a role in the clinical evaluation of the acute traumatic facial nerve paralysis. It can be used immediately after trauma, because it does not depend on wallerian degeneration to occur.     

Rapid astroglial reactions in the motor cortex of adult rats following peripheral facial nerve lesions

We report on changes in the motor cortex of adult rats that rapidly and transiently followed various types of facial nerve lesions. These reactions led to enhanced immunoreactivities of various astroglial markers: S-100 protein (a Ca²⁺- and Zn²⁺-binding protein predominantly located in the cytosol of astrocytes), glial fibrillary acidic protein (a cytoskeletal protein) and connexin 43 (the astroglial gap junction protein). Reactions could be visualized 1 h after the facial nerve lesion and disappeared within about 5 days after surgery. Combined lesions of the facial and trigeminal nerves modified the spatial pattern of the astroglial reaction, similiar to intramuscular injections of botulinum toxin, which inhibits the release of acetylcholine in motor endplates. Data presented suggest that peripheral interference with muscular functions rapidly induces modifications in the motor cortex.     

中耳手术中的面神经定位

目的结合颞骨解剖和面神经手术，明确适用于手术的面神经解剖标志。方法44具颞骨标本面神经解剖，106例周围性面神经麻痹的面神经减压手术。根据面神经周围的固定解剖标志，确定面神经位置。结果①面神经垂直段标志：水平半规管后中1／3交界处垂直线提示面神经后缘；砧骨短角上缘弧度延长线为面神经垂直段前缘；面神经与水平半规管基本在同一深度；②面神经水平段标志：位于砧骨短突之下；在水平半规管隆突前缘向前上呈30。行走；在匙突后方，面神经与匙突平行形成中上鼓室内侧面交界缘；经过匙突面神经向前上行走到膝状神经节；③膝状神经节定位：从镫骨头到匙突等距离延长线为膝状神经节位置；④鼓索神经定位：鼓索从左侧鼓沟的3点或右侧鼓沟的9点出骨管，沿鼓沟向前行走于砧骨长突外侧和锤骨颈内侧；鼓索神经从面神经发出处距离茎乳孔5—8mm；鼓索位于鼓膜紧张部与松弛部交界处。所有手术所见面神经走向符合解剖所见。结论中耳乳突的固定标志是面神经定位的参照物，其中水平半规管的位置最恒定，根据参照物确定面神经位置提高了手术的安全性。     

Water-jet dissection in parotid surgery--initial clinical results

INTRODUCTION: The most frequent complication following parotidectomies is postoperative facial nerve dysfunction. In animal experiment we successfully studied the technique of water-jet-dissection for safe and functional preservation in facial nerve dissection in parotid gland surgery. The aim of the present study was to evaluate our animal experiments clinically. METHODS: Until November '99 ten patients with benign parotid gland tumors (4 female, 6 male, age 32-77 years) underwent lateral or latero-segmental parotidectomies using water-jet-dissection ("Hydro-Jet", Andreas Pein Medizintechnik GmbH, Schwerin, Germany). All operations were performed under permanent intraoperative facial nerve monitoring ("Neurosign 100", Fa. Inomed, Tenningen, Germany). The postoperative facial nerve function was measured daily by the House-Brackmann and Stennert-Paresis-Index for at least one week. RESULTS: A quick parotid gland and safe facial nerve dissection could be performed in all operations using the 120 microns-nozzle with effective working pressures from 30-50 bar. In addition strong connective tissue fibers were transected with scissors. Intraoperative facial nerve lesions did not occur and cardiopulmonary complications due to eventual cutting-fluid-resorption were not seen. After surgery all patients had a normal facial nerve function. DISCUSSION: The results of our studies showed that the technique of water-jet-dissection provides safe facial nerve dissection and preservation during parotid gland surgery. CONCLUSIONS: The tissue selective cutting qualities of the new surgical method are an excellent alternative compared to standard dissection methods in parotid surgery.     

