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This study aimed to reveal the preferred initial treatment for Koos grade 3 vestibular schwannomas (VS). We performed a two-institutional retrospective study on 21 patients with Koos grade 3 VS undergoing resection at Yokohama Medical Center and 37 patients undergoing radiosurgery at Yokohama Rosai Hospital from 2010 to 2021. Tumor control, complications, and functional preservation were compared. The median pre-treatment volume and follow-up duration were 2845 mm3 and 57.0 months, respectively, in the resection group and 2127 mm3 and 81.7 months, respectively, in the radiosurgery group. In the resection group, 16 (76.2%) underwent gross total resection, and three patients (14.3%) experienced regrowth; however, no one required additional treatment. In the radiosurgery group, the tumor control rate was 86.5%, and three cases (8.1%) required surgical resection because of symptomatic brainstem compression. Kaplan-Meier analyses revealed that tumors with delayed continuous enlargement and large thin-walled cysts were significantly associated with poor prognostic factors (p = 0.0027, p < 0.001). The pre-radiosurgery growth rate was also associated with the volume increase (p = 0.013). Two cases (9.5%) required additional operation due to complications such as post-operative hematoma and cerebrospinal fluid leaks in the resection group, whereas temporary cranial neuropathies were observed in the radiosurgery group. Two patients (9.5%) had poor facial nerve function (House-Brackmann grading grade 3) in the resection group, while no one developed facial paresis in the radiosurgery group. Trigeminal neuropathy improved only in the resection group.Radiosurgery can be considered for the treatment of Koos grade 3 VS for functional preservation. However, resection may also be considered for patients with severe trigeminal neuropathy or a high risk of volume increments, such as large thin-walled cysts and rapid pre-treatment growth.
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Neuroma Acústico , Radiocirurgia , Humanos , Neuroma Acústico/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Radiocirurgia/métodos , Adulto , Idoso , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Procedimentos Neurocirúrgicos/métodos , Gradação de TumoresRESUMO
PURPOSE: To evaluate the effectiveness and safety of electroacupuncture (EA) using intermittent wave stimulation in enhancing facial symmetry and nerve function in chronic Bell's palsy patients. METHODS: A 6-week assessor-blinded, randomized trial followed by an 18-week observational period was conducted. Sixty individuals with chronic Bell's palsy, showing no signs of recovery after 12 months, were equally divided to receive either 18 sessions of EA using intermittent wave stimulation or Transcutaneous Electrical Stimulation (TES), administered thrice weekly over 6 weeks. The primary outcome measure was the change in the total facial nerve index (TFNI) score from baseline to Week 6, with secondary outcomes including TFNI scores at Weeks 12 and 24, as well as the change in Sunnybrook Facial Grading System (SFG) score from baseline to Week 6, and SFG scores at Weeks 12 and 24. RESULTS: The EA group showed a significant improvement, with a mean total facial nerve index score increase of 24.35 (4.77) by Week 6 compared with 14.21 (5.12) in the Transcutaneous Electrical Stimulation group (P<.001). This superiority persisted during the 24-week follow-up. While no significant difference was observed in the Sunnybrook Facial Grading System score change from baseline to Week 6, variations were noted at Weeks 12 and 24. No major adverse effects were reported. CONCLUSION: EA with intermittent wave stimulation notably enhanced facial symmetry in chronic Bell's palsy patients over Transcutaneous Electrical Stimulation by Week 6, maintaining this edge throughout the follow-up.
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Paralisia de Bell , Eletroacupuntura , Humanos , Paralisia de Bell/terapia , Paralisia de Bell/diagnóstico , Nervo Facial , Projetos de Pesquisa , FaceRESUMO
PURPOSE: Facial nerve schwannomas (FNSs) are rare intracranial tumors, and the optimal management of these tumors remains unclear. We investigated the long-term follow-up results of FNS with good facial nerve function. METHODS: At nine medical centers in the Korean Facial Nerve Study Group, 43 patients undergoing observation periods longer than 12 months for FNS with good facial nerve function (House-Brackmann grade ≤ II) were enrolled, and clinical and radiographic data were obtained for these cases. RESULTS: The mean follow-up period was 63 months. In the majority of cases, tumors involved multiple segments (81.4%) and only eight cases were confined to a single site. There were no cases where the tumor was confined to the extratemporal region. Tumor size increased slightly, with an average estimated change of 0.48 mm/year. Twenty (46.5%) of 43 patients showed no change in tumor size. Seven patients (16.3%) showed worsening House-Brackmann (H-B) grade, of which two patients deteriorated from H-B grade I to II, four worsened to grade III, and one deteriorated to grade IV. The remaining 36 patients (83.7%) showed no change in facial nerve function. There was no difference in H-B grade according to tumor size at the time of diagnosis or change in tumor size. CONCLUSION: We conducted a large-scale observational study of FNS with good facial nerve function. Our study showed that many patients maintained facial nerve function during long-term follow-up. Conservative management with regular examination and imaging can be an appropriate option for managing FNS with good facial nerve function.
