Facial nerve function and hearing after microsurgical removal of sporadic vestibular schwannomas in a population-based cohort.

BACKGROUND: Vestibular schwannoma (VS) is a benign tumor originating from the vestibulocochlear nerve. The optimal treatment strategy is debated, since surgery may result in iatrogenic facial nerve injury. We report the results of VS surgery in a population-based unselected cohort in a center with access to Cyber Knife (CK) radiosurgery. METHODS: We reviewed 117 consecutive operations and found 95 patients who had their primary operation due to vestibular schwannoma between 2001 and 2017. Facial nerve function was evaluated with the House-Brackmann (HB) scale and hearing with the EU classification. RESULTS: The population consisted of 37 males and 58 females with a median age of 54 years (range 19-79). One year after surgery 67% of patients had a good outcome (HB 1-2). The rate of good outcome was 90% if no facial nerve damage was observed during intraoperative monitoring, the size of the tumor was under 30 mm and no hydrocephalus was present. During the study period, the treatment strategy changed from total to near-total resection after the introduction of CK radiosurgery, which could be used as a second-line treatment in case of residual tumor regrowth. This resulted in an improvement of outcomes (0% HB 5-6) despite the larger tumor sizes (25 ± 14 mm vs. 31 ± 9 mm, p < 0.05). Hearing preservation rates did not increase. CONCLUSIONS: Near-total resection and subsequent CK radiosurgery in case of residual tumor regrowth during follow-up seems to provide a good outcome of facial nerve function even in large VSs.

The predictive value of preoperative apparent diffusion coefficient (ADC) for facial nerve outcomes after vestibular schwannoma resection: clinical study.

OBJECT: Diffusion MRI has been used to predict intraoperative consistency of tumors. Apparent diffusion coefficient (ADC) has shown predictive value as an imaging biomarker in many CNS tumors but has not been studied in a large cohort of patients with vestibular schwannoma. In this study, we examine the utility of ADC as a predictive biomarker for intraoperative tumor characteristics and postoperative facial nerve outcome. METHODS: A retrospective review of patients who underwent vestibular schwannoma resection at our institution from 2008 to 2018 yielded 87 patients, of which 72 met inclusion criteria. Operative reports and clinical records were reviewed for clinical data; MRI data were interpreted in a blinded fashion for qualitative and quantitative biomarkers, including tumor ADC. RESULTS: Mean tumor ADC values did not predict intraoperative consistency or adherence (p = 0.63). Adherent tumors were associated with worse facial nerve outcomes (p = 0.003). Regression tree analysis identified 3 ADC categories with statistically different facial nerve outcomes. The categories identified were ADC < 1006.04 × 10-6 mm2/s; ADC 1006.04-1563.93 × 10-6 mm2/s and ADC ≥ 1563.94 × 10-6 mm2/s. Postoperative and final House-Brackmann (HB) scores were significantly higher in the intermediate ADC group (2.3, p = 0.0038). HB outcomes were similar between the group with ADC < 1006.04 × 10-6 mm2/s and ≥ 1563.94 × 10-6 mm2/s (1.3 vs 1.3). CONCLUSIONS: Middle-range preoperative ADC in vestibular schwannoma suggests a less favorable postoperative HB score. Preoperative measurement of ADC in vestibular schwannoma may provide additional information regarding prognostication of facial nerve outcomes.

Minipterional Craniotomy for Treatment of Unruptured Middle Cerebral Artery Aneurysms. A Single-Center Comparative Analysis with Standard Pterional Approach as Regard to Safety and Efficacy of Aneurysm Clipping and the Advantages of Reconstruction.

