Contribution and safety of the side-to-end hypoglossal-to-facial transfer in multidisciplinary facial reanimation.

BACKGROUND: This study evaluates facial and tongue function in patients undergoing side-to-end hypoglossal-to-facial transfer (HFT) with additional techniques. METHODS: Thirty-seven patients underwent a side-to-end HFT. Twelve had additional cross-face grafts, and 9 had an additional masseter-to-facial transfer. Facial was assessed with House-Brackmann (HB), Sunnybrook Facial Grading Scale (SFGS), and eFACE. Martins scale and the Oral-Pharyngeal Disability Index (OPDI) were used to assess tongue function. RESULTS: Ninety-four percent of cases reached HB grades III-IV. Mean total SFGS score improved from 16 ± 15 to 59 ± 11, while total eFACE score from 52 ± 13 to 80 ± 5. Dual nerve transfers were a predictor for a better eFACE total score p = 0.034, ß = 2.350 [95% CI, 0.184-4.516]), as well as for a higher SFGS total score (p = 0.036, ß = 5.412 [95% CI, 0.375-10.449]). All patients had Martin's grade I. Mean postoperative OPDI scores were 84 ± 17 (local physical), 69 ± 16 (simple and sensory motor components), 82 ± 14 (complex functions), and 73 ± 22 (psychosocial). CONCLUSIONS: The side-to-end HFT offers predictable facial function outcome and preserves tongue function in nearly all cases. Dual nerve transfers appear to improve the final outcome.

Combined Sequential Bilateral Hypoglossal-to-facial and Masseter-to-facial Transfers for Bilateral Facial Paralysis.

Bilateral facial paralysis is a challenging situation requiring complex management. Surgical treatment can include nerve transfers, mainly masseter-to-facial, or muscle transfers, gracilis free flap, or temporalis transposition. Deciding on the surgical option depends on the duration of the paralysis and the feasibility of facial muscles. We present the case of a 10-year-old child with permanent bilateral facial paralysis after brainstem tumor surgery. The patient was treated with bilateral simultaneous hypoglossal-to-facial transfer followed by bilateral simultaneous masseter-to-facial 12 months later. After 23 months of follow-up and specific physical therapy, she has good and symmetric resting tone, complete eye closure, moderate bilateral smile excursion, mild lip pucker movement, and good oral competence. The combination of these two nerve transfers, when possible, gives the opportunity of restoring movement taking the best of each technique, with acceptable results and no significant clinical deficits in the donor sites.

A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: An international group consensus.

This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4-25 years; mean 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an exten-sive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but instead aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this. However, where evidence is not yet conclusive, the group members issued statements and, in some cas-es, made recommendations based on their clinical experience.

The Experience of a Facial Nerve Unit in the Treatment of Patients With Facial Paralysis Following Skull Base Surgery.

: The management of facial paralysis following skull base surgery is complex and requires multidisciplinary intervention. This review shows the experience of a facial nerve (FN) unit in a tertiary university referral center. A multidisciplinary approach has led to the breaking of some old treatment paradigms. An overview of five FN scenarios is presented. For each setting a contemporary approach is proposed in contrast to the established approach. 1) For patients with an anatomically preserved FN with no electrical response at the end of surgery for vestibular schwannoma, watchful waiting is usually advocated. In these cases, reinforcement with an interposed nerve graft is recommended. 2) In cases of epineural FN repair, with or without grafting, and a poor expected prognosis, an additional masseter-to-facial transfer is recommended. 3) FN transfer, mainly hypoglossal-to-facial and masseter-to facial, are usually chosen based on the surgeons' preference. The choice should be based on clinical factors. A combination of techniques improves the outcome in selected patients. 4) FN reconstruction following malignant tumors requires a combination of parotid and temporal bone surgery, involving different specialists. This collaboration is not always consistent. Exposure of the mastoid FN is recommended for lesions involving the stylomastoid foramen, as well as intraoperative FN reconstruction. 5) In patients with incomplete facial paralysis and a skull base tumor requiring additional surgery, consider an alternative reinnervation procedure, "take the FN out of the equation" before tumor resection. In summary, to achieve the best results in complex cases of facial paralysis, a multidisciplinary approach is recommended.

Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology. / Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL.

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve.

Facial nerve repair: the impact of technical variations on the final outcome.