End-to-side neurorrhaphy and lateral axonal sprouting in a long graft rat model

OBJECTIVE/HYPOTHESIS: Controversy exists regarding collateral axonal sprouting across an end-to-side neurorrhaphy to provide functional motor reinnervation of a target organ without compromise of the donor nerve. Rat models may be limited in the study of end-to-side repair given potential contamination from the proximal nerve stump of the recipient distal nerve and the use of antagonistic muscle groups for donor and recipient. The current study attempts to address these issues by using a rat model in which an end-to-side coaptation is performed with a long graft interposed between the intact donor tibial nerve and the divided, distal contralateral tibial nerve. MATERIALS AND METHODS: The graft used in proximal end-to-side coaptation consisted of both sciatic nerves in a donor syngeneic animal. The distal repair to the contralateral tibial nerve was done immediately or in a delayed fashion to allow potential motor axons to transverse the graft before division of the recipient tibial nerve. RESULTS: After 24 weeks, axons were noted to transverse the entire distance of the graft and into the contralateral distal posterior tibial nerve. A significant increase in axonal numbers was observed in the immediate repairs compared with the delayed. No animal recovered functional motor ability on the contralateral side as assessed by walking tracks. CONCLUSIONS: These findings suggest the importance of immediate distal neurotrophic factors in encouraging nerve regeneration even in a long graft end-to-side repair. Our model is successful in demonstrating innervation through an end-to-side coaptation but questions its use given the lack of motor recovery.     

In vivo visualization of the cochlear nerve and nuclei with fluorescent axonal tracers.

In recent years multichannel neuroprostheses have been developed which directly stimulate the central auditory pathway. Substantially these have been used in cases of total hearing loss caused by neurofibromatosis type 2 where bilateral damage to the auditory nerve prevents more peripheral stimulation. The electrode carrier of the auditory brainstem implant (ABI) is designed to be placed on the cochlear nucleus complex residing at the lateral brainstem surface. Despite altered anatomy due to tumor growth or preceding surgery, correct electrode placement is essential to maximize the variety of pitch percept elicited during electrical stimulation with the ABI without producing side-effects. In order to assist intraoperative identification of the proximal auditory nerve and cochlear nuclei, the non-toxic fluorescent axonal tracers Fast Blue or Fluorogold were injected into the cochlea of rats and Java monkeys. Four to seven days after tracer application, labeling of the eighth cranial nerve, its entrance into the brainstem and the primary radiation of auditory fibers into the cochlear nucleus could be demonstrated as colored fluorescence on the living brain under appropriate ultraviolet illumination. Additional histological processing revealed groups of retrogradely labeled neuronal cell bodies in both species. Our results suggest that this method could also be used in humans in order to aid surgeons with the proper positioning of the electrode array.     

Water-jet dissection in parotid surgery: an experimental study in dogs

OBJECTIVE: The objective of the present study was to investigate the application of the water-jet dissection method in parotid surgery by way of animal experiments, paying particular attention to the clinical and histological reactions of the facial nerve. STUDY DESIGN: An animal experimental study. METHODS: Total bilateral parotidectomies with retention of the facial nerve were performed on 19 beagle dogs by means of the Hydro-Jet device (Andreas Pein Medizintechnik Company, Schwerin, Germany) using different jet diameters and operating pressures. All operations were performed with continuous intraoperative facial monitoring (Neurosign 100, Inomed Company, Teningen, Germany). The dogs were monitored postoperatively over an average period of 20.3 days (range, 14-35 d). Local findings and facial nerve status were documented daily. In a second phase, the dissected nerves were resected and the animals were killed. Samples of water-jet-dissected parotid tissue, as well as all dissected nerve branches, underwent histological examination and were compared with clinical and electrophysiological findings. RESULTS: It was possible to perform operations easily on all parotid glands by means of the Hydro-Jet using the small, 120-microm jet at operating pressures of 40 to 60 bar and to dissect the facial nerve quickly and safely with retention of its functional capability (n = 34). The dissection of nerves using larger-diameter jets (150 and 200 microm [n = 64]) resulted in a total of two reversible and seven irreversible partial pareses. CONCLUSIONS: The study has shown that it is possible to perform tissue-selective operations on the parotid gland by means of the Hydro-Jet using the 120-microm jet at operating pressures of 40 to 60 bar, ensuring safe, atraumatic dissection of the facial nerve with retention of its functional capability. The advantages of the new Hydro-Jet method offer a valuable alternative compared with the normal dissection methods adopted in parotid surgery. Thus the results of the present investigation currently are being checked within the framework of a clinical study at our clinic.     

