Elsevier

World Neurosurgery

Volume 84, Issue 2, August 2015, Pages 368-375
World Neurosurgery

Original Article
Comparison of Direct Side-to-End and End-to-End Hypoglossal-Facial Anastomosis for Facial Nerve Repair

https://doi.org/10.1016/j.wneu.2015.03.029Get rights and content

Background

The hypoglossal facial anastomosis (HFA) is the gold standard for facial reanimation in patients with severe facial nerve palsy. The major drawbacks of the classic HFA technique are lingual morbidities due to hypoglossal nerve transection. The side-to-end HFA is a modification of the classic technique with fewer tongue-related morbidities.

Objectives

In this study we compared the outcome of the classic end-to-end and the direct side-to-end HFA surgeries performed at our center in regards to the facial reanimation success rate and tongue-related morbidities.

Methods

Twenty-six successive cases of HFA were enrolled. In 9 of them end-to-end anastomoses were performed, and 17 had direct side-to-end anastomoses. The House-Brackmann (HB) and Pitty and Tator (PT) scales were used to document surgical outcome. The hemiglossal atrophy, swallowing, and hypoglossal nerve function were assessed at follow-up.

Results

The original pathology was vestibular schwannoma in 15, meningioma in 4, brain stem glioma in 4, and other pathologies in 3. The mean interval between facial palsy and HFA was 18 months (range: 0–60). The median follow-up period was 20 months. The PT grade at follow-up was worse in patients with a longer interval from facial palsy and HFA (P value: 0.041). The lesion type was the only other factor that affected PT grade (the best results in vestibular schwannoma and the worst in the other pathologies group, P value: 0.038). The recovery period for facial tonicity was longer in patients with radiation therapy before HFA (13.5 vs. 8.5 months) and those with a longer than 2-year interval from facial palsy to HFA (13.5 vs. 8.5 months). Although no significant difference between the side-to-end and the end-to-end groups was seen in terms of facial nerve functional recovery, patients from the side-to-end group had a significantly lower rate of lingual morbidities (tongue hemiatrophy: 100% vs. 5.8%, swallowing difficulty: 55% vs. 11.7%, speech disorder 33% vs. 0%).

Conclusion

With the side-to-end HFA technique the functional restoration outcome is at least as good as that following the classic end-to-end HFA, but the complications related to the complete hypoglossal nerve transection can be avoided. Best results are achieved if this procedure is performed within the first 2 years after facial nerve injury. Patients with facial palsy of longer duration also have the chance for good functional restoration after HFA.

Introduction

Facial palsy is one of the most devastating complications that may occur after surgery of the cerebellopontine angle and brain stem lesions. In spite of the striking development in microsurgical techniques and remarkable advances in intraoperative facial nerve monitoring, facial paralysis of varying degrees is not an uncommon postoperative event 7, 8, 42.

Various surgical interventions have been proposed for reanimation of the paralyzed face ranging from static corrections of asymmetry to dynamic reanimation procedures. It is widely accepted that, when possible, primary end-to-end facial nerve repair with or without an interposition graft offers the best hope for recovery, both in intracranial and extracranial facial nerve transections 11, 45, 46. However, such a repair is impossible when the proximal stump of the facial nerve at the brain stem is not available, in case of destruction of the intrapontine facial nucleus and when the facial nerve is anatomically preserved but the patient has inadequate recovery of facial paresis due to internal axonotmesis and subsequent suboptimal regeneration 11, 15, 30, 32, 33, 34.

In these cases facial crossover neurotization through other cranial nerves may be considered. In 1895, Charles Alfred Balance was the first to perform facial to spinal accessory crossover anastomosis 5, 40, 41, 42. In 1901, Körte and Bernhardt performed the first hemihypoglossal-facial anastomosis 12, 19, 41. The facial and hypoglossal nerves have a cortical topographic proximity in the motor cortex. Both nerves receive afferent input from the trigeminal reflex arcs and act synergistically in the coordination of some mimetic and prandial functions, and both contain myelinated motor fibers with similar fascicular anatomy 3, 4. These features made the hypoglossal-facial anastomosis (HFA) the most successful crossover facial nerve repair (11). Nevertheless, the classic end-to-end HFA is associated with inevitable hemiglossal atrophy and persistent speech, mastication, and/or swallowing difficulties that interfere with daily life 4, 12, 21, 22.

However, over the past 2 decades many variants of this procedure have been developed to reduce morbidities of the tongue function 3, 5, 7, 17, 19, 21, 43, 44, 47. In 1991, May et al. reported favorable results when using only half of the hypoglossal nerve joined to the extracranial facial nerve by a jump-cable graft (23). In 1994, Cusimano and Sekhar proposed a partial HFA by longitudinal splitting of the hypoglossal nerve (11).

In 1997, Sawamura et al. and in 1999, Darrouzet et al. proposed hemihypoglossal-facial anastomosis with rerouting of the intratemporal part of the facial nerve without using a nerve graft 4, 12, 33. With this technique the squeals of the hemiglossal atrophy are reduced and the limitations of the May technique are also covered.

Since then some studies reported application of the direct side-to-end HFA for facial reanimation 4, 12, 13, 15, 22, 31, 33, 34, 42. In this article we present our experience with direct side-to-end HFA via mobilization of the intramastoid facial nerve and compare the results with those of our classic end-to-end HFA patients. We also evaluate the role of some disputable factors on the results of facial reanimation.

Section snippets

Material and Methods

Twenty-six patients with iatrogenic facial palsy were retrospectively enrolled, including 20 male and 6 female patients with the average age of 38 years old (ranging from 2–69 years). The original lesion was vestibular schwannoma in 15, meningioma in 4, brain stem glioma in 4, and other pathologies in 3 (skull base metastasis from breast cancer, endolymphatic sac carcinoma, and adenoid cystic carcinoma). The preoperative grade of facial palsy was documented as House-Brackmann (HB) score, and

Results

The preoperative HB grade was 5 in 11 patients and 6 in the remaining 15 patients. The interval between occurrence of facial palsy and HFA was 18 months on average. In one patient the HFA was performed during the primary surgery for tumor removal. The longest interval was 60 months. Seven patients (27%) had an interval longer than 2 years. Eight patients had a history of radiotherapy/radiosurgery after their initial surgery. The median follow-up period was 20 months, ranging from 11 to 43

Discussion

Reanimation of the paralyzed face is still a great challenge despite all recent advances. A transected nerve will probably never function again as perfectly as it did originally. Still, the recovery can be very good (32). Since the late 19th century, surgical crossover neurotization of the damaged facial nerve was attempted using the phrenic nerve, glossopharyngeal nerve, contralateral facial nerve, spinal accessory nerve, and hypoglossal nerve 9, 14, 26, 27, 47. Due to the undesirable side

Conclusion

The facial reanimation outcome after the side-to-end HFA is at least as good as that following the classic end-to-end HFA. Major complications caused by the complete transection of the hypoglossal nerve, such as lingual atrophy and difficulty in the oral phase of swallowing, can be avoided with the side-to-end technique. Best results are achieved if this procedure is performed within the first 2 years after facial nerve injury. Even when facial palsy is of longer duration, facial reanimation is

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    Conflict of interest statement: The authors confirm that they have received no financial support for this study, and none of the authors have a conflict of interest in this study.

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