Transcranial Electrocortical Stimulation to Monitor the Facial Nerve Motor Function During Cerebellopontine Angle Surgery

OBJECTIVE: This study was conducted to investigate the success rate of using the facial motor evoked potential (FMEP) of orbicularis oculi and oris muscles for facial nerve function monitoring with use of a stepwise protocol, and its usefulness in predicting facial nerve outcome during cerebellopontine angle (CPA) surgeries. METHODS: FMEPs were recorded intraoperatively from 60 patients undergoing CPA surgeries. Transcranial electrocortical stimulation (TES) was performed using corkscrew electrodes positioned at hemispheric montage (C3/C4 and CZ). The contralateral abductor pollicis brevis muscle was used as the control response. Stimulation was always applied contralaterally to the affected side using 1, 3, or 5 rectangular pulses ranging from 200 to 600 V with 50 mu s of pulse duration and an interstimulus interval of 2 ms. Facial potentials were recorded from needles placed in the orbicularis oculi and oris muscles. RESULTS: FMEP from the orbicularis oris and oculi muscles could be reliably monitored in 86.7% and 85% of the patients, respectively. The immediate postoperative facial function correlated significantly with the FMEP ratio in the orbicularis oculi muscle at 80% amplitude ratio (P =.037) and orbicularis oris muscle at 35% ratio (P =.000). FMEP loss was always related to postoperative facial paresis, although in different degrees. CONCLUSION: FMEPs can be obtained reliably by using TES with 3 to 5 train pulses. Stable intraoperative FMEPs can predict a good postoperative outcome of facial function. However, further refinements of this technique are necessary to minimize artifacts and to make this method more reliable.

Elevated Amygdala Activity to Sad Facial Expressions: A State Marker of Bipolar but Not Unipolar Depression

Background: Difficulties in emotion processing and poor social function are common to bipolar disorder (BD) and major depressive disorder (MDD) depression, resulting in many BID depressed individuals being misdiagnosed with MDD. The amygdala is a key region implicated in processing emotionally salient stimuli, including emotional facial expressions. It is unclear, however, whether abnormal amygdala activity during positive and negative emotion processing represents a persistent marker of BD regardless of illness phase or a state marker of depression common or specific to BID and MDD depression. Methods: Sixty adults were recruited: 15 depressed with BID type 1 (BDd), 15 depressed with recurrent MDD, 15 with BID in remission (BDr), diagnosed with DSM-IV and Structured Clinical Interview for DSM-IV Research Version criteria; and 15 healthy control subjects (HC). Groups were age- and gender ratio-matched; patient groups were matched for age of illness onset and illness duration; depressed groups were matched for depression severity. The BDd were taking more psychotropic medication than other patient groups. All individuals participated in three separate 3T neuroimaging event-related experiments, where they viewed mild and intense emotional and neutral faces of fear, happiness, or sadness from a standardized series. Results: The BDd-relative to HC, BDr, and MDD-showed elevated left amygdala activity to mild and neutral facial expressions in the sad (p < .009) but not other emotion experiments that was not associated with medication. There were no other significant between-group differences in amygdala activity. Conclusions: Abnormally elevated left amygdala activity to mild sad and neutral faces might be a depression-specific marker in BID but not MDD, suggesting different pathophysiologic processes for BD versus MDD depression.

Quantitative parameters of facial motor evoked potential during vestibular schwannoma surgery predict postoperative facial nerve function

Background Facial motor evoked potential (FMEP) amplitude ratio reduction at the end of the surgery has been identified as a good predictor for postoperative facial nerve outcome. We sought to investigate variations in FMEP amplitude and waveform morphology during vestibular schwannoma (VS) resection and to correlate these measures with postoperative facial function immediately after surgery and at the last follow-up. Methods Intraoperative orbicularis oculi and oris muscles FMEP data from 35 patients undergoing surgery for VS resection were collected, then analysed by surgical stage: initial, dural opening, tumour dissection (TuDis), tumour resection (TuRes) and final. Findings Immediately after surgery, postoperative facial function correlated significantly with the FMEP amplitude ratio during TuDis, TuRes and final stages in both the orbicularis oculi (p = 0.003, 0.055 and 0.028, respectively) and oris muscles (p = 0.002, 0.104 and 0.014, respectively). At the last follow-up, however, facial function correlated significantly with the FMEP amplitude ratio only during the TuDis (p = 0.005) and final (p = 0.102) stages for the orbicularis oris muscle. At both time points, postoperative facial paresis correlated significantly with FMEP waveform deterioration in orbicularis oculi during the final stage (immediate, p = 0.023; follow-up, p = 0.116) and in orbicularis oris during the TuDis, TuRes and final stages (immediate, p = 0.071, 0.000 and 0.001, respectively; follow-up, p = 0.015, 0.001 and 0.01, respectively). Conclusions FMEP amplitude ratio and waveform morphology during VS resection seem to represent independent quantitative parameters that can be used to predict postoperative facial function. Event-to-baseline FMEP monitoring is quite useful to dictate when intraoperative changes in surgical strategy are warranted to reduce the chances of facial nerve injury.

Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve Clinical article

Object. The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed. Methods. Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41 W. and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients. Results. Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%. Conclusions. Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches. with or without Closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients. (DOI: 10.3171/2008.10.JNS08612)

An anatomical study on the lingual-facial trunk

Purpose We quantified variations of the lingual artery origin, measured the lingual artery origin distance from clinical relevant landmarks and compared the lingual artery diameters with normal and variable origin. Methods Forty-two formalin fixed male cadavers were bilaterally evaluated. Measurements were performed with the aid of an electronic digital caliper. Results The origin distances from the common carotid artery bifurcation was 1.05 +/- 0.11 and 1.02 +/- 0.11 cm for the right and left lingual arteries respectively with no differences compared to the lingual-facial trunks. The diameters of the lingual arteries were 0.25 +/- 0.01 and 0.26 +/- 0.01 cm for the right and left sides, respectively, while the lingual facial trunks showed diameters of 0.21 +/- 0.02 and 0.24 +/- 0.02 cm for the right and left sides, respectively. Conclusions The present study adds information on the lingual artery diameter and its anatomical relation to clinically useful landmarks.

Facial Lipoatrophy: Appearances Are Not Deceiving

Lipodystrophy syndrome (LS) has been reported as visible markers that cat? identify HIV status. Changes in body shape are detrimental in terms of psychological welfare and may affect well-being and increase the stigma associated with HIV disease. In the current study, the pychosocial impact of LS was evaluated. A total of 84 HIV-infected patients receiving antiretroviral therapy and exhibiting dyslipidemia were interviewed in an urban hospital setting in Brazil in 2006 using a standardized questionnaire. Of the 84 patients exhibiting dyslipidemia, 40 patients also exhibited body changes, and of these, 25 had facial lipoatrophy. From a psychosocial perspective, patients presenting with facial lipoatrophy reported alterations in self-image and self-esteem and believed that other people noticed their body changes. The results are relevant for nurses who need to be well-prepared to recognize lipodystrophy, to implement nursing interventions including lifestyle changes, and to provide psychosocial support to patients with LS.

Amygdala activation to masked happy facial expressions

The amygdala has a key role in automatic non-conscious processing of emotions. Highly salient emotional stimuli elicit amygdala activity, and happy faces are among the most rapidly perceived facial expressions. In backward masking paradigms, an image is presented briefly and then masked by another stimulus. However, reports of amygdala responses to masked happy faces have been mixed. In the present Study, we used functional magnetic resonance imaging (fMRI) to examine amygdala activation to masked happy, sad, and neutral facial expressions. Masked happy faces elicited greater amygdala activation bilaterally as compared to masked sad faces. Our findings indicate that the amygdala is highly responsive to non-consciously perceived happy facial expressions. (JINS, 2010, 16, 383-387.)

Changes in facial morphology after adenotonsillectomy in mouth-breathing children

Background. Morphological and dentofacial alterations have been attributed to impaired respiratory function. Objective. To examine the influence of mouth breathing (MB) on children facial morphology before and after adenoidectomy or adenotonsillectomy. Methods. Thirty-three MB children who restored nasal breathing (NB) after surgery and 22 NB children were evaluated. Both groups were submitted to lateral cephalometry, at time 1 (T1) before and at time 2 (T2) 28 months on average postoperatively. Results. Comparison between the MB and NB groups at T1 showed that mouth breathers had higher inclination of the mandibular plane; more obtuse gonial angle; dolichofacial morphology; and a decrease in the total and inferior posterior facial heights. Twenty-eight months after the MB surgical intervention, they still presented a dolichofacial morphologic pattern. During this period, MB altered the face growth direction and decreased their mandible plane inclination, with reduction in the SN.GoGn, PP.MP, SNGn, and ArGo.GoMe parameters as well as an increase in BaN.PtGn. Conclusion. After the MB rehabilitation, children between 3 and 6 years old presented significant normalization in the mandibular growth direction, a decrease in the mandible inclination, and an increase in the posterior facial height. Instead, they still persisted with a dolichofacial pattern when compared with nasal breathers.