Pterional craniotomy (PT) has long been the standard approach for the treatment of middle cerebral artery (MCA) aneurysms, even though it may cause temporalis muscle atrophy, facial nerve injury, and masticatory difficulties. Minipterional craniotomy (MPT) is an alternative approach that may provide the same surgical corridor, limiting the risk of postoperative esthetic and functional complications. From January 2011 to December 2014 we consecutively performed 68 craniotomies for surgical treatment of unruptured MCA aneuryms: 37 were standard PT and 31 were MPT. There were no significant differences in mean age, sex, and aneurysm topography between the two groups. The mean skin incision length was 14 cm in the PT group and 6 cm in the MPT group. According to the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), there were no significant differences in clinical outcome at discharge or follow-up between the two groups. Also, the rates of complete aneurysm exclusion were comparable. However, the number of patients complaining of masticatory disorders was higher among those treated with PT. Finally, the number of complications observed in the PT group was higher than that in the MPT group, but only the differences in mean hospitalization length and necessity for a dural patch for reconstruction were statistically significant. In conclusion, the MPT approach is a safe and effective alternative to the standard PT for the treatment of unruptured MCA aneurysms.

Retrograde Parotidectomy and facial nerve outcomes: A case series of 44 patients.

PURPOSE: The most common surgical method to remove benign parotid tumors remains the prograde approach. We examined if a retrograde surgical technique offers better outcomes than historical prograde controls. MATERIALS AND METHODS: A retrospective chart review at Stanford Hospital was conducted to identify retrograde parotidectomies between February 2012 and October 2014 that were staffed by the senior author (DS) with resident involvement. Facial nerve (FN) outcomes and other post-surgical parameters were recorded. RESULTS: We identified 44 consecutive cases and found that 18.2% (n=8) of patients experienced temporary paresis and 2.3% (n=1) experienced minor (HB 2) permanent paresis limited to one branch. The average hospital length of stay was 0.64 days and complication rate was 6.8%. CONCLUSION: The retrograde technique has complication rates comparable to historical rates for the prograde technique and is amenable to minimally invasive outpatient superficial parotidectomy.

Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study.

OBJECTIVES: To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting. DESIGN AND SETTING: Multicentre retrospective study in eight tertiary referral hospitals over 17 years. PARTICIPANTS: Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised. MAIN OUTCOME MEASURES: Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded. RESULTS: In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves. CONCLUSIONS: We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.

Surgical Strategy and Facial Nerve Outcomes in Petrous Bone Cholesteatoma.

OBJECTIVE: To review the classification and management of petrous bone cholesteatomas (PBCs) at our center and the outcomes of facial nerve (FN) management in these lesions. METHODS: This was a retrospective study. The setting was a quaternary referral center for skull base pathology in Italy. A total of 200 patients with 201 PBCs were included in the study. All patients diagnosed radiologically with PBCs were classified according to the Sanna classification. All patients were surgically treated and followed up with radiology. The main outcome measures - classification of PBCs, the surgical approach used, disease control, and FN outcomes - were analyzed. RESULTS: Supralabyrinthine PBCs were the most common type with 92 cases (45.8%) followed by the massive PBCs with 72 cases (35.8%). Preservation of preoperative FN function was highest in the infralabyrinthine (72.2%) and infralabyrinthine-apical (73.3%) types. The transotic approach was used in 66 cases (32.8%) in this series. The modified transcochlear approach type A was applied in 55 cases (27.3%). Active management of the nerve (rerouting, anastomosis, or grafting) was required in 53 cases (26.4%). Postoperatively, of the 116 cases with FN House-Brackmann grade I and II, 107 cases (92.2%) retained the same grade or improved. Recurrence was seen in 7 cases (3.5%). The mean duration of follow-up was 6.3 years. CONCLUSIONS: Radical disease clearance must take precedence over hearing and FN preservation in PBCs. Active FN management, including rerouting, end-to-end anastomosis, and cable nerve grafting, routinely come to play in the surgical management of PBCs, and the postoperative FN results after such interventions can be satisfactory in most cases.

Linear accelerator radiosurgery for vestibular schwannomas: Results of medium-term follow-up.

