A Management of Facial Nerve in the Lateral Skull Base Surgery

A facial nerve has an important role in human activity. It takes part not only in facial movements but also in articulation and facial expression, that is, tools of communication. This nerve emerges from the brain stem, then passes through a temporal bone, and parotid gland. Various structures are situated on the route of facial nerve. So, various tumors in the temporal bone, temporomandibular mandibular joint, and infratemporal fossa may involve this nerve and surgical intervention may interfere facial nerve function. Especially in the management of malignant tumor, a complete removal of lesion requires in surgical resection, however, sometimes facial nerve function or the nerve itself were sacrificed.

From 1999 to 2012, we experienced 74 skull base surgery which required management of facial nerve in some form. Overall, 45 cases only requires identification of facial nerve anatomy and monitoring of its function. Among these, the facial dismasking flap was performed. In these cases, facial nerve was widely elevated and moved with the skin flap. Five required facial nerve rerouting. Temporal section and suturing of branch of facial nerve were performed in 3 cases and section and suturing of main trunk were performed in 10 cases. Eight cases underwent an anastomosis of facial nerve and hypoglossal nerve. In the rest of the three cases, facial nerve was removed with tumor and no reconstruction was performed at the same time.

After the surgery, various degrees of facial nerve palsies were noted and nerve damages were corresponded to the surgical intervention. In the case that underwent facial rerouting and temporal section and suturing, incomplete palsy (HB III-VI) was noted. We instruct self-massage of the face as a rehabilitation of the facial nerve for such patients. In these cases, facial nerve function recovered (HB II-IV) within a year. However, complete recovery was not observed among these patients. Cases with an anastomosis of facial nerve and hypoglossal nerve showed total palsy immediately after the surgery. Rehabilitation was based on movement of the tongue and partial recovery was observed in all cases (HB III-IV). After 1 year, patient with complete palsy or complaining clinical or cosmetic problems, such as incomplete eye closure or blepharophimosis, plastic surgery was recommended.

In this presentation, we mainly report our management of facial nerve during surgery and patient's rehabilitation program based on muscle extension massage.