Cephalometric evaluation of facial pattern and hyoid bone position in children with obstructive sleep apnea syndrome

Objectives: To assess the development of face and hyoid bone in children with obstructive sleep apnea syndrome (OSAS) through lateral cephalometries. Materials and methods: Children aged 7-10 years with mixed dentition and with no previous otorhinolaryngologic, orthodontic or speech therapy treatments were studied. Twenty nasal breathers were compared to 20 mouth breathing children diagnosed as OSAS patients. All children underwent otorhinolaryngologic evaluation and cephalometries; children with OSAS also underwent nocturnal polysomnography in a sleep laboratory. Results: Children with OSAS presented increase in total and lower anterior heights of the face when compared to nasal breathers. In addition, children with OSAS presented a significantly more anterior and inferior position of the hyoid bone than nasal breathers. No significant differences in upper, anterior or posterior heights of the face were observed between groups. Conclusion: The results suggest that there are evident and early changes in facial growth and development among children with OSAS, characterized by increased total and inferior anterior heights of the face, as well as more anterior and inferior position of the hyoid bone. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Esthetic Analysis of Gingival Components of Smile and Degree of Satisfaction in Individuals With Cleft Lip and Palate

Objective: To evaluate soft tissue characteristics in individuals with cleft lip and palate and the degree of satisfaction of these individuals after rehabilitation. Setting: Hospital for Rehabilitation of Craniofacial Anomalies, Brazil. Patients: Forty-five individuals with repaired complete unilateral cleft lip and palate, aged 15 to 30 years. Interventions: One hundred thirty-five frontal facial photographs were obtained at rest and in natural and forced smile. Specialists in periodontics evaluated the soft tissue characteristics. Both patients and specialists evaluated the smiles and scored them as esthetically unpleasant, acceptable, or pleasant. Main Outcome Measures: Comparison of the cleft area with the contralateral region was performed for evaluation of soft tissue. The results of the degree of satisfaction with smile were expressed as percentages and means. The findings between patients and periodontists experienced or inexperienced with cleft care were compared. Results: Statistically significant differences were observed for alveolar process deficiency and absence of papilla in the esthetic area between groups (p < .05). Results show 84.4% of individuals considered their smile as esthetically pleasant. Specialists in periodontics of both groups scored the natural smile and forced smile as esthetically acceptable. There was a statistically significant difference in the mean of patients compared with both groups of specialists in periodontics (p < .05). Conclusions: Evaluation and knowledge of the soft tissue characteristics is extremely important for successful rehabilitation. The esthetic values and degree of patient satisfaction are essential for treatment success, since smile reconstruction should be esthetically pleasant to the patient.

Paralisia facial periférica bilateral na leucemia linfóide aguda: relato de caso

A mímica facial é fundamental para a expressão e comunicação humana, que são possíveis apenas através da integridade do nervo facial. Sendo assim, a paralisia facial periférica (PFP) pode deixar seqüelas estéticas, funcionais e psicológicas. A causa mais comum é a paralisia de Bell (50 a 80%), onde a maioria dos pacientes apresenta manifestação unilateral. O acometimento bilateral simultâneo é raro, sendo a leucemia a neoplasia que com maior freqüência pode resultar nesse tipo de manifestação. A seguir, relatamos o caso de um paciente de dezoito anos de idade apresentando leucemia linfóide aguda (LLA) e PFP simultânea, ambas refratárias ao tratamento quimioterápico, culminando com o óbito cinco meses após o início da PFP. Realizou-se considerações importantes sobre a fisiopatologia da PFP na LLA, além de uma revisão da literatura.

O papel do acesso via fossa média no tratamento da paralisia facial traumática

Há vários aspectos controversos no tratamento da paralisia facial traumática. Um destes é a natureza precisa da intervenção cirúrgica a ser usada, uma vez que a decisão de ser realizada tenha sido feita. FORMA DE ESTUDO: Clínico retrospectivo. OBJETIVOS E MÉTODOS: Entre o período de junho de 1984 e junho de 1993, 220 casos de paralisia facial traumática com boa função coclear foram tratados na Universidade de São Paulo pela seguinte técnica cirúrgica: descompressão dos segmentos mastóideo e timpânico através do acesso transmastoídeo e descompressão do gânglio geniculado e dos 50% distais do segmento labiríntico, usando-se o acesso pela fossa média. Apresentamos uma revisão de literatura e a discussão e resultados de nosso trabalho.