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Geniculate ganglion hemangioma (GGH) is rarely presented in the neurosurgical literature. It extends extradurally on the middle fossa floor and displaces the intratemporal part of the facial nerve. Surgical treatment is advisable at early symptoms. Proposed techniques include fascicular-sparing resection or nerve interruption with grafting. No definitive conclusions exist about the superiority of a certain technique in preserving facial nerve integrity and function. Through the description of a surgically managed symptomatic GGH, we herein discuss literature data about the surgical results of fascicular-sparing resection versus grafting. A PRISMA-based literature search was performed on the PubMed database. Only articles in English and published since 1990 were selected and furtherly filtered based on the best relevance. Statistical comparisons were performed with ANOVA. One hundred sixteen GGHs were collected, 56 were treated by fascicular-sparing resection, and 60 were treated by grafting. The facial function was improved, or unchanged, in 53 patients of the fascicular-sparing group and 30 patients of the grafting one. Sixty-five patients achieved a good (House-Brackmann (HB) grade III) postoperative facial outcome, of which 47 and 18 belonged to the fascicular-sparing and grafting group, respectively. Greater efficacy of the fascicular-sparing technique in the achievement of a better facial outcome was found (p = 0.0014; p = 0.0022). A surgical resection at the earliest symptoms is critical to preserve the facial nerve function in GGHs. Fascicular-sparing resection should be pursued in symptomatic cases with residual facial function (I-III HB). Conversely, grafting has a rationale for higher HB grades (V-VI). Broader studies are required to confirm these findings and turn them into new therapeutic perspectives.
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Neoplasias dos Nervos Cranianos , Paralisia Facial , Hemangioma , Humanos , Gânglio Geniculado/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Neoplasias dos Nervos Cranianos/cirurgia , Nervo Facial/cirurgia , Hemangioma/cirurgia , Paralisia Facial/cirurgiaRESUMO
PURPOSE: We aimed to explore the influence of preoperative gamma knife treatment on the clinical effect of microsurgical resection of vestibular schwannoma. METHODS: The data of patients who underwent vestibular schwannoma resection in our hospital between November 2010 and December 2019 were retrospectively collected. According to the data collected retrospectively and the inclusion and exclusion criteria, we selected these patients and divided them into Group A (with preoperative gamma knife treatment) and Group B (without preoperative gamma knife treatment). The pre/postoperative clinical manifestations, neurological function grade, postoperative complications, tumor recurrence and increase were collected and compared between the two groups. RESULTS: There were 40 and 823 patients enrolled in Groups A and B, respectively. There were no significant differences in the general condition, tumor size and side, or neurological performance of the patients in those two groups before the operation. At the last follow-up, the number of patients with poor facial nerve function was 15 (39.5%) in Group A and 170 (20.7%) in Group B (P = 0.021 < 0.05). In Group A and Group B, disequilibrium occurred in 14 (36.8%) patients and 124 (15.1%) patients, respectively, after the operation (P = 0.012 < 0.05). Seven (17.5%) patients had pneumonia in Group A, and 21 (2.6%) patients had pneumonia in Group B (P = 0.04 < 0.05) after the operation. CONCLUSION: When a patient with vestibular schwannoma undergoes microsurgical surgery, the preoperative history with gamma knife treatment may make recovery from postoperative facial paralysis difficult for the patients, making them more prone to suffer from postoperative disequilibrium and postoperative pneumonia.