甲状腺外科手术中喉返神经的解剖

目的：探讨甲状腺外科手术中喉返神经的解剖特点和方法。方法：回顾性分析56例甲状腺疾病患者在手术中解剖的63条喉返神经的有关资料：结果：48条喉返神经入喉前分成前、后两支．占喉返神经总数的76．19％。29条(46．03％)喉返神经位于甲状腺下动脉的深部．19条(30．56％)喉返神经位于甲状腺下动脉的浅面．8侧(12．70％)甲状腺下动脉分叉．神经穿行其间．7侧(11．11％)术中未发现甲状腺下动脉：术后喉返神经暂时麻痹1例,永久麻痹1例。结论：充分掌握喉返神经的解剖特点．术中正确辨认并安全地解剖喉返神经是避免喉返神经损伤的关键。     

Delayed nerve repair is associated with diminished neuroenhancement by FK506

OBJECTIVES/HYPOTHESIS: The immunosuppressive agent FK506 has been shown in many studies to enhance nerve regeneration and to accelerate functional recovery after immediate nerve repair. However, in clinical practice the diagnosis and treatment of patients with peripheral nerve injuries is often delayed. The study investigated whether FK506 would retain its neuroregenerative properties when nerve repair and initiation of FK506 therapy were delayed for 7 days. STUDY DESIGN: In vivo laboratory study. METHODS: Thirty-two Lewis rats underwent tibial nerve transection and were randomly assigned to four experimental groups: immediate repair with FK506 treatment, immediate repair without FK506 treatment, 7-day delayed repair with FK506 treatment, and 7-day delayed repair without FK506 treatment. Treated animals received daily subcutaneous injections of 2 mg/kg FK506. Serial walking track measurements were performed at 14, 16, and 18 days after nerve repair. On day 18 after repair, peripheral nerves were injected with a fluorescent tracer for retrograde labeling. On day 21, peripheral nerves and spinal cords were harvested for histomorphometric analysis and motor neuron cell body counts, respectively. RESULTS: Animals that underwent immediate repair with FK506 had significantly higher fiber counts and percentages of nerve than the other three groups (P <.05) but did not show statistically significant earlier functional recovery. The remaining three groups had intermediate levels of nerve regeneration that were not significantly different. Retrograde abled motor neurons counts were decreased in animals with delayed nerve repair that received no FK506 (P <.05). CONCLUSION: In a rat tibial nerve transection model, the neuroregenerative effects of FK506 diminished markedly when repair and initiation of FK506 therapy were delayed by 7 days.     

Perineural invasion of the facial nerve by a cutaneous squamous cell cancer: a case report

We report a case of perineural invasion of the facial nerve by a cutaneous squamous cell carcinoma in a 59-year-old man who presented with a slowly progressive facial paralysis. We performed a distal facial nerve dissection and a simple mastoidectomy with facial recess exposure for resection to negative margins. We also performed a simultaneous facial reconstruction and reanimation procedure with excellent results. External-beam radiation completed the treatment regimen. In addition to describing this case, we review current concepts in diagnosis and therapy, as well as the historical background of malignant perineural invasion of the cranial nerves.     

