Parotidectomy: review of treatment and outcomes

Background: Parotidectomy is a common surgical procedure performed for a wide array of benign and malignant tumours. The aim of the present study was to review a single-institution experience with parotidectomy over a 10 year period. Methods: We retrospectively reviewed 170 patients who had parotidectomy performed. The preoperative investigations, clinicopathological parameters, perioperative morbidity and mortality were assessed. Results: One hundred and six (62%) of the patients were men. The mean age was 54 years (range 21-80). Indications for parotidectomy included benign tumour (44%), malignant tumour (42%), inflammatory parotid disease (7%) and miscellaneous (5%). The most common benign tumour was pleomorphic adenoma (25%). The most common malignant tumour was metastatic cutaneous squamous cell carcinoma (SCC) (19%). Fine needle aspiration cytology was performed in 83% patients with a sensitivity and specificity for benign tumours of 76% and 97%, respectively. The sensitivity and specificity for malignant tumours was 90% and 99%, respectively. One (0.6%) patient died in the postoperative period. Postoperative complications included wound infection (2.3%), wound haematoma (3.5%) and seroma (6.6%). Six patients (3.5%) developed temporary complete facial paresis, while 33 patients (20%) developed temporary partial facial palsy in the immediate postoperative period. The 2-year disease-free and disease-specific survival for those patients with metastatic cutaneous SCC were 75% and 76%, respectively. Conclusions: The most common indications for parotidectomy were pleomorphic adenoma and metastatic cutaneous SCC. Our perioperative morbidity and survival for patients with malignant parotid disease compare favourably with other institutional series.

Paralisia Facial: Técnicas de Reconstrução Neuro-Muscular

Several surgical procedures have been proposed through the years for the treatment of facial paralysis. The multiplicity and diversity of techniques portray the complexity and challenge represented by this pathology. Two basic dynamic options are available: -Reconstruction of nerve continuity through direct micro suture, with interposition grafts or nerve transpositions. -Regional muscular transposition, most often using the temporalis. Facial reanimation with the temporalis transfer has withstood the test of time and still is a reference technique. In a few weeks, good results can be obtained with a single and rather simple surgical procedure. Functional free flaps have been used with increasing frequency in the last two decades, most often combining a cross-facial nerve graft followed by a gracilis free flap nine months later. With this method there is a potential for restoration of spontaneous facial mimetic function. Apparently there is a limit in microsurgical technique and expertise beyond which there is no clear improvement in nerve regeneration. Current research is now actively studying and identifying nerve growth factors and pharmacological agents that might have an important and complementary role in the near future.

Unmasking of the trigemino-accessory reflex in accessory facial anastomosis

To evaluate the possible blink reflex responses in facial muscles reinnervated by the accessory nerve. Method: Eleven patients with a complete facial palsy were submitted to a surgical repair by an accessory facial nerve anastomosis (AFA). In this pathological group, blink reflex was studied by means of percutaneous electrical stimulation of the supraorbital nerve and recording from the orbicularis oculi muscle. A control group comprised seven normal people and seven patients with a complete Bell's facial palsy; in this group, responses on the sternocleidomastoideus (SCM) muscles were studied after supraorbital nerve stimulation. Results: All the patients with AFA showed a consistent degree of facial reinnervation. Ten out of the 11 patients with AFA showed reflex responses; in six, responses were configured by a double component pattern, resembling the R1 and R2 components of the blink reflex; three patients had an R1-like response and one patient showed a unique R2 component. Mean values of latencies were 15.2 (SD 4.6) ms for the R1 and 85.3 (SD 9.6) ms for the R2. In the control group, eight out of 14 people had evidence of reflex responses in the SCM muscles; these were almost exclusively configured by a bilateral late component (mean latency 63.5 (SD 15.9) ms) and only one of the subjects showed an early response at 11 ms. Conclusion: The trigemino-accessory reflex response in the pathological group was more complex and of a significantly higher incidence than in the control group. These differences could be tentatively explained by a mechanism of synaptic plasticity induced by the impairment of the efferent portion of the reflex. This could unmask the central linking between the trigeminal and the accessory limbs of the reflex. The findings described could be a demonstration of neurobionomic function in the repairing process of the nervous system.