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Neuroma Acústico , Radiocirurgia , Humanos , Neuroma Acústico/patologia , Estudos Retrospectivos , Resultado do Tratamento , Recidiva Local de Neoplasia/cirurgia , Radiocirurgia/efeitos adversos , Nervo Facial/patologiaRESUMO
OBJECTIVE: Surgery and radiosurgery represent the most common treatment options for vestibular schwannoma. A systematic review and meta-analysis were conducted to compare the outcomes of surgery versus stereotactic radiosurgery (SRS). METHODS: The Cochrane library, PubMed, Embase, and clinicaltrials.gov were searched through 01/2021 to find all studies on surgical and stereotactic procedures performed to treat vestibular schwannoma. Using a random-effects model, pooled odds ratios (OR) and their 95% confidence intervals (CI) comparing post- to pre-intervention were derived for pre-post studies, and pooled incidence of adverse events post-intervention were calculated for case series and stratified by intervention type. RESULTS: Twenty-one studies (18 pre-post design; three case series) with 987 patients were included in the final analysis. Comparing post- to pre-intervention, both surgery (OR: 3.52, 95%CI 2.13, 5.81) and SRS (OR: 3.30, 95%CI 1.39, 7.80) resulted in greater odds of hearing loss, lower odds of dizziness (surgery OR: 0.10; 95%CI 0.02, 0.47 vs. SRS OR: 0.22; 95%CI 0.05, 0.99), and tinnitus (surgery OR: 0.23; 95%CI 0.00, 37.9; two studies vs. SRS OR: 0.11; 95%CI 0.01, 1.07; one study). Pooled incidence of facial symmetry loss was larger post-surgery (14.3%, 95%CI 6.8%, 22.7%) than post-SRS (7%, 95%CI 1%, 36%). Tumor control was larger in the surgery (94%, 95%CI 83%, 98%) than the SRS group (80%, 95%CI 31%, 97%) for small-to-medium size tumors. CONCLUSION: Both surgery and SRS resulted in similar odds of hearing loss and similar improvements in dizziness and tinnitus among patients with vestibular schwannoma; however, facial symmetry loss appeared higher post-surgery.
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Perda Auditiva , Neuroma Acústico , Radiocirurgia , Zumbido , Humanos , Neuroma Acústico/cirurgia , Radiocirurgia/métodos , Microcirurgia/métodos , Nervo Facial/cirurgia , Zumbido/cirurgia , Tontura , Resultado do Tratamento , Vertigem , Estudos RetrospectivosRESUMO
PURPOSE: Although the estimated prevalence is extremely low, facial nerve schwannoma (FNS) is the most common primary tumor of the facial nerve (FN). In the present study, the outcome of surgical management in 18 patients with FNS was analyzed and an appropriate time for surgery was proposed. MATERIALS AND METHODS: A total of 18 patients with FNS who underwent surgical management by a single surgeon from 1999 to 2018 were retrospectively analyzed. RESULTS: Among the 18 patients, five had no facial paralysis before surgery. Near-total removal was performed in three cases, and two cases were managed with decompression. In 13 cases with various degree of preoperative facial palsy, nerve continuity was lost during surgery. FN was reconstructed using cable graft in ten cases, direct anastomosis in one case, and facial-hypoglossal nerve transfer in one case. Facial reanimation surgery without FN reconstruction was performed in one case due to a long-standing facial paralysis before surgery. Preoperative House-Brackmann (H-B) grade in all patients was significantly worse as tumor size increased. The correlation was not observed between the duration and severity of preoperative facial palsy. Analysis of 12 patients who underwent FN reconstruction revealed that all patients with good preoperative facial function (H-B grade II-III) recovered to H-B grade III after surgery (7/7, 100%). However, patients with poor preoperative facial function (H-B grade IV or worse) had only a 40% (2/5) chance of improving to grade III after surgery. Preoperative tumor size and duration of facial palsy did not affect postoperative final facial function. CONCLUSION: We suggest that H-B grade III facial palsy is the best time for surgical intervention, regardless of the tumor size or duration of facial palsy.
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Neoplasias dos Nervos Cranianos , Paralisia Facial , Neurilemoma , Neoplasias dos Nervos Cranianos/cirurgia , Nervo Facial , Paralisia Facial/etiologia , Paralisia Facial/patologia , Paralisia Facial/cirurgia , Humanos , Neurilemoma/patologia , Neurilemoma/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The current grading of facial nerve function is based on subjective impression with the established assessment scale of House and Brackmann (HB). Especially for research a more objective method is needed to lower the interobserver variability to a minimum. We developed a semi-automated grading system based on (facial) surface EMG-data measuring the facial nerve function of 28 patients with vestibular schwannoma surgery. The sEMG was recorded preoperatively, postoperatively and after 3-12 months. In addition, the HB grade was determined. After manual selection and preprocessing, the data were subjected to machine learning classificators (Logistic regression, SVM and KNN). Lateralization indices were calculated and multivariant machine learning analysis was performed according to three scenarios [differentiation of normal (1) and slight (2) vs. impaired facial nerve function and classification of HB 1-3 (3)]. The calculated AUC for each scenario showed overall good differentiation capability with a median AUC of 0.72 for scenario 1, 0.91 for scenario 2 and multiclass AUC of 0.74 for scenario 3. This study approach using sEMG and machine learning shows feasibility regarding facial nerve grading in perioperative VS-surgery setting. sEMG may be a viable alternative to House Brackmann regarding objective evaluation of facial function especially for research purposes.