Pathological features of the facial nerve in patients with facial palsy of varying aetiology. Light and electron microscopic study

Facial nerve specimens obtained during reinnervation surgery from 31 patients with facial palsy of varying aetiology were studied. In patients who had a facial palsy after attenuation during acoustic schwannoma removal the facial nerve had normal populations of myelinated nerve fibres in the sensory zone but their numbers and sizes were severely reduced and fibrosis was increased in the motor zone. The latter also had large numbers of endoneurial tubes with thin unmyelinated axons. When the facial nerve had been severed in tumour removal, it had practically no remaining nerve fibres. In three out of four patients with middle ear cholesteatoma, the distal facial nerve stump showed severe fibrosis. In patients with iatrogenic trauma and skull fracture, the distal stump usually showed few myelinated nerve fibres, endoneurial tubes with thin unmyelinated fibres and increased fibrosis. The pathological changes observed indicate that in all cases the motor fibres distal to the lesion have undergone Wallerian degeneration and demyelination and in most a subsequent partial regeneration. However, the regeneration remained incomplete. The distal stump of the facial nerve with numerous endoneurial tubes in most cases of the material presented appear to provide favourable structural preconditions for reinnervation surgery.     

Facial nerve grafts: from cerebellopontine angle and beyond

OBJECTIVES: To review the outcomes from facial nerve cable grafting in a variety of pathologic conditions and to determine the possible causes of poor facial function after facial nerve grafting. STUDY DESIGN: A retrospective review of patients undergoing facial nerve grafts through a neurotologic procedure. SETTING: This study was performed at a university-based tertiary referral center. PATIENTS: All 27 patients undergoing a neurotologic procedure that required a facial nerve graft from 1982 to 1997 were reviewed. Fourteen patients had grafts from the facial nerve stump at the brainstem. INTERVENTIONS: All patients had facial nerve function determined by the senior neurotologist and through use of historical data and photographs. MAIN OUTCOME MEASURE: A facial nerve repair recovery score was developed for facial nerve transection and repair. The House-Brackmann scale was found to be inappropriate for transected and repaired nerves. RESULTS: Facial function was found in 23/25 (92%) patients with at least 8 months follow-up. Statistical analysis revealed no significant correlation between graft length and recovery score. Patients who had the nerve grafted to a site distal to the meatal foramen had a mean outcome that was nearly one grade level better than those with an anastomosis proximal to the meatal foramen (i.e., at the brainstem), but this did not reach statistical significance. CONCLUSIONS: Facial nerve grafting is an effective way of restoring facial motor function. A new facial recovery grading scale is proposed for repaired or grafted facial nerves.     

The facial nerve in the presence of a head and neck neoplasm: assessment and outcome after surgical management

PURPOSE OF REVIEW: The face is the mirror of personality. Facial expression is the most important part of verbal and nonverbal communication. Patients with head and neck neoplasm and facial palsy are more stigmatized by the latter than by the tumor itself. Facial nerve reconstruction in such a patient is a great challenge. This review gives an overview of the assessment of facial palsy, surgical reconstruction, and postoperative treatment. RECENT FINDINGS: MRI, CT, and electromyography are indispensable tools in the assessment of preoperative facial palsy in patients with head and neck neoplasm. When part of the facial nerve has to be sacrificed during surgery, the best functional results are achieved with direct facial nerve suture, interposition graft, or by a hypoglossal-facial nerve interposition jump anastomosis. The latter is the best choice when the reanimation is planned between 6 months and 2 years after tumor surgery. In any case, the eye is best rehabilitated with upper lid loading. Temporalis muscle transposition gives fast and good results for the restoration of the corner of the mouth after radical surgery. Reanimation by free muscle transfer for head and neck cancer patients is rarely indicated. Botulinum toxin treatment is an excellent postoperative aid for refining the result; the optimal modality of postoperative physiotherapy is still unclear. SUMMARY: Surgical reanimation of the face in head and neck patients has reached a high standard. Strategies to decrease misdirected reinnervation after nerve suture have to be established in clinical practice for further improvement of facial rehabilitation.