Ultraestrutura do nervo facial intratemporal em pacientes com paralisia facial idiopática: estudo de evidências de infecção viral

A etiologia da paralisia facial periférica idiopática (PFPI) ainda é uma incógnita, no entanto, alguns autores aventam a possibilidade de ser uma infecção viral. OBJETIVO: Analisar a ultraestrutura do nervo facial procurando evidências virais que possam nos fornecer dados etiológicos. MATERIAL E MÉTODO: Foram estudados 20 pacientes com PFP, com graus de moderado a severo, de ambos os sexos, entre 18-60 anos, provenientes de Ambulatório de Distúrbios do Nervo Facial. Os pacientes foram divididos em dois grupos: Estudo, onze pacientes com PFPI e Controle, nove pacientes com Paralisia Facial Periférica Traumática ou Tumoral. Foram estudados fragmentos de bainha do nervo facial ou fragmentos de seus cotos, que durante a cirurgia de reparação do nervo facial, seriam desprezados ou encaminhados para estudo anatomopatológico. O tecido foi fixado em glutaraldeído 2% e analisado em Microscopia Eletrônica de Transmissão. RESULTADO: Observamos no grupo estudo atividade celular intensa de reparação com aumento de fibras colágenas, fibroblastos com organelas desenvolvidas, isentos de partículas virais. No grupo controle esta atividade de reparação não foi evidente, mas também não foram observadas partículas virais. CONCLUSÃO: Não foram encontradas partículas virais, no entanto, houve evidências de intensa atividade de reparação ou infecção viral.

Neck Nerve Trunks Schwannomas: Clinical Features and Postoperative Neurologic Outcome

Objectives/Hypothesis: To analyze clinical and epidemiological features of neck nerve schwannomas, with emphasis on the neurologic outcome after surgical excision sparing as much of nerve fibers as possible with enucleation technique. Study Design: Retrospective study. Methods: Review of medical records from 1987 to 2006 of patients with neck nerve schwannomas, treated in a single institution. Results: Twenty-two patients were identified. Gender distribution was equal and age ranged from 15 to 61 years (mean: 38.6 years). Seven vagal, four brachial plexus, four sympathetic trunk, three cervical plexus, and two lesions on other sites could be identified. Most common symptom was neck mass. Local or irradiated pain also occurred in five cases. Median growing rate of tumors was 3 mm per year. Nerve paralysis was noted twice (a vagal schwannoma and a hypoglossal paralysis compressed by a vagal schwannoma). Different techniques were employed, and seven out of nine patients kept their nerve function (78%) after enucleation. No recurrence was observed in follow-up. Conclusions: Schwannomas should be treated surgically because of its growing potential, leading to local and neural compression symptoms. When possible, enucleation, which was employed in 10 patients of this series, is the recommended surgical option, allowing neural function preservation or restoration in most instances. This is especially important in the head and neck, where denervation may have a significant impact on the quality of life.

Facial Palsy After Blunt Trauma and Without Facial Bone Fracture

A 14-year-old patient had a low-energy facial blunt trauma that evolved to right facial paralysis caused by parotid hematoma with parotid salivary gland lesion. Computed tomography and angiography demonstrated intraparotid collection without pseudoaneurysm and without radiologic signs of fracture in the face. The patient was treated with serial punctures for hematoma deflation, resolving with regression and complete remission of facial paralysis, with no late sequela. The authors discuss the relationship between facial nerve traumatic injuries associated or not with the presence of facial fractures, emphasizing the importance of early recognition and appropriate treatment of such cases.

Phrenic nerve diabetic neuropathy in rats: unmyelinated fibers morphometry

We have demonstrated that phrenic nerves` large myelinated fibers in streptozotocin (STZ)-induced diabetic rats show axonal atrophy, which is reversed by insulin treatment. However, studies on structural abnormalities of the small myelinated and the unmyelinated fibers in the STZ-model of neuropathy are limited. Also, structural changes in the endoneural vasculature are not clearly described in this model and require detailed study. We have undertaken morphometric studies of the phrenic nerve in insulin-treated and untreated STZ-diabetic rats and non-diabetic control animals over a 12-week period. The presence of neuropathy was assessed by means of transmission electron microscopy, and morphometry of the unmyelinated fibers was performed. The most striking finding was the morphological evidence of small myelinated fiber neuropathy due to the STZ injection, which was not protected or reversed by conventional insulin treatment. This neuropathy was clearly associated with severe damage of the endoneural vessels present on both STZ groups, besides the insulin treatment. The STZ-diabetes model is widely used to investigate experimental diabetic neuropathies, but few studies have performed a detailed assessment of either unmyelinated fibers or capillary morphology in this animal model. The present study adds useful information for further investigations on the ultrastructural basis of nerve function in diabetes.