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Nervo Facial , Neuroma Acústico , Eletromiografia , Face , Humanos , Neuroma Acústico/cirurgia , Variações Dependentes do Observador , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Most studies reported that cystic vestibular schwannoma (CVS) surgery has a less favourable prognosis than solid vestibular schwannoma (SVS) surgery. However, some studies report that it is unclear whether surgical outcomes for these conditions exhibit significant differences. The aim of this meta-analysis was to pool the current literature and describe and analyse any differences in the clinical symptoms and surgical outcomes among CVS and SVS. PubMed, Embase, and Cochrane databases were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through April 22, 2020. Outcomes were analysed using a meta-analysis of the proportions. The results of the search yielded 17 studies that met the criteria for inclusion and analysis, involving 3074 participants (including 821 patients with CVSs and 2253 patients with SVSs). No significant differences in the extent of tumour resection (gross-total resection versus non-gross-total resection; RR, 0.93; 95% CI, 0.86-1.01; p = 0.096) and most other outcomes were noted between CVS and SVS cohorts. However, facial nerve function (House-Brackmann Grade I or II versus III or more) of CVS patients was worse (RR, 0.86; 95% CI, 0.78-0.93; p < 0.001) compared with SVS patients with more than 1 year of follow-up after surgery. The criteria of cystic acoustic neuroma needs to be further unified, and prospective cohort studies with larger sample sizes should be performed for further verification of these results in the future.
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Neuroma Acústico , Nervo Facial , Humanos , Neuroma Acústico/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate the results of combined management of large vestibular schwannomas (VS) with initial subtotal resection (STR) followed by adjuvant stereotactic radiosurgery (SRS), with a particular emphasis on the timing and regimen of irradiation. METHODS: Seventeen patients underwent STR of a VS followed by SRS, whereas five others were observed after STR. Early SRS (<6 months after surgery) and late SRS (>6 months after surgery) were done in 8 and 9 patients, respectively. Single- and multisession SRS treatments were administered in 10 and 7 patients, respectively. The mean follow-up durations after surgery and SRS were 40 and 28 months, respectively. RESULTS: The rates of radiological and oncological tumor control after SRS were 82% and 100%, respectively. The tumor volume at the last follow-up and its relative changes after SRS did not differ significantly on the basis of the irradiation timing (early versus late) or on the basis of the irradiation regimen (single-session versus multisession). In no patient who was observed after STR of a VS was tumor regrowth noted during a mean follow-up period of 49 months. At 12 months after surgery, motor function of the ipsilateral facial nerve corresponded to House-Brackmann grades I, II, III, and IV in 16 patients (73%), 3 patients (14%), 1 patient (5%), and 2 patients (9%), respectively. Facial nerve function at the last follow-up did not differ significantly on the basis of the irradiation timing (early versus late) or on the basis of the irradiation regimen (single-session versus multisession). CONCLUSION: The combination of initial STR followed by adjuvant SRS is an effective treatment strategy for patients with a large VS. Although the optimal timing and regimen of postoperative irradiation of the residual lesion should be defined further, our preliminary data suggest that either early or late SRS after surgery may provide good tumor control and optimal functional results.
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Neuroma Acústico , Radiocirurgia , Nervo Facial , Seguimentos , Humanos , Neuroma Acústico/radioterapia , Neuroma Acústico/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Carga TumoralRESUMO
OBJECTIVE: The present study evaluated outcomes after preplanned partial surgical removal of a large vestibular schwannoma (VS) followed by low-dose Gamma Knife surgery (GKS). METHODS: Between January 2000 and May 2015, 47 patients with a unilateral VS (median maximum diameter 32 mm) underwent preplanned partial tumor removal at our clinic. GKS for a residual lesion was done within a median time interval of 3 months. The median prescription dose was 12 Gy. The median length of subsequent follow-up was 74 months. RESULTS: The actuarial tumor growth control rates without a need for additional management at 3, 5, and 15 years after GKS were 92%, 86%, and 86%, respectively. At the time of the last follow-up, the function of the ipsilateral facial nerve corresponded to House-Brackmann grade I in 92% of patients. Significant improvement of ipsilateral hearing was noted in two patients after partial tumor removal and in one after GKS. Among 16 patients who presented with ipsilateral serviceable hearing, it was preserved immediately after surgery in 81% of cases and at the time of the last follow-up in 44%. Salvage surgical treatment was required in 9% of patients. CONCLUSION: Preplanned partial surgical removal followed by low-dose GKS provides a high level of functional preservation in patients with a large VS.
