Facial Nerve Paralysis and Methods of Facial ReanimationJASON LEPSE, MS4UNIVERSITY OF KANSAS SCHOOL OF MEDICINE

Objectives Case Presentation

Workup and Treatment

Overview of facial reanimation

Discussion of hypoglossal nerve transfer

Patient outcome

References

H&PBackground: 72 yo female referred to Dr. Gooi on 7/25/16 from ENT at OSH for evaluation of a right parotid mass

HPI: Right lip weakness in 4/2015◦ Progressed over next few months to entire right face◦ No taste on right by 12/2015◦ Diagnosed with Bell’s palsy ◦ Followed with Neurology

◦ Serial MRI’s all read as negative◦ MRI in June 2016 significant for a right parotid mass

* Modified from documentation by Dr. Zhen Gooi

H&P HPI Continued

◦ CT Neck: partially calcified 9 mm mass along the posterior inferior deep aspect of the right parotid gland ◦ FNA and core-needle biopsy

◦ Malignant epithelial cells present, further classification pending surgical excision◦ 8/2016: fullness of right side of face and tenderness to deep palpation in addition to facial weakness

PMH: Blepharospasm, benign intention tremor, hypertension

PSH: Knee and shoulder arthroplasty, tonsillectomy with pre-op radiation

FH: No family history of cancer

SH: Former smoker quit 1986, no EtOH

ROS: Denies fevers chills, rash, dysphagia, dyspnea, odynophagia, unintentional weight loss, sialorrhea or mouth dryness. Denies vision loss, hearing loss or tinnitus

* Modified from documentation by Dr. Zhen Gooi

H&P Exam

◦ Vitals: WNL◦ General: NAD, strong voice breathing comfortably◦ Ears: TMs clear and mobile; no effusions noted ◦ Nose: No external deformity◦ Oral Cavity: Mucosa unremarkable without suspicious lesions or asymmetry; floor of mouth/tongue soft. ◦ Oropharynx: Mucosa unremarkable without suspicious lesions or asymmetry◦ Parotid gland: No palpable parotid mass◦ Neck: No masses or lymphadenopathy

*Modified from documentation by Dr. Zhen Gooi

H&P Exam continued

◦ Neuro: Cranial Nerve VII Exam◦ Forehead: House Brackmann 6.◦ Eye opening: House Brackmann 4, inability to close, scleral show, Bell's phenomenon◦ Buccal region: House Brackmann 1, full movement◦ Lips: House Brackmann 6 ◦ Video

◦ Laryngoscopy positive for left vocal cord paralysis

*Modified from documentation by Dr. Zhen Gooi

Workup CT Chest: No evidence of metastases, or other significant abnormality

MRI Brain: Unremarkable

MRI Neck:◦ Deep parotid mass with abnormal extension extending cranially

along the entire right facial nerve into the fundus of the internal auditory canal along a span of 3 mm of the distal meatal segment, consistent with perineural spread of tumor

◦ Prominent cervical lymph nodes

PET CT: parotid mass and right level 1B lymph node

Patient was presented at tumor board

T1 weighted MRI of neck soft tissue- Axial cuts

Horizontal semicircular canal

Geniculate ganglion

Labyrnthine segment

Second genu

Tympanic segment

Stapes

Mastoid segment

Superficial parotid being peeled off nerve

Facial NerveSCM

Specimen: 5.2 cm greatest dimensionTumor : 1.3 x 0.9 x 0.8 cm

Facial Reanimation Approach Nonsurgical Management Surgical Management

◦ Dynamic◦ Facial nerve neurorrhaphy◦ Cable graft◦ Nerve transposition◦ Muscle transposition◦ Microneurovascular transfer

◦ Static procedures 1

Two-system method can be utilized when deciding which procedure is best 2

Proximal system: facial nerve nucleus and proximal facial nerveDistal system: distal nerve branches and facial musculature

Facial Reanimation Techniques Direct Anastomosis: proximal and distal systems intact

◦ Indicated when defect is ≤18 mm 3

◦ Best if done within 72 hours of nerve transection (no Wallerian degeneration)