A morphometric study on the longitudinal and lateral symmetry of the sural nerve in mature and aging female rats

Aging affects peripheral nerve function and regeneration in experimental models but few literature reports deal with animals aged more than one year. We investigated morphological and morphometric aspects of the sural nerve in aging rats. Female Wistar rats 360, 640 and 720 days old were killed, proximal and distal segments of the right and left sural nerves were prepared for light microscopy and computerized morphometry. No morphometric differences between proximal and distal segments or between right and left sides at the same levels were found in all experimental groups. No increase in fiber and axon sizes was observed from 360 to 720 days. Likewise, no difference in total myelinated fiber number was observed between groups. Myelinated fiber population distribution was bimodal, being the 720-days old animals` distribution shifted to the left, indicating a reduction of the fiber diameters. The 9 ratio distribution of the 720-days old animals` myelinated fiber was also shifted to the left, which suggests axonal atrophy. Morphological alterations due to aging were observed, mainly related to the myelin sheath, which suggests demyelination. Large fibers were more affected than the smaller ones. Axon abnormalities were not as common or as obvious as the myelin changes and Wallerian degeneration was rarely found. These alterations were observed in all experimental groups but were much less pronounced in rats 360 days old and their severity increased with aging. in conclusion, the present study indicates that the aging neuropathy present in the sural nerve of female rats is both axonal and demyelinating. (C) 2008 Elsevier B.V. All rights reserved.

The aging lacrimal gland: Changes in structure and function

The afferent nerves of the cornea and conjunctiva, efferent nerves of the lacrimal gland, and the lacrimal gland are a functional unit that works cooperatively to produce the aqueous component of tears. A decrease in the lacrimal gland secretory function can lead to dry eye disease. Because aging is a risk factor for dry eye disease, study of the changes in the function of the lacrimal gland functional unit with age is important for developing treatments to prevent dry eye disease. No one mechanism is known to induce the changes that occur with aging, although multiple different mechanisms have been associated with aging. These fall into two theoretical categories: programmed theories of aging (immunological, genetic, apoptotic, and neuroendocrine) and error theories of aging (protein alteration, somatic mutation, etc). Lacrimal glands undergo structural and functional alteration with increasing age. In mouse models of aging, it has been shown that neural stimulation of protein secretion is an early target of aging, accompanied by an increase in mast cells and lipofuscin accumulation. Hyperglycemia and increased lymphocytic infiltration can contribute to this loss of function at older ages. These findings suggest that an increase in oxidative stress may play a role in the loss of lacrimal gland function with age. For the afferent and efferent neural components of the lacrimal gland functional unit, immune or inflammatory mediated decrease in nerve function could contribute to loss of lacrimal gland secretion with age. More research in this area is critically needed.

Morphological Study of Myoneural Interaction between the Levator Labii Superioris Muscle and its Motor Nerve in Rats

The progress of science in search of new techniques of the nerve regeneration and the functional repair in reinnervated muscle has been the target of many researchers around the world. Consequently, nerves and muscles in different body segments asked for more enlightenment of their morphology, their interrelation with other anatomic structures and their peculiarities. One of the most significant areas that need deeper studies is the region of the head and neck, since they are often affected by important pathologies. In order to offer the researcher`s community a morphological myoneural interaction model, this study elected the levator labii superioris muscle and its motor nerve, the buccal branch of the facial nerve (VII pair) not only for its special characteristics, but also its value on the facial expression. The rat was chosen for this investigation for being easy to obtain, to keep, to manipulate and to compare this experiment with many others studies previously published. The techniques used were Mesoscopic (dissection), histoenzymologic and morphometric ones. In the results the muscle proved to have a predominance of fast twich fibers (FG and FOG) and superficial location, with a proximal bone and a distal cutaneous insertion. Its motor nerve, the buccal branch of the facial nerve (VII pair), breaks through the muscle belly into its deep face, and comprised a heterogeneous group of myelinic nerve fibers disposed in a regular form in all fascicle. Near the motor point, the nerve showed to be composed of two fascicles with different sizes. Due to the small nerve dimensions, the nerve fibers have a smaller diameter if compared to the motor nerve of pectineus muscle of the cat. Further studies with neural tracers have already had a start in order to provide more information about the distribution and the architecture of these fibers.

Intraorbital Abducens Nerve Schwannoma

BACKGROUND: Schwannomas of the abducens nerve are extremely rare tumors. The tumor may be located within the cavernous sinus or more often at the prepontine region. However, literature research has identified only one case of isolated schwannoma of the orbit, arising from the terminal branches of the abducens nerve to the lateral rectus muscle. This is only the second report of an abducens nerve schwannoma located entirely intraconal. CASE DESCRIPTION: We report a case of an intraorbital abducens nerve schwannoma in a 42-year-old man with no signs of neurofibromatosis. The lesion resulted in progressive diplopia and focal abducens palsy. The clinical, radiologic, and pathologic features are presented. RESULTS: We point the particular aspects and discuss the possible treatments and approaches to preserve nerve function. CONCLUSIONS: Being a benign lesion, one of the goals has always been total removal. The knowledge of the correct anatomic features made us believe that the VI nerve function could be preserved. Our case is the first example of a total removal with eye abduction preserved. Because of that, we believe that it is reasonable to aim for these goals in future cases.