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Neuroma Acústico , Radiocirurgia , Nervo Facial , Seguimentos , Humanos , Neuroma Acústico/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Vestibular schwannomas (VSs) are benign neoplasms of the Schwann cells of cranial nerve VIII, and treatment of VS typically involves surgical resection. However, tumor recurrence may necessitate reintervention, and secondary treatment modalities include repeat surgical resection or adjuvant radiosurgery. The purpose of this study is to examine the scientific literature in order to determine whether surgical resection or radiosurgery for recurrent VS results in better tumor control, hearing preservation, and preservation of facial nerve function. METHODS: The PubMed, Scopus, Embase, Cochrane, and Web of Science databases were searched for studies reporting on patients undergoing either radiosurgery or repeat surgical resection after primary surgical resection for recurrent VS. Statistical analyses were performed on the compiled data, primarily outcome data involving tumor control, hearing preservation, and preservation of facial nerve function. RESULTS: We analyzed the data of 15 individual studies involving 359 total patients, and our results reveal that tumor control rates are comparable between adjuvant radiosurgery (91%, CI: 88-94%) and secondary resection (92%, CI 75-98%). However, adjuvant radiosurgery was shown to preserve good facial nerve function better (94%, CI 84-98%) compared to secondary surgical resection (56%, CI 41-69%). CONCLUSION: With comparable tumor control rates and better preservation of good facial nerve function, this study suggests that secondary radiosurgery for recurrent VS is associated with both optimal tumor control and preservation of good facial nerve function.
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Nervo Facial/cirurgia , Perda Auditiva/epidemiologia , Neuroma Acústico/radioterapia , Complicações Pós-Operatórias/epidemiologia , Radiocirurgia/métodos , Humanos , Neuroma Acústico/cirurgia , Radiocirurgia/efeitos adversos , Nervo Vestibulococlear/cirurgiaRESUMO
INTRODUCTION: Radiation therapy of small vestibular schwannomas is quite often used as an effective alternative to surgical treatment. At the same time, 2-10% of patients are detected with radioresistant tumors progressing to varying degrees, which is associated with continued tumor growth. In these cases, a decision on surgical resection or re-irradiation of the tumor is made depending on the neurological symptoms, patient's somatic status, and neuroimaging data. Surgical outcomes and intraoperative findings in pre-irradiated patients have been poorly represented in the literature, for which reason we decided to conduct this study. The paper presents a series of patients with vestibular schwannomas who underwent surgical removal of the tumor after radiotherapy. MATERIAL AND METHODS: A total of 39 patients with vestibular schwannomas after radiotherapy underwent surgery at the Burdenko Neurosurgical Institute in 2007-2017. Of these, 22 patients had a tumor removed after a previously performed combined surgical and radiotherapy treatment (group I), and 17 patients underwent tumor resection after previous radiological treatment (group II). The surgical outcomes were studied depending on various factors, and an analysis of the morphological changes in vestibular schwannomas after radiological treatment was carried out. RESULTS: In group I, the tumor was resected totally in 18% of patients, almost totally in 5% of patients, subtotally in 68% of patients, and partially in 9% of patients. In group II, the tumor was resected totally in 6% of patients, almost totally in 12% of patients, subtotally in 76% of patients, and partially in 6% of patients. We found that post-radiation changes in patients undergoing surgery led to an increase in the response of neurovascular structures to surgical intervention, development of pronounced fibrosis around tumors, and changes in the structure of tumors that became more solid. As a result, surgical morbidity increased, and the patient's quality of life after surgery deteriorated.
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Neuroma Acústico , Humanos , Neuroma Acústico/terapia , Qualidade de Vida , Radiografia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Cystic vestibular schwannoma (CVS) is classified as Type A and Type B based on the overall cyst location and cyst wall thickness in magnetic resonance imaging. A retrospective analysis was performed to compare surgical considerations and outcomes between Type A and Type B groups of CVS. We selected 188 patients diagnostic for CVS with surgical resection, and divided them into Type A and Type B groups. General information, preoperative symptoms, the result of neuroimaging, and audiological tests were recorded. Surgical approach, completeness of tumor resection, and intraoperative facial nerve (FN) integrity were taken down. After operation, the short-term and long-term FN functions, complications, and recurrence rate were evaluated. The total tumor removal rate in Type A group was higher than that in Type B group (86.1 vs 72.5 %, p = 0.021). Anatomical FN integrity was preserved in 173 patients (92.0 %), with no significant differences between Type A and Type B. FN function was better in Type A group at hospital discharge. Besides, a good FN function rate was inversely proportional to the tumor size. The long-term FN function and all of the complications had no significant differences between the two groups. Patients in the Type B group are prone to have a lower total tumor removal rate and transient FN dysfunction. The long-term FN function was similar in both groups. Tumor size is another important indication of FN function. All postoperative complications occurred in patients with a tumor larger than grade 3, regardless of the subtypes of CVS.
