Modified hypoglossal-facial nerve anastomosis for peripheral-type facial palsy caused by pontine infarction: A case report and literature review

Background

Peripheral-type facial palsy could be caused by a lesion in the tegmentum of the pons, such as infarction, with a rare occurrence. We herein described a case of unilateral peripheral-type facial palsy induced by dorsolateral pontine infarction and treated this patient using modified hypoglossal-facial nerve anastomosis.

Case presentation

A 60-year-old female presented with dizziness, hearing drop, diplopia, and peripheral-type facial palsy. Brain Magnetic Resonance Imaging showed a dorsolateral pontine infarction on the right side which exactly refers to the location of the ipsilateral facial nucleus or facial nerve fascicles at the pons. Subsequent electrophysiological examinations confirmed poor facial nerve function of this patient and modified hypoglossal-facial nerve anastomosis was then performed.

Conclusions

This case reminded medical practitioners not to ignore the possibility of involvement of a central cause in peripheral-type facial palsy patients. In addition, modified hypoglossal-facial nerve anastomosis served as a useful skill improvement that may help reduce hemiglossal dysfunction while restoring facial muscle function.

Meningioma originating from the oculomotor nerve without dural attachment in a child

Meningioma originating from the oculomotor nerve without dural attachment in children has been rarely reported. A 6-year-old patient presented ptosis of the right eye for 5 years. MRI indicated an occupying lesion in the right cavernous sinus. A tumor originating from the oculomotor nerve without dural attachment was found during subsequent surgery and confirmed as meningioma by pathology. Subsequently, the tumor was removed completely, and the oculomotor nerve was reconstructed using the sural nerve. The patient's symptoms were relieved partially after 3 months. The findings of this case suggested that the mechanisms underlying meningioma involve ectopic arachnoid cap cells within the nerve sheath. Thus, the tumor should be removed completely; also, nerve reconstruction is suggested.

Posterior ostectomy of a mandibular distal segment for nerve bundle traction to tensionless anastomosis of an inferior alveolar nerve

Tensionless adaptation of nerve ends is a challenging task in the repair of damaged inferior alveolar nerve (IAN). A new technique is introduced with posterior ostectomy of a mandibular distal segment after sagittal splitting for nerve bundle traction to tensionless anastomosis of nerve ends. We were able to create tensionless anastomosis of an IAN defect without autogenous or alloplastic graft using this method. This method is suitable for neurorrhaphy after neuroma removal in cases of IAN damage during dental procedures.

Masseteric nerve position on the "temporomandibular joint-chin tip" artificial axis: an anatomical study

PURPOSE

The use of the masseteric nerve develops in the surgery of facial paralysis rehabilitation. The objective of this study was to determine the topography of the masseteric nerve and to deduce and predict a precise and reproducible anatomical cluster to facilitate its clinical identification during V-VII neurotization surgery.

METHOD

For the purpose of this work, a cadaveric study was performed on 31 hemi-faces. All dissections were performed bilaterally and comparatively, following steps aiming at simulating, as close as possible, the clinical conditions of a facial palsy rehabilitation by V-VII anastomosis.

RESULT

For the identification of the masseteric nerve, bony reference points were used, i.e., the temporomandibular joint (TMJ) and the chin point (CT). A virtual axis was drawn between the TMJ and the CT, and the distance [TMJ-MN] determining the smallest length h was then plotted against the distance [TMJ-CT] determining the largest length H, thus allowing the calculation of an h/H proportion ratio (PR) indicating the proximal part of the masseteric nerve from the TMJ. The average length h between the TMJ and the NM was 3.5 cm (± 0.1 cm) from the TMJ, i.e., an average ratio h/H [TMJ-MN]/[TMJ-CT] of 28.1% 4.0 and a median ratio of 28.6% of the distance [TMJ-CT].

CONCLUSION

Our study opens new perspectives for facilitating its identification and use, offering practitioners a tool to make V-VII the neurotization procedure less complex, with the eventual prospect of a minimally invasive procedure combining imaging, surgery, and augmented reality.

The Masseteric-Facial Anastomosis With Intratemporal Translocation of the Facial Nerve: Step-by-Step Technique and Results

BACKGROUND

In the absence of a viable proximal nerve stump, damaged after surgical procedures around the skull base, numerous techniques for facial reanimation have been developed over time, aiming to restore baseline symmetry and active mimicry.

OBJECTIVE

To report experience using the masseteric nerve as a direct transfer to the facial nerve rerouted after intratemporal translocation. This paper illustrates the main steps of the technique and the quality of results.