OBJECTIVES: To analyze the outcome of facial nerve (FN) reconstruction, the impact of technical variations in different conditions and locations, and the importance of additional techniques in case of suboptimal results. STUDY DESIGN: Retrospective study. SETTING: University-based tertiary referral center. PATIENTS: Between 2001 and 2017, reconstruction of the FN was performed on 36 patients with varying underlying diseases. INTERVENTIONS: FN repair was performed by direct coaptation (n = 3) or graft interposition (n = 33). Microsurgical sutures were used in 17 patients (47%) and fibrin glue was used in all cases. Additional reinnervation techniques (hypoglossal-facial or masseter-facial transfers) were performed in five patients with poor results after initial reconstruction. MAIN OUTCOME MEASURES: FN function was evaluated using the House-Brackmann (HB) and the electronic clinician-graded facial function (eFACE) grading systems. Minimum follow-up was 12 months. RESULTS: FN reconstruction yielded improvement in 83% of patients, 21 patients (58.3%) achieving a HB grade III. The eFACE median composite, static, dynamic and synkinesis scores were 69.1, 78, 53.2, and 88.2 respectively. A tendency towards better outcome with the use of sutures was found, the difference not being significant. All patients undergoing an additional reinnervation procedure achieved a HB grade III, eFACE score being 74.8. CONCLUSIONS: FN reconstruction offers acceptable functional results in most cases. No significant differences are expected with technical variations, different locations or conditions. In patients with poor initial results, additional reinnervation techniques should be always considered. The eFACE adds substantial information to the most used HB scale.

Safety and efficacy of incobotulinumtoxinA doses up to 800 U in limb spasticity: The TOWER study.

OBJECTIVE: To evaluate safety (primary objective) and efficacy of increasing doses (400 U up to 800 U) of incobotulinumtoxinA (Xeomin, Merz Pharmaceuticals GmbH) for patients with limb spasticity. METHODS: In this prospective, single-arm, dose-titration study (NCT01603459), patients (18-80 years) with spasticity due to cerebral causes, who were clinically deemed to require total doses of 800 U incobotulinumtoxinA, received 3 consecutive injection cycles (ICs) with 400 U, 600 U, and 600-800 U incobotulinumtoxinA, respectively, each followed by 12-16 weeks' observation. Outcomes included adverse events (AEs), antibody testing, Resistance to Passive Movement Scale (REPAS; based on the Ashworth Scale), and Goal Attainment Scale. RESULTS: In total, 155 patients were enrolled. IncobotulinumtoxinA dose escalation did not lead to an increased incidence of treatment-related AEs (IC1: 4.5%; IC2: 5.3%; IC3: 2.9%). No treatment-related serious AEs occurred. The most frequent AEs overall were falls (7.7%), nasopharyngitis, arthralgia, and diarrhea (6.5% each). Five patients (3.2%) discontinued due to AEs. No patient developed secondary nonresponse due to neutralizing antibodies. Mean (SD) REPAS score improvements from each injection to 4 weeks postinjection increased throughout the study (IC1: -4.6 [3.9]; IC2: -5.9 [4.2]; IC3: -7.1 [4.8]; p < 0.0001 for all). The proportion of patients achieving ≥3 (of 4) treatment goals also increased (IC1: 25.2%; IC2: 50.7%; IC3: 68.6%). CONCLUSION: Escalating incobotulinumtoxinA doses (400 U up to 800 U) did not compromise safety or tolerability, enabled treatment in a greater number of muscles/spasticity patterns, and was associated with increased treatment efficacy, improved muscle tone, and goal attainment. CLINICALTRIALSGOV IDENTIFIER: NCT01603459. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that, for patients with limb spasticity, escalating incobotulinumtoxinA doses (400 U up to 800 U) increases treatment efficacy without compromising safety or tolerability.

Evolution of Patients With Immediate Complete Facial Paralysis Secondary to Acoustic Neuroma Surgery.

OBJECTIVE: To study the evolution of patients with immediate complete facial paralysis after acoustic neuroma surgery in different scenarios and assess different facial reanimations techniques. METHODS: This study included 50 patients with complete facial paralysis immediately after acoustic neuroma surgery. Data were analyzed into 4 groups according to the need and type of reconstruction of the facial nerve, either none, immediate, or on a deferred basis. All patients had intraoperative facial nerve monitoring, and facial nerve function was evaluated according the House-Brackmann (HB) scale. RESULTS: Of all patients with immediate total paralysis, no patients achieved totally normal facial function (grade I), and only 5 (10%) recovered to a grade II. For all groups included, the majority of patients (82%) achieved an acceptable final facial function (grade III HB). In this series, only 2 patients remained with a grade VI facial function. CONCLUSIONS: The possibility of recovering near normal facial function after a grade VI facial paralysis is very low. Procedures like the immediate repair of the facial nerve with an interposed donor graft may provide better facial function in patients with partially injured facial nerve. Even in cases of total section, there are other procedures that can improve the results.

[Hemi-hypoglossal-facial intratemporal side to side anastomosis]. / Anastomosis hipoglosofacial intratemporal hemiterminoterminal.

Conventional hypoglossal-facial anastomosis and the interposition jump graft variation are the most popular techniques for facial nerve reconstruction resulting from proximal facial nerve injury. We present a modification of this technique, the hemi-hypoglossal facial intratemporal side to side anastomosis, which overcomes many of the failings of previous techniques. The method involves mobilization of the intratemporal facial nerve, which is anastomosed to a partially incised hypoglossal nerve. It is especially indicated in patients with multiple cranial nerve palsies.