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Neuroma Acústico/patologia , Neuroma Acústico/cirurgia , Complicações Pós-Operatórias , Adolescente , Adulto , Idoso , Doenças dos Nervos Cranianos/etiologia , Doenças do Nervo Facial/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia , Neuroma Acústico/diagnóstico por imagem , Estudos Retrospectivos , Adulto JovemRESUMO
The aim of the study was to describe the refinements to the classic enlarged translabyrinthine approach (ETLA) by modifying the bony dissection range of temporal bone and to analyze the main outcomes achieved in a series of vestibular schwannoma (VS) cases submitted to microsurgery by ETLA. This was a retrospective study of 382 patients who underwent VS surgical removal via ETLA between January 2001 and December 2012. Among those cases, 332 were via classic ETLA, while 28 cases were via ETLA with blind sac technique and middle ear eradication and 22 via transotic approach. Total tumor removal was achieved in 368 cases, whereas near total removal in 11 patients and subtotal in 3 patients. In cases of large VS (>3 cm) via classic ETLA, good short-term and long-term facial nerve function (HB I-II) was gained in 27.8 % (32/115) and 42.6 % (49/115) cases, respectively, meanwhile in VS operated via blind sac technique, good short-term (p = 0.048) and long-term (p = 0.044) facial nerve function was reached in 44.0 % (22/50) and 60.0 % (30/50) cases, respectively. Postoperative facial nerve function was proved to be better in modified ETLA group. CSF leakage occurred in 16 (4.2 %) patients via classic ETLA. In 115 cases of large VS (>3 cm), postoperative CSF leakage occurred in 10 (8.7 %) patients. Whereas in 50 cases via blind sac technique, none developed CSF leakage (p = 0.03). The incidence of CSF leakage was lower in modified ETLA group. Our refinements to classic ETLA by changing the temporal bone resection range provide a wide surgical field, well prevention of CSF leakage and preservation of facial nerve function in large VS.
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Vazamento de Líquido Cefalorraquidiano/prevenção & controle , Tomada de Decisão Clínica , Dissecação/efeitos adversos , Microcirurgia/efeitos adversos , Neuroma Acústico/cirurgia , Osso Temporal/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vazamento de Líquido Cefalorraquidiano/diagnóstico , Vazamento de Líquido Cefalorraquidiano/epidemiologia , Dissecação/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neuroma Acústico/patologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Osso Temporal/patologia , Adulto JovemRESUMO
The assessment of facial nerve function plays a crucial role in the diagnosis and treatment of facial nerve disorders.The assessment system for facial nerve function is primarily categorized into subjective and objective systems.While the subjective assessment system is relatively simple, it lacks accuracy as it can be influenced by the subjectivity of evaluator.Whereas, the objective system offers higher precision and stability, providing more quantitative information. In recent years, benefited with advancements in computer vision and artificial intelligence,we have witnessed increasingly accurate,stable and intelligent facial nerve assessment systems gradually implemented in clinical practice.When selecting a specific facial nerve assessment system,factors such as clinical scenarios,assessment objectives,patient characteristics should be considered.
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Nervo Facial , Humanos , Nervo Facial/fisiologia , Doenças do Nervo Facial/diagnóstico , Doenças do Nervo Facial/fisiopatologia , Inteligência ArtificialRESUMO
Objective:To investigate the factors and efficacy of different surgical techniques used in facial nerveï¼FNï¼ reconstruction. Methods:A retrospective analysis was conducted on 24 patients who underwent facial nerve reconstruction surgery in our department from January 2016 to January 2021. The duration of total facial nerve paralysis was less than 18 months. The study included 5 surgical techniques, including 6 cases of FN anastomosisï¼Group Aï¼, 5 cases of FN graftingï¼sural nerve or great auricular nerveï¼ï¼Group Bï¼, 5 cases of side-to-end facial-hypoglossal nerve anastomosisï¼Group Cï¼, 4 cases of side-to-end FN graftingï¼sural nerve or great auricular nerveï¼ hypoglossal nerve anastomosisï¼Group Dï¼, and 4 cases of dual nerve reanimationï¼Group Eï¼. The postoperative follow-up period was ≥1 year. Results:The HB-â ¢ level of FN function at 1 year after surgery was 83.3%ï¼5/6ï¼ in group A, 60.0%ï¼3/5ï¼ in group B, 40.0%ï¼2/5ï¼ in group C, 25.0%ï¼1/4ï¼ in group D, and 50.0%ï¼2/4ï¼ in group E. In patients without multiple FN repair, the incidence of synkinesis was 15.0%ï¼3/20ï¼, while no cases of synkinesis were observed in patients with dual nerve reanimation. The patients who underwent hypoglossal-facial side-to-end anastomosis showed no hypoglossal nerve dysfunction. Conclusion:Different FN repair techniques result in varying postoperative FN function recovery, as personalized repair should be managed. Among the various techniques, FN end-to-end anastomosis after FN transposition is recommended as to reduce the number of anastomotic stoma, while hypoglossal-facial side-to-end anastomosis is advocated as to prevent postoperative hypoglossal nerve dysfunction. Additionally, dual nerve repair can effectively improve smile symmetry and reduce synkinesis, which enhances patients' quality.
