A patient in their late 60s had a vestibular schwannoma subtotally resected 7 years ago. They experienced transient facial weakness with a full recovery. It required gamma-knife to treat the remnant. They then experienced an acute facial palsy for a few days after gamma knife, then once again recovered completely.

They had five years of follow up with no recurrence and were finally dismissed from surveillance. Two years later, they developed slight facial weakness with balance issues and an MRI demonstrated a large recurrence. This was resected with likely facial nerve sacrifice 3 months ago. The V nerve was non-functioning (no muscle bulk, corneal anesthesia) accompanied by lower cranial nerve deficits (had been g-tube dependent). Laryngologist says “I worry about weakening 12- could worsen swallow”. Flaccid exam.

What would be your plan?