BACKGROUND: To examine tumour control, via volume changes, and the complications of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) treatment of vestibular schwannomas (VSs) on medium-term follow-up. METHODS: Between September 2003 and November 2009 fifty consecutive patients with VSs treated with SRS using a marginal dose of 12.5 Gy utilizing a LINAC equipped with a micro-multileaf collimator were identified. Evaluation included serial magnetic resonance imaging (MRI), and neurological and hearing examinations. RESULTS: The median tumour volume at treatment was 2.4 (range: 0.24-10.59) cm3. The intracranial diameter of the tumours ranged between 7.7 and 28.7 (median: 15.8) mm. Follow-up MRI was available for analysis on 49 patients. The median radiological follow-up period was 5.8 (range: 1.4-9.2) years. The median tumour volume at last follow-up was 1.1 (range: 0.03-5.3) cm3. VS decreased in size in 45 (90%) patients, with a median reduction in tumour volume of 1.46 (range: 0.06-9.29) cm3 or a median tumour size reduction of 59% of the baseline (range: 6-90%) in these patients. VS remained stable in 2 patients and increased in size in 2 patients. Only 1 patient (2%) required additional intervention (surgery). 15 patients had useful hearing pre-treatment; 10 post-treatment pure-tone audiograms of these patients were available. 5 (50%) patients still had useful hearing post treatment. Non-auditory adverse radiation effects included new (House-Brackmann grade II) or worsened facial nerve palsy (House-Brackmann grade II to grade V) in 2 (4%) patients and trigeminal sensory disturbance in 2 (4%) patients. CONCLUSIONS: At medium term, the vast majority of VSs treated with LINAC-based SRS exhibit tumour shrinkage. The slightly higher rate of facial nerve palsy compared with Gamma Knife surgery (GKS) results may be related to the learning curve. Other complications were similar to reported GKS results for VSs of comparable sizes.

Strategy for the surgical treatment of vestibular schwannomas in patients with neurofibromatosis type 2.

OBJECTIVE: Guidelines for appropriate management of vestibular schwannomas in NF2 patients are controversial. In this paper we reviewed our experience with patients with NF2 for the results of surgical treatment with particular reference to hearing and facial nerve preservation. METHODS: We included in the study 30 patients (16 women and 14 men) with the diagnosis of NF2 treated in our department between 1998 and 2014 who underwent surgery for vestibular schwannoma removal with a follow-up for at least 1 year. In 3 cases, the vestibular schwannomas were unilateral. Six patients with bilateral vestibular schwannomas underwent unilateral procedure. Therefore, 51 acoustic tumors were studied in 30 patients. RESULTS: No operative death we noted. Significant deterioration to the non-functional level occurred in 19 out of 22 cases with well-preserved preoperative hearing. Only three ears maintained their preoperative good hearing. Hearing was preserved in cases of small schwannoma not exceeding 2 cm. Among 21 patients who underwent bilateral operations hearing was preserved in 3 out of 7 cases when smaller tumor or better hearing level side was attempted at first surgery. In contrary none of the 14 patients retained hearing when the first operation concerned the worse-hearing ear. Among 14 tumors up to 2 cm there was only one case of moderately severe facial nerve dysfunction (House-Brackmann Grade IV) in the long follow-up. CONCLUSION: Early surgical intervention for vestibular schwannoma in NF2 patient is a viable management strategy to maintain hearing function and preserve facial nerve function.

Multiple sclerosis-related trigeminal neuralgia: a prospective series of 43 patients treated with gamma knife surgery with more than one year of follow-up.