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Anastomose Cirúrgica , Nervo Facial , Paralisia Facial , Nervo Hipoglosso , Procedimentos de Cirurgia Plástica , Humanos , Estudos Retrospectivos , Paralisia Facial/cirurgia , Nervo Facial/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Anastomose Cirúrgica/métodos , Masculino , Feminino , Nervo Hipoglosso/cirurgia , Período Pós-Operatório , Resultado do Tratamento , Adulto , Pessoa de Meia-Idade , Transferência de Nervo/métodosRESUMO
BACKGROUND: Vestibular schwannoma (VS), also known as acoustic neuroma, is a benign, well-encapsulated, and slow-growing tumor that originates from Schwann cells, which form the myelin sheath around the vestibulocochlear nerve (VIII cranial nerve). The surgical treatment of this condition presents a challenging task for surgeons, as the tumor's location and size make it difficult to remove without causing damage to the surrounding structures. In recent years, fluorescein sodium (FS) has been proposed as a tool to enhance surgical outcomes in VS surgery. This essay will provide an analytical comparison of the use of FS in VS surgery, evaluating its benefits and limitations and comparing surgical outcomes with and without FS-assisted surgery. METHODS: In a retrospective study conducted at San Filippo Neri Hospital, we examined VS cases that were operated on between January 2017 and December 2023. The patients were divided into two groups: group A, which consisted of patients who underwent surgery without the use of FS until January 2020 (102 cases), and group B, which included patients who underwent surgery with FS after January 2020 (55 cases). All operations were performed using the retrosigmoid approach, and tumor size was classified according to the Koos, et al. classification system. The extent of surgical removal was evaluated using both the intraoperative surgeon's opinion and postoperative MRI imaging. Preoperatively and postoperatively, facial nerve function and hearing were assessed. In group B, FS was used to assist the surgical procedures, which were performed using a surgical microscope equipped with an integrated fluorescein filter. Postoperative clinical and MRI controls were performed at six months and annually, with no patients lost to follow-up. RESULTS: This study investigated the impact of intraoperative fluorescein exposure on tumor resection and clinical outcomes in patients with VS. The study found a statistically significant difference in the tumor resection rates between patients who received fluorescein intraoperatively (p = 0.037). Further analyses using the Koos classification system revealed a significant effect of fluorescein exposure, particularly in the Koos 3 subgroup (p = 0.001). Notably, no significant differences were observed in hearing loss or facial nerve function between the two groups. A Spearman correlation analysis revealed a positive correlation between tumor size and Koos, age, and size, but no significant correlation was found between facial nerve function tests. CONCLUSIONS: FS-assisted surgery for VS may potentially enhance tumor resection, allowing for more comprehensive tumor removal.