METHODS

Eleven patients were treated with a masseteric direct transfer to the facial nerve. Its extratemporal rerouting toward the zygoma allowed tension-free coaptation between donor and recipient nerves.

RESULTS

Of the 11 patients, 8 had a good to excellent recovery, showing different patterns of time and scores, according to age, surgical timing, and masseteric nerve function quality. The return of activity in the frontalis muscle, never obtained after reinnervation via the hypoglossal nerve, is of particular interest. The quality of the smile can be improved with re-education and practice but remains under volitional control. A true emotional response is still lacking.

CONCLUSION

The masseteric nerve is an excellent alternative to the hypoglossal nerve and can reinnervate the whole territory of the facial nerve rerouted after intratemporal translocation. The overall results are remarkable, but the low quality of the trigeminal nerve, eventually affected by the first surgery, may be an important limitation. Even if the patients appear more at ease in re-education than with other techniques, a fully natural facial expression remains impossible to obtain.

Comparison of conduit and autograft efficiency in repairing femoral nerve injury in New Zealand rabbits

Background: Peripheral nerve injuries may affect all age groups and exert devastating impacts on the professional and personal life of the patients. The investigation of nerve regeneration and use of biomaterials and synthetic materials have resulted in advancements in the treatment of peripheral nerve injuries and lesions. Nerve conduits can be used to adjoin the digital sensory nerve spaces of less than 3 cm, especially when the direct tension-free repair of peripheral nerve lesions is not possible. The present study was conducted to evaluate the use of nerve conduits by functional and nonfunctional parameters (i.e. histological study). Methods: This experimental study was conducted on 30 male rabbits. After cutting or crushing the right femoral nerve of the rabbits, they were divided into 3 groups: group 1, with right femoral nerve cut; group 2, with right femoral nerve crushed; and group 3, with right femoral nerve cut using a conduit. The 3 groups were evaluated after 1, 8, and 16 weeks for functional parameters (i.e. walking track analysis). In addition, they were subjected to nonfunctional examination (i.e. histological study) after 16 weeks, then, the results were compared. Results: The 3 groups showed no statistically significant differences in motor recovery in the eighth and 16th weeks (p>0.05). Based on the histological study, group 3 with an end-to-end nerve cutting using a conduit, showed a significantly higher axon count compared to groups 2 and 3 (p<0.05). Conclusion: End-to-end anastomosis using conduit led to axon growth; moreover, comparable functional recovery was observed with end-to-end neurorrhaphy in a rabbit model. Given that the diameter of the nerves and muscles, which might be neurotized in humans, and is much bigger and not comparable to that of the rabbits, it is highly recommended to conduct studies on animals with the larger size, such as primates, to facilitate the generalization of the results to humans.

Hemihypoglossal-Facial Nerve Anastomosis for Facial Nerve Reanimation: Case Series and Technical Note

BACKGROUND

Hypoglossal nerve injury may result in swallowing and speech problems. To reduce this morbidity and allow the performance of the hypoglossal-facial nerve anastomosis bilaterally, a technique that includes partial splitting of the hypoglossal nerve and skeletonization of the facial nerve within the mastoid process has been applied. The aim of this study is to present clinical results regarding the facial and hypoglossal nerves after the procedure.

METHODS

Prospectively collected data from 56 consecutive patients who underwent hemihypoglossal-facial nerve anastomosis (HHFA) were analyzed. The outcome was correlated with epidemiologic data, initial disease, the presence of neurofibromatosis type 2, previous radiosurgery, and the time between nerve injury and reconstructive surgery.

RESULTS

Forty-eight (84%) patients achieved satisfactory outcomes; 8 of them (14%) showed some improvement, and in 1 patient (2%) there was no improvement during long-term observation. The result at follow-up was not related to the time interval between the 2 procedures. However, recovery times for facial tonicity were statistically significantly longer if the procedure was performed after 12 months (P = 0.044). There was no statistically significant association between patient age (P = 0.96) or sex (P = 0.13) and facial nerve function. HHFA resulted in no or minimal tongue atrophy without deviation in 53 patients (93%), and the remainder had mild hemiatrophy with tongue deviation <30 degrees.

CONCLUSIONS

HHFA is an effective technique for facial nerve reanimation with acceptable morbidity related to tongue function. Patients with a longer duration of facial palsy still have a good chance for restoration of facial movement but require longer recovery periods.