Relação da presença de hiperacusia em pacientes com paralisia facial periférica de Bell

A paralisia de Bell é uma paralisia facial unilateral de início súbito e de causa desconhecida. Pode afetar a salivação, o paladar e o lacrimejamento dependendo do topografia do acometimento do nervo facial, e os pacientes podem referir hipersensibilidade auditiva. Nos pacientes com paralisia de Bell, o reflexo estapediano está ausente. OBJETIVO: O objetivo desta investigação foi o de verificar se os pacientes com paralisia de Bell apresentam hiperacusia. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Foram examinados 18 pacientes aleatórios apresentando paralisia facial periférica de Bell. Foi realizada avaliação otorrinolaringológica completa, teste de Hilger, teste de Schirmer, gustometria, audiometria tonal e vocal, imitanciometria e teste de desconforto auditivo. A faixa etária entre 31 e 40 anos foi a mais afetada pela PFP nesta amostra. RESULTADO: Os pacientes do sexo feminino foram os mais afetados estando acometidos em 61% dos casos. A hemi-face direita foi acometida em 56% dos casos. O grau de acometimento local mais encontrado foi o grau IV em 44% dos casos e os graus III e V em 28% dos casos cada. A queixa de hiperacusia esteve presente em apenas um paciente, o que representa 5,5% dos casos. Todos os pacientes estudados apresentaram diminuição nos gráficos audiométricos do limiar de tolerância auditiva, sendo que o reflexo estapediano protege, em média 16 dB, nestes pacientes. CONCLUSÃO: Portanto, concluímos que pacientes com paralisia de Bell apresentam clinicamente queixas de hiperacusia semelhantes da população geral, porém, audiometricamente, o limiar de tolerância auditivo no lado paralisado é menor do que em relação ao do lado normal.

Pesquisa do vírus herpes simples na saliva de pacientes com paralisia facial periférica de Bell

Os primeiros herpes-vírus a serem descritos foram os tipos 1 e 2, cuja denominação é herpes simplex 1 e 2 ou HSV-1 e HSV-2. Estes vírus possuem características biológicas particulares, tais como a capacidade de causar diferentes tipos de doenças, assim como estabelecer infecções latentes ou persistentes por toda a vida dos hospedeiros e de serem reativados causando lesões que podem se localizar no sítio da infecção primária inicial ou próxima a ele. Postula-se que a reativação deste vírus no gânglio geniculado esteja relacionada com a paralisia de Bell. Nesta situação, os vírus, que estariam latentes neste gânglio, sofreriam reativação e replicação difundindo-se pelo nervo facial e seus ramos, dentre eles o nervo corda do tímpano, que ao estimular a secreção salivar possibilitaria a identificação do DNA viral na saliva dos pacientes. Até recentemente, um grande número de pacientes eram diagnosticados como portadores de uma forma desta paralisia, chamada de idiopática ou de paralisia de Bell. Com o advento da técnica de estudo do DNA viral pelo método da reação da polimerase em cadeia (PCR), diversos autores encontraram DNA do vírus herpes simplex tipo I no líquido cefalorraquidiano, na secreção lacrimal, na saliva e nos gânglios geniculados de pacientes com paralisia de Bell. OBJETIVO: observar a prevalência do vírus herpes simplex tipo I pela técnica de PCR, na saliva de pacientes com PFP de Bell, relacionando-a com a evolução clínica destes casos. METODOLOGIA: Avaliamos 38 pacientes portadores de Paralisia Facial Periférica de Bell, que foram submetidos a anamnese, exame médico geral e otorrinolaringológico e coleta de saliva para detecção do DNA viral pela técnica de PCR. O grupo controle correspondeu a 10 adultos normais. RESULTADOS: Obtivemos positividade para o DNA viral em 11 casos dos 38 avaliados, o que corresponde a 29% da amostra. Este resultado foi estatisticamente significante se comparado ao grupo controle, no qual não foi obtido nenhum caso de positividade. CONCLUSÃO: Concluiu-se que a presença do HSV-1 na saliva de pacientes portadores de PFP de Bell indica que a reativação viral pode ser a etiologia desta doença. A detecção do vírus na saliva destes pacientes não influencia o prognóstico da doença.

Degloving médio-facial como via de acesso a tumores nasossinusais

Abordagens cirúrgicas comuns para maxilectomia medial incluem a rinotomia lateral e a via de acesso degloving médio-facial. A rinotomia lateral fornece um excelente campo cirúrgico, mas deixa proeminentes cicatrizes na face. Já o degloving médio-facial tem sido superior à rinotomia lateral, pois não deixa nenhuma cicatriz externa, embora saibamos que este procedimento tem suas limitações¹. Este estudo tem o objetivo de descrever os resultados estéticos e de melhor acesso transoperatório de cirurgias nasossinusais via degloving, com avaliação da morbidade pós-operatória através das seguintes variáveis: hemoglobina pré e pós-operatória, necessidade de transfusão sangüínea, presença de complicações, uso de tampão nasal, uso de antibiótico, fio cirúrgico utilizado, tempo de internamento pós-operatório e presença de recidiva. Foi realizado um estudo retrospectivo a partir de 16 pacientes internados no Hospital Geral de Fortaleza SESA/SUS durante o período de dezembro de 1999 a novembro de 2003. Pelos dados obtidos, conclui-se que a via de acesso degloving é eficaz no tratamento de lesões nasossinusais extensas, com bons resultados estéticos e com reduzida morbidade pós-operatória.