Mengenali Facial Palcy pada Trauma Wajah dan Tatalaksana Pembedahan

Bell's palsy is the most common neurological disorder affecting the cranial nerves with an onset that is rapid and unilateral, and it is common cause of facial paralysis worldwide. Bell's palsy occurs due to compression or enlargement of the stylomastoid foramen and causes nerve obstruction or damage caused by trauma, infection, inflammation, autoimmune, ischemic. This article aims to review bell's palsy, specifically motor nerve alignment, surgical disorders and management of bell's palsy. Source searches were carried out on online portals for journal publications such as Google Scholar (scholar.google.com) and the National Centre for Biotechnology Information/NCBI (ncbi.nlm.nih.gov), with the keyword “Facial palcy, dan Bell’s palcy”. In the United States, the annual incidence of Bell's palsy is approximately 23 cases per 100,000 people. Permanent facial paralysis and non-transient functional deficits are the main indications for surgical reconstruction of facial nerve function. The indications for surgery depend on the severity of the nerve lesion, blunt trauma that causes nondegenerative neuropraxia does not require surgical reconstruction, whereas disorders leading to degenerative neurotmesis require surgery.

Complete Facial Paralysis Caused by Stabbing With a Car Key at the Stylomastoid Foramen

Non-iatrogenic traumatic facial paralysis is most common in intratemporal facial nerve injury caused by temporal bone fracture, followed by intraparotid facial nerve branch injury. Facial paralysis caused by injury to the extratemporal trunk of the facial nerve is extremely rare. We present a case of a 60-year-old man suffering from immediate complete left peripheral facial paralysis due to blunt transection of extratemporal trunk of facial nerve by stabbing with a car key. There was a facial nerve defect about 1 cm in length. The great auricular nerve was grafted to repair the facial nerve. Over 12 months, his facial nerve function improved to a House–Brackmann III/VI.

Osteological studies of skull base neurovascular area in reference to infratemporal approach to skull basec

Surgical approaches to the lateral skull base often lead to tearing of vessels and piecemeal removal of the tumour. This study is aimed to delineate exact relationship of the various foramina at the lateral skull base. The coronal dimensions of the jugular foramina are larger as compared to sagittal with right sided dominance also noticed in the case of carotid canal. The width of “Keel” separating the carotid and jugular foramina normally varies from 0.4 to1.4 centimetres and may not always suggest the erosion of the foramen of skull base scans, unless the erosion is associated with irregularity or demineralization the thickness of this keel really depends upon relative size of the vessels and location of foramina. Area between stylomastoid foramen, carotid canal and jugular foramen is roughly wedge shaped. The angle subtended by carotid and jugular at the stylomastoid foramen is about 36.84whereas the location of stylomastoid foramen and internal carotid axis pose an angle of 83:16. The angle subtended by stylomastoid and jugular at carotid on an average 59:31. The space between these structures is measured to be 0.642centimetres which can be verified on tomograms. By using these measurements, the precise location of the upper end of the vessels could be predicted, whereas the superior stump could be clamped with minimal exposure of the skull base and identification and location of the last four cranial nerves is found out. This could avoid injuries and subsequent morbidity while carrying out surgery in this region.

The cranial nerves

There are 12 pairs of cranial nerves that are individually named and numbered using Roman numerals. Only some cranial nerves are mixed in function, i.e. they carry both sensory and motor fibres; others are purely sensory or motor and some may also carry pre- or post-ganglionic parasympathetic fibres. They pass through foramina in the base of the skull and are the olfactory (through cribriform plate to the nasal cavity), optic (through the optic foramen to the eye), oculomotor (through the cavernous sinus and superior orbital fissure to supply the eye), trochlear (as per oculomotor), trigeminal (three main branches that pass through the superior orbital fissure, foramen rotundum and foramen ovale, respectively), abducens (as per oculomotor), facial (through stylomastoid foramen to supply muscles of facial expression), vestibulocochlear (through the internal acoustic canal to control balance and hearing), glossopharyngeal, vagus, accessory (all pass through the jugular foramen) and hypoglossal (through the hypoglossal canal to control movements of the tongue) nerves.