RESUMO
Objective:To summarize the clinical characteristics and therapeutic effect of traumatic facial nerve palsy. Methods:Sixty-eight cases of traumatic facial nerve palsy were retrospectively analyzed from January 2015 to May 2023. Results:The median course of disease was 33 days. The facial nerve function of the patients was grade HB-â ¡in 2 cases, grade HB-â ¢ in 4 cases, grade HB-â £in 16 cases, grade HB-â ¤ in 37 casesï¼38 earsï¼, and grade HB-â ¥ in 9 cases. 42 cases occurred immediately after injury and 26 cases were delayed. CT examination of temporal bone revealed longitudinal fractures in 51 casesï¼52 earsï¼ , transverse fractures in 6 cases and mixed fractures in 4 cases. No definite temporal bone fracture was found in the remaining 7 cases. The segments of facial nerve injury in 49 casesï¼50 earsï¼ were geniculate ganglion and adjacent, in 7 cases were vertical segment, in 7 cases were horizontal segment, in 2 cases were horizontal segment and vertical segment; and the other 3 cases could not be evaluated. Conservative treatment with glucocorticoids was used in 23 ears and surgery was used in 46 ears. Patients were followed up 6-24 months after treatment, including 20 cases of grade HB-â , 19 cases of grade HB-â ¡, 23 casesï¼24 earsï¼ of grade HB-â ¢, 4 cases of grade HB-â £, and 1 case of grade HB-â ¤.One patient was lost to follow-up. After treatment, the facial nerve function of patients was significantly improvedï¼P<0.05ï¼, and there were significant differences between conservative treatment group and surgical treatment group in the course of facial nerve palsy, the ratio of facial palsy immediately after injury, the nerve function before treatment and the nerve function after treatmentï¼P<0.05ï¼. There were no significant differences in age, sex, hearing condition, temporal bone fracture, facial nerve injury segment and rate of favorable neurologic outcomesï¼P>0.05ï¼. The comparison of patients with neurodegeneration rate>90% and ≤90% showed that the facial nerve function of patients with neurodegeneration rate>90% before treatment was significantly worseï¼P<0.05ï¼, but there was no significant difference between the facial nerve function after treatmentï¼P>0.05ï¼. There was no significant difference in facial nerve function between middle fossa approach group and mastoid approach groupï¼P>0.05ï¼. Conclusion:Patients with traumatic facial nerve palsy should be evaluated individually. Patients with mild facial nerve palsy, low neurodegeneration rate and short course of disease can be treated conservatively and followed up closely. Patients with severe facial nerve palsy, high neurodegeneration rate and more than 6 weeks of disease can be actively considered surgery. Good prognosis can be obtained by correct evaluation and treatment.
Assuntos
Traumatismos do Nervo Facial , Paralisia Facial , Humanos , Paralisia Facial/etiologia , Paralisia Facial/diagnóstico , Paralisia Facial/terapia , Estudos Retrospectivos , Masculino , Feminino , Traumatismos do Nervo Facial/terapia , Traumatismos do Nervo Facial/diagnóstico , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Adolescente , Osso Temporal/lesões , Nervo Facial , Glucocorticoides/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: Koos grade 4 vestibular schwannoma (KG4VS) is a large tumor that causes brainstem displacement and is generally considered a candidate for surgery. Few studies have examined the relationship between morphological differences in KG4VS other than tumor size and postoperative facial nerve function. The authors have developed a landmark-based subclassification of KG4VS that provides insights into the morphology of this tumor and can predict the risk of facial nerve injury during microsurgery. The aims of this study were to morphologically verify the validity of this subclassification and to clarify the relationship of the position of the center of the vestibular schwannoma within the cerebellopontine angle (CPA) cistern on preoperative MR images to postoperative facial nerve function in patients who underwent microsurgical resection of a vestibular schwannoma. METHODS: In this paper, the authors classified KG4VSs into two subtypes according to the position of the center of the KG4VS within the CPA cistern relative to the perpendicular bisector of the porus acusticus internus, which was the landmark for the subclassification. KG4VSs with ventral centers to the landmark were classified as type 4V, and those with dorsal centers as type 4D. The clinical impact of this subclassification on short- and long-term postoperative facial nerve function was analyzed. RESULTS: In this study, the authors retrospectively reviewed patients with vestibular schwannoma who were treated surgically via a retrosigmoid approach between January 2010 and March 2020. Of the 107 patients with KG4VS who met the inclusion criteria, 45 (42.1%) were classified as having type 4V (KG4VSs with centers ventral to the perpendicular bisector of the porous acusticus internus) and 62 (57.9%) as having type 4D (those with centers dorsal to the perpendicular bisector). Ventral extension to the perpendicular bisector of the porus acusticus internus was significantly greater in the type 4V group than in the type 4D group (p < 0.001), although there was no significant difference in the maximal ventrodorsal diameter. The rate of preservation of favorable facial nerve function (House-Brackmann grades I and II) was significantly lower in the type 4V group than in the type 4D group in terms of both short-term (46.7% vs 85.5%, p < 0.001) and long-term (82.9% vs 96.7%, p = 0.001) outcomes. Type 4V had a significantly negative impact on short-term (OR 7.67, 95% CI 2.90-20.3; p < 0.001) and long-term (OR 6.05, 95% CI 1.04-35.0; p = 0.045) facial nerve function after surgery when age, tumor size, and presence of a fundal fluid cap were taken into account. CONCLUSIONS: The authors have delineated two different morphological subtypes of KG4VS. This subclassification could predict short- and long-term facial nerve function after microsurgical resection of KG4VS via the retrosigmoid approach. The risk of postoperative facial palsy when attempting total resection is greater for type 4V than for type 4D. This classification into types 4V and 4D could help to predict the risk of facial nerve injury and generate more individualized surgical strategies for KG4VSs with better facial nerve outcomes.