A 74-year-old man had a facial nerve tumor resected elsewhere 9 months ago based on a 6 month clinical history of facial palsy (unclear if complete or partial) and a radiological suspicion of a mastoid facial nerve schwannoma. No tumor was described in the pathological report (angioma?). The nerve defect was reconstructed with a greater auricular nerve graft with no recovery. The patient was seen in our unit with 15 months of flaccid paralysis. Otoscopy shows canal wall down a cavity obliterated with soft tissue (tiny meatoplasty). Diffusion MRI suggests cholesteatoma in the cavity. What would you do now?
Search
Categories
Recent Posts
- Post Irradiation for AN and Meningioma
- 33 yo M s/p right vestibular schwannoma resection with immediate post-op flaccid facial paralysis now 14 months out from surgery.
- 33yo m with geniculate ganglion venous malformation
- Does Full Dental Smile Have to Be with a Bulky Face?
- Dynamic options for reanimation of mouth in partial paralysis?
Search tags
autoimmune
Bell Palsy
bulbar palsy
Cranial nerve transfer
Cross face nerve graft
elderly
Electro-stimulation
Facial Therapy
flaccid paralysis
Free muscle transfer
Grading systems
middle ear
multiple cranial nerve palsy
myositis
nerve graft
Objective analysis
Pediatric
PROMs
Reanimation
Subjective analysis
tumor
vestibular schwannoma
viewpoints
Recent Comments
- Tessa Hadlock on Post Irradiation for AN and Meningioma
- Tessa Hadlock on 33 yo M s/p right vestibular schwannoma resection with immediate post-op flaccid facial paralysis now 14 months out from surgery.
- Luis Lassaletta on 33 yo M s/p right vestibular schwannoma resection with immediate post-op flaccid facial paralysis now 14 months out from surgery.
- Tessa Hadlock on 33 yo M s/p right vestibular schwannoma resection with immediate post-op flaccid facial paralysis now 14 months out from surgery.
- Tessa Hadlock on 33yo m with geniculate ganglion venous malformation
This is a challenging case, with duration of the paralysis in the limit for a reinnervation technique.
As a recurrent or residual cholesteatoma is suspected, revision surgery should be performed, probably a canal wall down mastoidectomy with resection of the cholesteatoma, and enlargement of the meatoplasty. Resection of any suspicion remnants of the tumor or tumor-like previous lesion should be performed.
About the facial reanimation, with 15 months of facial paralysis in a 74-year-old patient, a good result with a reinnervation technique is still possible, but in this case the patient’s expectations and attitude should be considered. Also, EMG to rule out fibrillation potentials could be useful.
If reinnervation is decided:
– If the mastoid portion is preserved and reaches the 12: side to end 12-7 transfer + masseter to facial (zygomatic or buccal branch)
– If the mastoid portion is not preserved: masseter to facial (zygomatic or buccal branch) with a fascia lata to the nasolabial fold and a rhytidectomy.
If the patient prefers an easier and faster solution, and/or signs of muscle atrophy are present, a temporal muscle elongation (Labbe’s technique) in addition to specific eye care could be offered.