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Abstract
The facial nerve coursing through the temporal bone provides a challenge to the otologic surgeon. Advances in surgical instrumentation and refinements of surgical strategies enable the otologist to uncover the entire course of the facial nerve safely from brainstem to its exit from temporal bone. The most common cause of facial nerve paralysis is Bell's palsy, followed by traumatic facial paralysis, herpes zoster oticus, and intratemporal tumous lesion. The surgical approaches to the injured facial nerve depend on its causes. Acute, severe facial nerve paralysis caused by viral infection or trauma can be managed by early use of transmastoid approach, middle cranial approach, or combined approach. In case of intratemporal benign tumor with favorable facial function, great care must be taken not to damage the facial nerve with nerve preservation technique. However, in malignant tumor with favorable facial function, the priority must be placed on the complete resection than to the facial nerve preservation. In consideration of selecting surgical technique of facial nerve paralysis reconstruction, clinician must find out the cause, degree and duration of paralysis for the appropriate technique.
Figures and Tables
Figure 1
View of intratemporal facial nerve during neural decompression.
56-year old male patient with herpes zoster oticus of right side. Facial nerve decompression was done using middle cranial fossa approach. Black arrow indicates the difference of swolen segment between geniculate ganglion and tympanic segment. Pinkish normal tympanic segment was visible on this approach.
Figure 2
A 38-year-old man had complete facial palsy due to injury near the geniculate ganglion of the facial nerve. The surgical intervention to decompress and remove bony impingement and granulation tissue employed a combined approach through the middle cranial fossa and a transmastoid approach.
(A) The right facial nerve was injured near the geniculate ganglion; some granulation tissue is visible on the CT scan (red arrow).
(B) Swelling and hyperemic change in the geniculate ganglion, including the labyrinthine and tympanic segments of the facial nerve, were visible through the middle cranial fossa approach (blue arrows).
(C) Bony impingement and granulation tissue were found near the tympanic segment of the facial nerve via the transmastoid approach (white arrow).
Figure 3
The fundus exposure technique for huge vestibular schwannomas with normal facial function.
(A) After complete labyrinthectomy, it was shown that a thin bony wall covered the facial nerve and the mass at the fundus of internal auditory canal. Using the electrical stimulator, we divided the facial nerve from the schwannoma.
(B) Widening the exposed window of fundus, we advanced the separating procedure from the schwannoma.
(C) After the mass was debulked, the path of the facial nerve could be seen (it was not exposed due to the compressive effect of the huge mass).
(D) Along the exposed path of the facial nerve, the mass was debulked and removed. The capsule of the mass was easily separated from the facial nerve.
Figure 4
The stripping technique for facial nerve schwannoma with good facial function.
(A) After complete mastoidectomy on right side, the tumor was found to originate from the geniculate ganglion of the facial nerve.
(B) Complete local exposure of the tumor and normal nerve appearance is needed to identify the junction between the intact nerve and the capsule of the tumor. Dissecting with sharp microscissors at the junction, we can strip the tumor from the intact facial nerve.
Figure 5
A 65-year-old woman had complete facial palsy on left side due to iatrogenic injury at the tympanic segment of the facial nerve.
The surgical intervention of neural repair was employed via transmastoid approach. Closure without tension (white arrow).
(A) After cutting greater superficial petrosal nerve, the approximated ends of the nerve repair site must match in terms of the endoneural surface
(B) A 9~0 or 10~0 monofilament suture is placed through the epineurium. About 5 knots are tied in order to prevent the suture from unraveling.
Figure 6
A 44-year-old woman had complete facial palsy on right side due to cholesteatoma at the tympanic segment of the facial nerve.
The surgical intervention of sural nerve graft was employed via transmastoid approach. Closure without tension (white arrow).
(A) To suture donor to recipient, the epineurium is peeled back to expose the protruding endoneural surface.
(B) The ends of the donor and recipient nerves should be brought together without tension. Nerve reversed so that the distal end of the graft is attached to the proximal end of the donor nerve.
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