Facial Nerve Reconstruction with Free Vascularized Composite Nerve Flap from Intrapetrous Portion to Terminal Branches—Case Report

The case presented here is a delayed reconstruction of a facial nerve defect after radical parotidectomy without a useful nerve stump at the stylomastoid foramen. A composite free flap was used to reconnect the nerve’s intrapetrous portion to the peripheral branches and reconstruct the soft-tissue deficit.

Elongated Styloid Process: Mapping the incidence in Greek population

Background: Styloid process (SP) is a needle shaped projection of the temporal bone, which lies in close proximity to several important anatomical structures of the head and neck. It attracts the attention of anatomists, otolaryngologists and head and neck surgeons, as an abnormally long SP is linked with a clinical condition known as Eagle Syndrome. There are numerous studies in the literature investigating morphometric characteristics of SP, including its length in different populations. The aim of this study is to investigate the incidence of SP elongation in Greek population and to construct an epidemiologic map showing the incidence of SP elongation across different regions of Greek territory. Materials and methods: Two hundred and nine skulls retrieved from cemeteries across Greece were meticulously examined. Ninety-four male skulls and one-hundred and fifteen females, all of Hellenic origin. SP length was measured from the lowest inner point of the surface between the SP and the stylomastoid foramen to its tip, utilizing a digital caliper and a steel wire. Data from this study were statistically analyzed and combined with data from other studies in Greek population in order to construct a detailed epidemiologic map. Results: The mean length was 27.26 ± 5.89 mm for the left and 27.84 ± 6.31 mm for the right SP. In males 36.4% of the left and 37.8% of the right SP were elongated. In females the incidence of SP elongation was 14.3% and 15.5% for left and right side respectively. Statistically significant association was observed between gender and SP length but not between age and SP length. Conclusion: This study enriches the literature by adding information about elongated SP incidence in Greek population. It reviews the existing studies about SP length in Greeks and presents an epidemiologic map showing the incidence of SP elongation across different regions in Greece. KEY WORDS: Skull, Eagle syndrome, Hellenic population, Elongated Styloid Process.

Facial nerve regeneration using silicone conduits filled with ammonia-functionalized graphene oxide and frankincense-embedded hydrogel

Background Silicone tube (ST) conduits have been accepted as a therapeutic alternative to direct nerve suturing in the treatment of nerve injuries; however, the search for optimal adjuncts to maximize the outcomes is still ongoing. Frankincense (Fr) and graphene oxide (GO) have both been cited as neuroregenerative compounds in the literature. This study assesses the efficacy of these materials using a ST conduit in a rat facial nerve motor neuron axotomy model, distal to the stylomastoid foramen. Methods Ammonia-functionalized graphene oxide (NH2-GO) and/or Fr extract were embedded in a collagen-chitosan hydrogel and were injected inside a ST. The ST was inserted in the gap between the axotomized nerve stumps. Return of function in eye closure, blinking reflex, and vibrissae movements were assessed and compared to control groups through 30 days following axotomy. To assess the histological properties of regenerated nerves, biopsies were harvested distal to the axotomy site and were visualized through light and fluorescence microscopy using LFB and anti-MBP marker, respectively. Results There was no significant difference in behavioral test results between groups. Histological analysis of the nerve sections revealed increased number of regenerating axons and mean axon diameter in NH2-GO group and decreased myelin surface area in Fr group. Using both NH2-GO and Fr resulted in increased number of regenerated axons and myelin thickness compared to the hydrogel group. Conclusions The findings suggest a synergistic effect of the substances above in axon regrowth, notably in myelin regeneration, where Fr supposedly decreases myelin synthesis.

Awake CT-guided percutaneous stylomastoid foramen puncture and radiofrequency ablation of facial nerve for treatment of hemifacial spasm