BACKGROUND: Trigeminal neuralgia (TN) related to multiple sclerosis (MS) is more difficult to manage pharmacologically and surgically. OBJECTIVE: This article aims to evaluate the safety and efficacy of Gamma Knife surgery (GKS) in this special group of patients. METHODS: Between July 1992 and November 2010, 43 cases with more than 1 year of follow-up were operated with GKS for TN related to MS and prospectively evaluated in the Timone University Hospital, Marseille, France. Radiosurgery using the Gamma Knife (model B or C or Perfexion) was performed. A single 4-mm isocenter was positioned at a median distance of 8 mm (range 5.7-14.7) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range 75-90) was delivered. RESULTS: The median follow-up period was 53.8 months (12-157.1). Thirty-nine patients (90.7%) were initially pain free. Their actuarial probability of remaining pain free without medication at 6 months, 1, 3, 5 and 10 years was 87.2, 71.8, 43.1, 38.3 and 20.5%, respectively, and remained stable till 12 years. The hypoesthesia actuarial rate at 6 months, 1 and 2 years was 11.5, 11.5 and 16%, and remained stable till 12 years. CONCLUSIONS: GKS proved safe and effective in this special group of patients.

Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma.

OBJECTIVE: We investigated the relationship between facial canal dehiscence and intraoperative middle ear and mastoid findings in patients operated on for cholesteatoma. METHODS: We examined retrospectively 334 patients who had been operated on for cholesteatoma in Izmir Katip Celebi University, Ataturk Research and Training Hospital, ENT Clinic, between April 1997 and April 2010. The patients were examined for facial canal dehiscence according to age, gender, side of the ear, surgery type, first or revision surgery, localization of the facial canal dehiscence, spread of the cholesteatoma, with the presence of lateral semi-circular canal (LSCC) fistula and any defect in the ossicle chain, and destruction in the posterior wall of the external auditory canal(EAC). RESULTS: Of the patients, 23.6% had facial canal dehiscence and detected most commonly in the right ear 28.9% and tympanic segment, 83.5%. Facial canal dehiscence was found to be 24.2-fold more common in patients with LSCC fistula and 4.1-fold more common in patients with destruction in the posterior wall of the (EAC). In patients located cholesteatoma in tympanic cavity+antrum and the tympanic cavity+all mastoid cells and with incus and stapes defect, increased incidence of dehiscence. Age, first or revision operation and canal wall down tympanoplasty (CWDT) or canal wall up tympanoplasty (CWUT) did not affect the incidence of dehiscence. CONCLUSIONS: That the likelihood of facial canal dehiscence occurrence is increased in patients with LSSC fistulas, destruction in the posterior wall of the EAC, or a stapes defect is important information for surgeons.

Less invasive transjugular approach with Fallopian bridge technique for facial nerve protection and hearing preservation in surgery of glomus jugulare tumors.

For the past three decades, surgery of glomus jugulare tumors (GJTs) has been characterized by extensive combined head and neck, neuro-otologic, and neurosurgical approaches. In recent years, the authors have modified the operative technique to a less invasive approach for preservation of cranial nerves while achieving satisfactory tumor resection. We evaluated and compared the clinical outcomes of our current less invasive approach with our previous more extensive procedures. The clinical records of 39 cases of GJT surgically treated between 1992 and 2011 were retrospectively reviewed. The less invasive transjugular approach with Fallopian bridge technique (LI-TJ) was used for the most recent five cases. The combined transmastoid-transjugular and high cervical (TM-HC) approach was performed in 30 cases, while four cases were treated with a transmastoid-transsigmoid approach with facial nerve translocation. Operative technique, extent of tumor resection, operating time, hospital stay, and morbidity were examined through the operative records, and a comparison was made between the LI-TJ cases and the more invasive cases. No facial nerve palsy was seen in the LI-TJ group while the TM-HC group demonstrated six cases (17.6%) of facial palsy (House-Brackmann facial nerve function grading scale grade II and III). The complication rate was 0 % in the LI-TJ group and 16.7% in the more invasive group. The mean operative time and hospital stay were shorter in the LI-TJ group (6.4 h and 4.3 days, respectively) compared with the more invasive group (10.7 h and 8.0 days, respectively). The LI-TJ approach with Fallopian bridge technique provided adequate tumor resection with cranial preservation and definitive advantage over the more extensive approach.