◦ Often not needed if branch is transected medial to lateral canthus 4

Repair with nerve graft: proximal and distal systems intact◦ Indicated when CN VII cannot be re-approximated without tension◦ Great auricular, sural and medial or lateral antebrachial cutaneous

nerves are most commonly used◦ Benefit seen in 6 mo; max at 12-18 mo ; likely no better than HB 3

Facial Reanimation Techniques Nerve Transfer: proximal system compromised, distal system intact

◦ Hypoglossal nerve transfer◦ Most popular and commonly used◦ Study of 53 patients over 10 years found no statistically significant difference in outcome between primary neurorrhapy, cable

graft or nerve transposition 5

◦ Masseteric nerve transposition ◦ Convenient position◦ Minimal morbidity from transection◦ Minimal synkinesis with speech 6

◦ Cross-facial Technique ◦ Distal branches from unaffected side are connected to branches of affected side by separate tunneled sural grafts◦ Potential for preserved emotional animation◦ Only 9/23 patients in one study and 1/10 patients in another developed movement rated as “good” 7,8

Facial Reanimation Techniques Muscle Transposition: distal and proximal systems compromised◦ Temporalis Tendon Transfer

◦ Primary goals are to restore symmetry of the smile and improve oral function.◦ Dynamic muscle transfer is improved by means of activity-based therapy◦ Smile retains natural vector pull◦ Coronoid process and attached temporalis are mobilized inferiorly and secured

to oral commissure and subcutaneous tissue in the region of the nasolabial fold

Facial Reanimation Techniques◦ Masseter muscle transposition

◦ Generally used when temporalis muscle transfer or temporalis tendon transfer are not viable options

◦ Vector pull is more horizontal 24

◦ Two slips of masseter are attached to the dermal layers of the skin at oral commissure for overcorrection of the smile

Facial Reanimation Techniques Microneurovascular muscle transfer: distal and proximal systems compromised

◦ Gracilis, latissimus dorsi, and pectoralis minor ◦ One or two stages

◦ Conflicting data on which achieves better results 23

◦ One study in pediatric patients showed single stage procedure with masseteric nerve allowed better excursion but only two-stage procedure led to spontaneous facial movement 20

◦ Large 655 patient study concluded that for the restoration of both truly spontaneous smile and facial muscle movement, free muscle transfer neurotized by the contralateral healthy facial nerve is best 9

Facial Reanimation Techniques Static Procedures

◦ Indicated in debilitated patients or those without muscle or nerve to use for dynamic reconstruction

◦ Benefit is immediate restoration of facial symmetry◦ Often performed for interim support in conjunction with facial nerve

repair or grafting◦ Alloderm typically used; also Gor-Tex

Facial Plastics: Upper eyelid gold weight◦ Closure is sufficient to cover the cornea is reported in 78% of cases ◦ Resolution of keratitis in 62 to 100% of cases 10

Considerations 2010 study of 105 patients supported dynamic reconstruction even with malignant pathology, prolonged preoperative palsy, proximal nerve injury site, radiotherapy or long graft length 11

Planned postoperative adjuvant radiation therapy should not affect decision as studies have shown no detrimental effects from radiation 21

Age over 60 related to worse outcome 6

Failure of nerve repairs or grafts may be attributed to 22

◦ Nerve fibrosis◦ Muscle fibrosis◦ Infection◦ Tension and separation at anastomosis

Hypoglossal Nerve Transfer Most common nerve transfer because anatomic and functional relationship to CN VII

◦ Course, caliber and anatomic location◦ Less donor morbidity than other nerves which have been used including

CN XI and phrenic

Very good option when paralysis has been present for >12 months or there is uncertainty of viability of proximal facial nerve stump 12

◦ Other authors report it is indicated within two years of onset 13

B: one year after hypoglossal nerve transfer

Hypoglossal Nerve Transfer In 1979 Conley et al described end-to-end suture of CN XII to proximal trunk of facial nerve (b) 14

End (CN VII) to side (CN XII) suture with interpositional nerve graft was introduced (f)

◦ CN XII is incised 30% for side anastomosis◦ Great auricular or sural nerve often used ◦ Less ipsilateral tongue atrophy- less dysphagia and dysarthria