OBJECTIVE Hemifacial spasm (HFS) is a debilitating neuromuscular disorder with limited treatment options. The current study describes a novel minimally invasive procedure that provided effective and sustained relief for patients with HFS. The authors provide a detailed description of the awake CT-guided percutaneous radiofrequency ablation (RFA) of the facial nerve for treatment of HFS, and they examine its clinical efficacy. This is the first time in the literature that this procedure has been applied and systematically analyzed for HFS. METHODS Patients with a history of HFS were recruited between August 2018 and April 2020. Those with a history of cerebellopontine lesions, coagulopathy, ongoing pregnancy, cardiac pacemaker or defibrillator implants, or who declined the procedure were excluded from the study. Fifty-three patients who met the study criteria were included and underwent awake CT-guided RFA. Under minimal sedation, a radiofrequency (RF) needle was used to reach the stylomastoid foramen on the affected side under CT guidance, and the facial nerve was localized using a low-frequency stimulation current. Patients were instructed to engage facial muscles as a proxy for motor monitoring during RFA. Ablation stopped when the patients’ hemifacial contracture resolved. Patients were kept for inpatient monitoring for 24 hours postoperatively and were followed up monthly to monitor resolution of HFS and complications for up to 19 months. RESULTS The average duration of the procedure was 32–34 minutes. Postoperatively, 91% of the patients (48/53) had complete resolution of HFS, whereas the remaining individuals had partial resolution. A total of 48 patients reported mild to moderate facial paralysis immediately post-RFA, but most resolved within 1 month. No other significant complication was observed during the study period. By the end of the study period, 5 patients had recurrence of mild HFS symptoms, whereas only 2 patients reported dissatisfaction with the treatment results. CONCLUSIONS The authors report for the first time that awake CT-guided RFA of the facial nerve at the stylomastoid foramen is a minimally invasive procedure and can be an effective treatment option for HFS.

Isolated Congenital Mastoid Cholesteatoma with no Involvement of Aditus Ad Antrum and Middle Ear

Cholesteatoma is a non-neoplastic, keratinized squamous epithelial lesion that affects the temporal bone. The middle ear is the most frequent, while the isolated cholesteatoma of the mastoid is rare. The aim of this study was to describe a rare case of isolated mastoid cholesteatoma with no involvement of aditus ad antrum and middle ear including a literature review of the topic. This case report describes the case of a 58 years old female with a cholesteatoma isolated in the mastoid region, evidenced by imaging (computer tomography and magnetic resonance). A mastoidectomy was performed: mastoid process was completely involved, but antrum was not reached. Moreover, it reached the soft tissue of stylomastoid foramen as well as the posterior belly of the digastric muscle. In the literature few articles described cases of cholesteatoma isolated in the mastoid region. Research was conducted using PubMed and reference list and there were considered only reports about cholesteatoma exclusively located in the mastoid process without involvement of antrum or middle ear. Fourteen articles were included in this review, with a total number of 23 cases of cholesteatoma isolated in the mastoid region. All papers analyzed reported the cases of isolated mastoid cholesteatoma that presented a congenital origin. Its diagnosis is difficult, therefore, imaging evaluation is mandatory and surgery is the treatment of choice. Mastoid cholesteatomas without involvement of aditus ad antrum and middle ear are rare and only 23 cases are reported in literature. Our case is in line with all clinical and diagnostic features of this rare disease, but it is the only one that evidenced an exposure of the soft tissue of stylomastoid foramen as well as the posterior belly of the digastric muscle. The treatment of choice was the surgical one, avoiding damaging of important anatomo-functional structure.

A New and Reliable Landmark in Parotid Surgery: Tragomastoid Groove (Akil Groove)

Background: Parotid surgery is a frequently performed surgery in otorhinolaryngology practice with many possible complications. Due to the high ratio of facial paralysis during parotid surgery, we defined a new landmark for identifying and protecting the facial nerve as early as possible during surgery. Materials and Methods: The study was designed as a prospective anatomical method. The important details and relationship of the tragomastoid groove to the facial nerve truncus were examined during surgery on 30 patients. In addition, the demographics of the patients, the type of surgery and the pathological results of surgeries were evaluated.Results: The mean distance of the tragomastoid groove to the facial nerve truncus was 20.53±1.71 mm, the mean deepness of the tragomastoid groove was 1.91+-0.26 mm, and the mean superficial part of the tragomastoid groove was 0.83±0.23 mm. The tragomastoid groove was situated either across from the facial nerve at the place where the facial nerve truncus exits the stylomastoid foramen or just inferior to the truncus in all patients. Conclusion: The tragomastoid groove was defined for the first time in the literature as a reliable landmark for identifying the facial nerve truncus easily during parotid surgery.