Monirah Albathi

Early Nerve Grafting for Facial Paralysis After Cerebellopontine Angle Tumor Resection With Preserved Facial Nerve Continuity.

IMPORTANCE Preserving facial nerve function is a primary goal and a key decision factor in the comprehensive management of vestibular schwannoma and other cerebellopontine angle (CPA) tumors. OBJECTIVE To evaluate the use of the pattern of facial paralysis recovery in the early postoperative months as a sole predictor in selecting patients for facial nerve grafting after CPA tumor resection when cranial nerve VII is uninterrupted. DESIGN, SETTING, AND PARTICIPANTS Sixty-two patients with facial paralysis and uninterrupted cranial nerve VII who developed facial paralysis after CPA tumor resection at The Johns Hopkins Hospital were followed up prospectively to assess for spontaneous recovery and to determine candidacy for facial reanimation surgery. The study dates and dates of analysis were January 1, 2009, to March 31, 2015. INTERVENTIONS After a minimum of 6 months of clinical follow-up and no signs of clinical recovery, patients underwent facial nerve exploration and a masseteric or hypoglossal nerve transfer. Intraoperative direct nerve stimulation was performed to assess for the presence of subclinical reinnervation. Patients were followed up for a minimum of 18 months after surgery to evaluate outcomes. MAIN OUTCOMES AND MEASURES Facial function and recovery were studied objectively with a Smile Recovery Scale, Facial Asymmetry Index, and House-Brackmann (HB) grading system. Other outcome measures included the duration of paralysis, time to recovery, and evidence of synkinesis. RESULTS Sixty-two patients (33 men, 29 women; mean age 51.8 years) with uninterrupted facial nerves after CPA tumor resection developed HB grade IV, V, or VI facial paralysis. Ten patients underwent nerve grafting by 12 months, 9 patients received grafting after 12 months, and 8 patients had no intervention. Thirty-five patients spontaneously recovered. In all patients who underwent nerve grafting, there were no detectable facial muscle movements or electromyographic response to direct facial nerve stimulation suggestive of occult reinnervation. Overall, early facial reanimation surgery resulted in a shorter total duration of paralysis. Masseteric nerve grafting resulted in earlier recovery compared with hypoglossal nerve grafting (5.6 vs 10.8 months, P = .005). Patients who showed no signs of recovery by 6 months after CPA surgery but declined facial reanimation surgery demonstrated at best HB grade V recovery after 18 months of observation. CONCLUSIONS AND RELEVANCE The recovery pattern in the early postoperative period among patients who develop facial paralysis after CPA tumor resection is a useful clinical tool in selecting patients for facial reanimation surgery. Patients can be counseled for facial reanimation surgery as early as 6 months after surgery because satisfactory facial functional recovery is unlikely to occur when there is no clinical evidence of spontaneous nerve regeneration in the first 6 months. LEVEL OF EVIDENCE 3.

Transposition of the intratemporal facial to hypoglossal nerve for reanimation of the paralyzed face: The VII to XII transpositionTechnique

IMPORTANCE The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation. OBJECTIVES To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation. DESIGN, SETTINGS, AND PARTICIPANTS A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center. MAIN OUTCOMES AND MEASURES Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis. METHODS Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system. RESULTS All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction. CONCLUSIONS AND RELEVENCE Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites. LEVEL OF EVIDENCE 4.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma: Combined Approach for Inverting Papilloma

Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP.

Upper lateral cartilage composite flap for closure of complicated septal perforations

To present a novel technique for the repair of large complicated nasal septal perforations using an upper lateral cartilage composite flap.

Vestibular vertigo is associated with abnormal sleep duration

BACKGROUND/OBJECTIVE Several small studies in animals and humans have suggested a relationship between vestibular function and sleep. In this study, we evaluate the association between vestibular vertigo and sleep duration in a large, representative sample of US adults. METHODS We used data from the National Health Interview Survey, which administered a Balance Supplement in 2008 in a sample of 20,950 adult respondents. We evaluated the cross-sectional association between vestibular vertigo (based on a well-validated definition) and sleep duration (defined as short <6 hours, normal 6-8 hours, and long >8 hours). We performed multiple and multinomial logistic regression analyses to estimate the odds ratio and relative risk ratio (RRR) of impaired sleep duration compared to normal sleep duration associated with vestibular vertigo. Analyses were adjusted for demographic, lifestyle and health behavior characteristics as well as relevant comorbid conditions. RESULTS Thirty percent of individuals with vestibular vertigo reported abnormal sleep duration (15.5% short duration and 14.8% long duration). In adjusted analyses, individuals with vestibular vertigo had a 1.75 (95% CI 1.45-2.11) RRR of having short sleep duration compared to individuals without vestibular vertigo, and a 1.55 (95% CI 1.26-1.91) RRR of having long sleep duration compared to individuals without vestibular vertigo. CONCLUSION This study presents epidemiologic evidence to support the association between vestibular function and sleep duration. Individuals with vestibular vertigo had a higher RRR for abnormally short or long sleep duration. Further work is needed to evaluate the causal direction(s) of this association.

Facial Asymmetry Index: Validation and Applications in Various Smile Restoration Techniques

Abstract Consistent and objective evaluation of the paralyzed face is imperative for documenting preoperative findings and assessing postoperative outcomes of reanimation techniques. Static and dynamic facial asymmetry are the key features of the paralyzed face. To date, there is no consensus among surgeons on how best to document facial asymmetry. The authors propose a Facial Asymmetry Index (FAI) as an objective measure of facial asymmetry and validate its use and reliability across numerous reanimation techniques. Frontal photographs of patients with unilateral facial nerve paralysis were analyzed. The length from the medial canthus to the ipsilateral oral commissure was compared between affected and nonaffected sides. The FAI is the difference between the two values, with a higher value reflecting poorer facial symmetry. Validation and reliability testing was then performed. There was a consistent decrease in the FAI with procedural intervention (FAI pre = 10.1, FAI post = 3.17; p < 0.0001). Furthermore, there was excellent inter‐ and intrarater reliability among independent judges. The FAI is a powerful and accessible tool to quantify operative outcomes for many lower facial nerve reanimation techniques.