Dissecting CN VII intratemporally and connecting end to a partially sectioned CN XII without graft has regained popularity (d)

Hypoglossal Nerve Transfer Efficacy

◦ Average of 5.5 months to appearance of first facial movements 12

◦ A study of 20 patients after interpositional jump graft, all had “good” facial tone and symmetry 15

◦ 13/20 had “excellent” restoration of facial movement◦ Only 3/20 had CN XII deficits

◦ Other studies recommend avoiding interpositional grafts if alternative direct nerve transfer option exists◦ Physical therapy after procedure is critical so patients can learn to activate the hypoglossal nerve during

planned facial movement 12

Drawbacks◦ No cortical adaptation resulting in spontaneous smile in any of 26 patients studied in a 655 patient review◦ 15% of patients in a 137 patient study developed hypertonia of middle 1/3 of face

◦ Often successfully treated with Botox 16

Outcome Functional outcome two weeks post-op

◦ Active at home and is independent in all her ADL's◦ Reports dizziness but improving◦ Trismus: only eating soft foods currently

Pathology: 1.3 x 0.9 x 0.8 cm salivary duct carcinoma ex pleomorphic adenoma of high grade with associated positive LVI, PNI, extraparenchymal extension and a close margin of 1 mm. PT3N0. Positive margin at geniculate ganglion

Carcinoma Ex-Pleomorphic Adenoma:◦ One of three malignant mixed tumors along with

carcinosarcoma and metastasizing pleomorphic adenoma◦ Most common presentation is patient in 6th or 7th decade with

long-standing mass that undergoes rapid growth over a few months

Outcome Now receiving adjuvant chemoradiation and PT

◦ Postoperative radiotherapy improves locoregional control from 50% to 80% in patients with advanced disease and close margins or perineural invasion 17

◦ University of Chicago study showed 5 year survival of 59% when adding chemotherapy as opposed to 10-15% with adjuvant radiation alone 18

◦ Planning on right upper lid gold weight implantation and right lower lid ectropion repair with Oculoplastics

Take-home Bell’s Palsy 19

◦ Diffuse CN VII involvement with or without loss of taste anterior 2/3◦ Onset is acute over 1-2 days; progressive reaching max within three weeks◦ Slowly progressive course with discrete distal branch involvement more indicative of tumor

Reconstruction Ladder◦ Many different ways to breakdown the numerous procedures for facial◦ Non-surgical vs Surgical

◦ Dynamic vs Static◦ Degree of surgical intervention◦ Duration of paralysis

References 1: Flint, Paul W., and Charles William Cummings. Cummings Otolaryngology: Head & Neck Surgery. Philadelphia, PA: Mosby Elsevier, 2010. Print.

2:Ridley, Ryan. "Facial Reanimation." UTMB Grand Rounds (2014): n. pag. Facial Reanimation 2010. UTMB. Web.

3: Humphrey CD, Kriet JD. Nerve repair and cable grafting for facial paralysis.Facial Plast Surg. 2008 May;24(2):170

4: Parnes, Steven. "Dynamic Reanimation for Facial Paralysis Treatment & Management." Dynamic Reanimation for Facial Paralysis Treatment & Management: Medical Therapy, Surgical Therapy, Intraoperative Details. Medscape, n.d. Web. 25 Aug. 2016.

5:Guntinas-Lichius, Orlando, Michael Streppel, and Eberhard Stennert. "Postoperative Functional Evaluation of Different Reanimation Techniques for Facial Nerve Repair." The American Journal of Surgery 191.1 (2006): 61-67. Web.

6: Socolovsky, Mariano, Roberto S. Martins, Gilda Di Masi, Gonzalo Bonilla, and Mario Siqueira. "Treatment of Complete Facial Palsy in Adults: Comparative Study between Direct Hemihypoglossal-facial Neurorrhaphy, Hemihipoglossal-facial Neurorrhaphy with Grafts, and Masseter to Facial Nerve Transfer." Acta Neurochir Acta Neurochirurgica 158.5 (2016): 945-57

7:Anderl H: Cross-face nerve transplant. Clin Plast Surg 1973; 6: pp. 433

8: :Samii M: Nerves of the head and neck: management of peripheral nerve problems. In Omer G, and Spinner M (eds): Management of Peripheral Nerve Problems. Philadelphia: WB Saunders, 1970.