Buccal branch as a guide for superficial parotidectomy.

UNLABELLED: Superficial parotidectomy is the preferred method for treating lesions of the parotid gland. Several methods of identification and dissection of the facial nerve have been reported, including antegrade and retrograde dissection. AIM: The aim of this study was to determine the role of the buccal branch of the facial nerve use as a guide in retrograde approach that minimizes injury to the facial nerve and maximizes the rate at which it recovers. RESULT: Fifteen patients who underwent superficial parotidectomy by retrograde approach between 2009 and 2011 at the Maxillofacial Department, Medical City Hospital Baghdad, were included in this study. The study group included 6 males and 9 females, with ages ranging from 25 and 66 years. Temporary facial nerve weakness was noticed in 4 patients (26.6%); full recovery of the facial nerve function in those patients had been noticed between 3 and 8 weeks. Sialocele was noticed in 1 patient (6.6%). CONCLUSIONS: Retrograde approach guided by buccal branch is simple and less time consuming and has less risk for facial nerve injury.

Analysis of the Outcome of Reoperative Face Lifts Using Sub-SMAS Techniques.

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.

Risk of complications with retromandibular transparotid vs. anteroparotid approach for condylar fractures: a systematic review and meta-analysis.

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.

Functional gland-preserving surgery via periauricular incision for pleomorphic adenoma of the parotid gland.

INTRODUCTION: Gland-preserving surgery is often used for benign tumours in the parotid gland. Partial superficial parotidectomy via a periauricular incision may bring satisfactory cosmetic outcomes but the disease control outcome remains unrevealed. This study evaluated functional and disease control outcomes after gland-preserving surgery via periauricular incision for pleomorphic adenoma of the parotid gland. METHODS: This longitudinal study included 248 consecutive patients with parotid pleomorphic adenoma who underwent the preservation of most normal parotid tissues and the facial nerve combined with the en-bloc resection of tumours via periauricular incision. Postoperative complications, subjective satisfaction, salivary function, and tumour recurrence were assessed in each patient. The secretory function of the salivary gland was measured using salivary scintigraphy at 6 months after surgery, and ultrasonography was regularly followed. RESULTS: Median tumour size was 2.5 cm (range, 0.8-5.2 cm) and median operation time was 55 min (range, 39-88 min). All tumours were safely removed by gland-preserving surgery via periauricular incision without extension to Blair or hairline incision and tumour spillage. Temporary and permanent paralysis of the facial nerve was 14 (5.6%) and none of the study patients, respectively. Postoperative complications were minor and Frey's syndrome was found in 6 (2.4%) patients. The Secretary function of the affected gland was equal to that of the unaffected gland. No patients had a recurrence for a median follow-up of 78 months (range, 24-126 months). CONCLUSIONS: Functional gland-preserving surgery via periauricular incision can treat pleomorphic adenoma in the parotid gland with satisfactory functional, cosmetic, and disease control outcomes.

The minimal access deep plane extended vertical facelift.