Interface Humana Músculo-Facial

Esta dissertação tem como principal objetivo a criação de uma interface humana, baseada na eletromiografia dos músculos orbicular do olho e frontalis. O algoritmo de programação do microcontrolador ATmega2560 deteta o piscar de olhos voluntário, conta o número de vezes que este acontece e verifica se preenche os requisitos necessários à execução de um comando. Para este efeito foram utilizados elétrodos para a captação do sinal eletromiográfico. O sinal analógico é condicionado pela Shield ECG/EMG da Olimex sendo enviado para o arduíno ATmega2560. Este microcontrolador administra todos os atuadores, dos quais o mais importante é um painel de comandos (quatro comandos diferentes), no qual existe um ponteiro motorizado que indica qual a ação a realizar. O código de execução é extremamente simples:  se o utilizador piscar os olhos três vezes, o ponteiro movimenta-se para a secção do painel imediatamente à direita; e  se o utilizador piscar os olhos quatro vezes, o ponteiro movimenta-se para a secção do painel imediatamente à esquerda. Os testes realizados com este dispositivo indicam que os utilizadores demoram menos de 10 minutos a aprender a utilizar e executar todos os comandos do painel. Apenas num dos testes realizados o dispositivo não funcionou. Dos utilizadores que realizaram o teste:  vários usam óculos;  um idoso com graves problemas auditivos, cegueira parcial e dificuldades locomotoras;  nenhum foi incapaz de piscar, pelo menos, um dos olhos voluntariamente; e  a maioria referiu que, com alguma concentração e principalmente se ouvirem o bip sonoro, a aprendizagem de utilização torna-se muito fácil. Apesar dos limites impostos à concretização de um projeto deste tipo (dos quais se evidenciam as dificuldades em conseguir voluntários com paralisia medular, bem como os limites orçamentais), pode-se afirmar que este dispositivo é eficaz e seria uma mais valia quando implementado num cenário de paralisia medular (total ou parcial). A melhoria de qualidade de vida de um utilizador com estes problemas físicos, ou outros que lhe comprometam a locomoção é garantida. O cenário em que vivem é tremendamente limitado sendo urgente criar soluções para tornar estas vidas mais cómodas. Com os devidos aplicativos, o utilizador poderia abrir portas ou janelas, acender ou apagar luzes, pedir ajuda, ajustar a posição da cama, controlar cadeiras de rodas, entre outros. É neste sentido que surge a minha motivação de criar algo que ajude estas pessoas.

Papel de la Interleucina 6 (IL-6) en la regulación de la expresión de Osteopontina (OPN) y CD44 tras axotomía del nervio facial

Investigación producida a partir de una estancia en la University of Sidney, Australia, entre octubre del 2008 y enero del 2009. Se ha desarrollado el proyecto titulado "Papel de la interleucina 6 (IL6) en la regulación de la expresión de Osteopontina (OPN) y de CD44 tras axotomía del nervio facial". Tras efectuar una transección del nervio facial, se indujo una reactividad glial en el núcleo facial (NF) localizado en el tronco cerebral, utilizando ratones transgénicos que sobrexpresan IL6 bajo promotor GFAP (tg GFAP-IL6), es decir selectivamente en astrocitos. Se han utilizado técnicas histoquímicas e inmunohistoquímicas, así como también se ha completado el estudio utilizando análisis de RPA, western blotting y citometría de flujo para la identificación de poblaciones celulares. Los resultados obtenidos indican que la OPN se expresa constitutivamente en las neuronas del NF. Tras axotomía del nervio facial, la expresión de OPN y CD44 incrementa en los ratones WT, mientras que en los tg GFAP-IL6 disminuye significativamente, sugiriendo que la IL6 podría estar involucrada en la modulación de la expresión de ambas moléculas. Sin embargo, no se ha visto diferencias en otros receptores de OPN como la integrina Alpha-5. La ctometría de flujo corroboró algunos de los resultados histológicos sobre la reactividad microglial y permitió concluir que la proporción de microglía activada (CD11b+/CD45+mid) y macrófagos (CD11b+/CD45+high) que expresan CD44 incrementa en in los tg GFAP-IL6 versus WT donde la mayor parte de microglia activada mostraba un perfil CD11b+/CD45+low.

Paralysie faciale: mise a jour pour le praticien [Facial palsy: update for the practitioner].

The clinical significance of facial palsy hinges on its psychosocial consequences. While its causes are very numerous, several infections account for a majority of cases: Lyme disease, geniculate zoster (Ramsay Hunt syndrome), while the role of HSV-1 in essential (Bell's) palsy remains controversial. Essentials of facial palsy management are discussed, including the importance of the functional grading of palsy, the complexity of Lyme disease serological diagnosis, and its treatment using doxycycline, antiviral and steroids treatment of geniculate zoster, while regarding essential facial palsy, only steroids, but not antiviral have been shown to improve functional recovery.