9: Gousheh J, Arasteh E. Treatment of facial paralysis: dynamic reanimation of spontaneous facial expression-apropos of 655 patients. Plast Reconstr Surg. 2011 Dec. 128(6):693e-703e

10: Levine R E, Shapiro J P. Reanimation of the paralyzed eyelid with the enhanced palpebral spring or the gold weight: modern replacements for tarsorrhaphy. Facial Plast Surg . 2000; 16 325-336

11: Iseli TA, Harris G, Dean NR, Iseli CE, Rosenthal EL. Outcomes of static and dynamic facial nerve repair in head and neck cancer. Laryngoscope

12: Gidley P W, Gantz B W, Rubinstein J T. Facial nerve grafts: from cerebellopontine angle and beyond. Am J Otol. 1999; 20 781-788

References 13 Beutner, Dirk, Jan C. Luers, and Maria Grosheva. "Hypoglossal-facial-jump-anastomosis without an Interposition Nerve Graft." The Laryngoscope (2013): n. pag. Web.

14: Conley J., Baker D. Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed face. Plast Reconst Surg 1979; 63:63–72.

15: May, Mark, Steven M. Sobol, and Sara J. Mester. "Hypoglossal-Facial Nerve Interpositional-Jump Graft for Facial Reanimation without Tongue Atrophy." Otolaryngology -- Head and Neck Surgery 104.6 (1991): 818-25.

16: Dressler, D., and P.w. Schonle. "Botulinum Toxin to Suppress Hyperkinesias after Hypoglossal-facial Nerve Anastomosis." Eur Arch Otorhinolaryngol European Archives of Oto-Rhino-Laryngology 247.6 (1990)

17: Terhaard, Chris H.j., Herman Lubsen, Coen R.n. Rasch, Peter C. Levendag, Hans H.à.m. Kaanders, Reineke E. Tjho-Heslinga, Piet L.a. Van Den Ende, and Fred Burlage. "The Role of Radiotherapy in the Treatment of Malignant Salivary Gland Tumors." International Journal of Radiation Oncology*Biology*Physics 61.1 (2005): 103-11.

18: Pederson, Aaron W., Joseph K. Salama, Daniel J. Haraf, Mary Ellen Witt, Kerstin M. Stenson, Louis Portugal, Tanguy Seiwert, Victoria M. Villaflor, Ezra Ew Cohen, Everett E. Vokes, and Elizabeth A. Blair. "Adjuvant Chemoradiotherapy for Locoregionally Advanced and High-risk Salivary Gland Malignancies." Head Neck Oncol Head & Neck Oncology 3.1 (2011): 31.

19: Ronthal, Michael. "Bell's Palsy: Pathogenesis, Clinical Features, and Diagnosis in Adults." Bell's Palsy: Pathogenesis, Clinical Features, and Diagnosis in Adults. Up To Date, n.d. Web. 22 Aug. 2016.

20: Snyder-Warwick AK, Fattah AY, Zive L, Halliday W, Borschel GH, Zuker RM. The degree of facial movement following microvascular muscle transfer in pediatric facial reanimation depends on donor motor nerve axonal density. Plast Reconstr Surg. 2015 Feb. 135 (2):370e-81e

21: McGuirt W F, McCabe B F. Effect of radiation therapy on facial nerve cable autografts. Laryngoscope. 1977; 87 415-428

22: Gousheh, Jamal, and Ehsan Arasteh. "Treatment of Facial Paralysis." Plastic and Reconstructive Surgery 128.6 (2011): n. pag. Web.

23: Kumar PA, and Hassan KM: Cross-face nerve graft with free-muscle transfer for reanimation of the paralyzed face: a comparative study of the single-stage and two-stage procedures. Plast Reconstr Surg 2002; 109: pp. 451

24: Hontanilla B, Qiu SS. Transposition of the hemimasseteric muscle for dynamic rehabilitation of facial paralysis. J Craniofac Surg. 2012 Jan. 23(1):203-5.