BACKGROUND: Modern facelift techniques have benefited from a "repopularization" of shorter incisions, limited skin elevation, and more limited dissection of the superficial musculoaponeurotic system (SMAS) and platysma in order to shorten postoperative recovery times and reduce surgical risks for patients. OBJECTIVES: The authors describe their minimal access deep plane extended (MADE) vertical vector facelift, which is a hybrid technique combining the optimal features of the deep plane facelift and the short scar, minimal access cranial suspension (MACS) lift. METHODS: The authors retrospectively reviewed the case records of 181 patients who underwent facelift procedures performed by the senior author (AAJ) during a two year period between March 2008 and March 2010. Of those patients, 153 underwent facelifting with the MADE vertical technique. With this technique, deep plane dissection releases the zygomatico-cutaneous ligaments, allowing for more significant vertical motion of the midface and jawline during suspension. Extended platysmal dissection was utilized with a lateral platysmal myotomy, which is not traditionally included in a deep plane facelift. The lateral platysmal myotomy allowed for separation of the vertical vector of suspension in the midface and jawline from the superolateral vector of suspension that is required for neck rejuvenation, obviating the need for additional anterior platysmal surgery. RESULTS: The average age of the patients was 57.8 years. The average length of follow-up was 12.7 months. In 69 consecutive patients from this series, average vertical skin excision measured 3.02 cm on each side of the face at the junction of the pre auricular and temporal hair tuft incision (resulting in a total excision of 6.04 cm of skin). Data from the entire series revealed a revision rate of 3.9%, a hematoma rate of 1.9%, and a temporary facial nerve injury rate of 1.3%. CONCLUSIONS: The common goal of all facelifting procedures is to provide a long-lasting, natural, balanced, rejuvenated aesthetic result with few complications and minimal downtime. The MADE vertical facelift fulfills these criteria and often yields superior results in the midface and neck areas, where many short scar techniques fail. Furthermore, this procedure can be performed under local anesthesia, which is a benefit to both patients and surgeons.

Extracapsular Dissection in Pleomorphic Adenomas of the Parotid Gland: Results After 13 Years of Follow-up.

OBJECTIVES/HYPOTHESIS: To assess long-term results after the treatment of parotid pleomorphic adenomas (PPAs) using different surgical techniques and focusing on recurrence rates and the risk of adverse effects. STUDY DESIGN: Retrospective analysis. METHODS: Retrospective analysis of 182 patients treated exclusively for PPAs at a tertiary referral center between 2000 and 2004. Thorough follow-up examinations over a mean period of 13 years were possible in 53.8% (n = 98/182). Tumors were categorized according to the European Salivary Gland Society (ESGS) system to improve the comparison of outcomes. After different surgical resection strategies, recurrence rates, postoperative facial nerve paresis (FNP), and incidence of Frey's syndrome were assessed. The follow-up period included clinical examinations and imaging of every patient in the treating department. RESULTS: Of 182 patients, extracapsular dissection (ED) was performed in 29.7%, and other surgical modalities (OSMs), including facial nerve dissection, in 70.3%. After the long-term follow-up, 98% of all the patients (n = 96/98) were recurrence free. When recurrence rates were compared, no significant differences were noted (P < .331). ED resulted in significantly lower FNP rates compared to OSMs (P < .001). FNP rates significantly increased with size and location of the tumors according to ESGS categories (temporary and permanent FNP, P = .04). Surgical invasiveness corresponded to a significant increase in the incidence of Frey's syndrome (P < .001). CONCLUSIONS: ED was associated with the lowest complication rates, but not with a higher risk of recurrence, when compared with OSM in the long-term course. As ED can be performed in the majority of PPAs, it can be regarded as the treatment of choice whenever possible. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E445-E451, 2021.

MISIAN (Minimally Invasive Surgery for Treatment of Unruptured Intracranial Aneurysms): A Prospective Randomized Single-Center Clinical Trial With Long-Term Follow-Up Comparing Different Minimally Invasive Surgery Techniques with Standard Open Surgery.

BACKGROUND: Unruptured intracranial aneurysms (UIAs) are increasingly diagnosed but treatment is still controversial. Although the descriptions and use of minimally invasive surgery (MIS) have increased, comparative studies with standard approaches are rare. OBJECTIVE: MISIAN (Minimally Invasive Surgery for Treatment of Unruptured Intracranial Aneurysms) is a prospective randomized single-center clinical trial with long-term follow-up comparing different MIS techniques with standard open surgery for treatment of UIAs. METHODS: We randomly allocated a standard pterional approach (PtA) or MIS (1:2) to 111 patients with UIAs of the anterior circulation (mean dome diameter, 6.4 mm; range, 3-20 mm). Patients selected for MIS underwent a second randomization between a transeyelid approach (TelA) or nanopterional approach (NPtA) (1:1). RESULTS: Forty-one patients were randomized to and treated with the PtA, 36 with the TelA, and 34 with the NPtA. Only patients treated with PtA had permanent facial nerve palsy (n = 4 [10%]; P = 0.032). MIS cosmetic results were considered better than those of PtA by independent observers (P < 0.001), and less temporal atrophy in the MIS group was also observed (P = 0.0034). The proportion of excellent results was higher in the TelA group than in the NPtA group (86% vs. 67.6%; P = 0.039). Patients undergoing MIS also reported consistently higher satisfaction and quality-of-life scores (P < 0.001). CONCLUSIONS: MIS is superior to standard PtA for microsurgical clipping of small UIAs of the anterior circulation in terms of cosmetic, satisfaction, and quality-of-life outcomes. The TelA or NPtA for UIAs did not show significant outcome differences at 12-18 months.

Risk Factors of Postoperative Facial Palsy for Benign Parotid Tumors: Outcome of 1,018 Patients.

OBJECTIVE: The aim of this study was to evaluate the rate of postoperative facial palsy in benign parotid tumors, as well as its risk factors, pathology, and clinical results. STUDY DESIGN: Retrospective analysis. METHODS: We performed a retrospective analysis of data from patients whose initial operation for a benign parotid tumor had been performed in our department between 1999 and 2020. RESULTS: We included 1,018 patients in this study. The most common tumor observed was pleomorphic adenoma (614 patients), followed by Warthin tumor (234 patients). Fine-needle aspiration cytology and frozen section biopsy were used to identify the tumor histopathology. The overall rate of postoperative facial nerve palsy was 19.5%; the rate was significantly higher in patients with large-diameter tumors or deep lobe tumors. Postoperative facial palsy improved within 24 months of surgery in all cases. There were no cases with permanent facial palsy. CONCLUSIONS: Postoperative facial nerve palsy developed regularly after surgery to remove benign parotid tumors despite preservation of the nerve. Palsy rate was high in patients with large tumors or deep lobe tumors. Despite the high risk of facial palsy in these patients and the benign nature of the tumor, we recommend surgery rather than follow-up observation, as the risk of postoperative facial palsy may increase as the tumor grows. It is important to provide an accurate explanation on the risks of postoperative complications to all patients to obtain appropriate informed consent for surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2857-E2864, 2021.

Best Practices in Facial Nerve Monitoring.

OBJECTIVES/HYPOTHESIS: Facial nerve monitoring (FNM) has evolved into a widely used adjunct for many surgical procedures along the course of the facial nerve. Even though majority opinion holds that FNM reduces the incidence of iatrogenic nerve injury, there are few if any studies yielding high-level evidence and no practice guidelines on which clinicians can rely. Instead, a review of the literature and medicolegal cases reveals significant variations in methodology, training, and clinical indications. STUDY DESIGN: Literature review and expert opinion. METHODS: Given the lack of standard references to serve as a resource for FNM, we assembled a multidisciplinary group of experts representing more than a century of combined monitoring experience to synthesize the literature and provide a rational basis to improve the quality of patient care during FNM. RESULTS: Over the years, two models of monitoring have become well-established: 1) monitoring by the surgeon using a stand-alone device that provides auditory feedback of facial electromyography directly to the surgeon, and 2) a team, typically consisting of surgeon, technologist, and interpreting neurophysiologist. Regardless of the setting and the number of people involved, the reliability of monitoring depends on the integration of proper technical performance, accurate interpretation of responses, and their timely application to the surgical procedure. We describe critical steps in the technical set-up and provide a basis for context-appropriate interpretation and troubleshooting of recorded signals. CONCLUSIONS: We trust this initial attempt to describe best practices will serve as a basis for improving the quality of patient care while reducing inappropriate variations. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:S1-S42, 2021.