Masseteric-facial nerve neurorrhaphy: results of a case series

OBJECTIVE: Facial palsy is a well-known functional and esthetic problem that bothers most patients and affects their social relationships. When the time between the onset of paralysis and patient presentation is less than 18 months and the proximal stump of the injured facial nerve is not available, another nerve must be anastomosed to the facial nerve to reactivate its function. The masseteric nerve has recently gained popularity over the classic hypoglossus nerve as a new motor source because of its lower associated morbidity rate and the relative ease with which the patient can activate it. The aim of this work was to evaluate the effectiveness of masseteric-facial nerve neurorrhaphy for early facial reanimation. METHODS: Thirty-four consecutive patients (21 females, 13 males) with early unilateral facial paralysis underwent masseteric-facial nerve neurorrhaphy in which an interpositional nerve graft of the great auricular or sural nerve was placed. The time between the onset of paralysis and surgery ranged from 2 to 18 months (mean 13.3 months). Electromyography revealed mimetic muscle fibrillations in all the patients. Before surgery, all patients had House-Brackmann Grade VI facial nerve dysfunction. Twelve months after the onset of postoperative facial nerve reactivation, each patient underwent a clinical examination using the modified House-Brackmann grading scale as a guide. RESULTS: Overall, 91.2% of the patients experienced facial nerve function reactivation. Facial recovery began within 2-12 months (mean 6.3 months) with the restoration of facial symmetry at rest. According to the modified House-Brackmann grading scale, 5.9% of the patients had Grade I function, 61.8% Grade II, 20.6% Grade III, 2.9% Grade V, and 8.8% Grade VI. The morbidity rate was low; none of the patients could feel the loss of masseteric nerve function. There were only a few complications, including 1 case of postoperative bleeding (2.9%) and 2 local infections (5.9%), and a few patients complained about partial loss of sensitivity of the earlobe or a small area of the ankle and foot, depending on whether great auricular or sural nerves were harvested. CONCLUSIONS: The surgical technique described here seems to be efficient for the early treatment of facial paralysis and results in very little morbidity

Do olfactory and gustatory psychophysical scores have prognostic value in COVID-19 patients? A prospective study of 106 patients

Background: The lack of objective data makes it difficult to establish the prognostic value of chemosensitive disorders in coronavirus disease 2019 (COVID-19) patients. We aimed to prospectively monitor patients diagnosed with COVID-19 to see if the severity of olfactory and gustatory dysfunction associates with subsequent disease severity. Methods: Multicentre prospective study that recruited 106 COVID-19 subjects at diagnosis. Chemosensitive functions were assessed with psychophysical tests within 4 days of clinical onset, at 10 and 20 days. Daily body temperature and oxygen saturation were recorded as markers of disease severity alongside need for hospitalisation. The correlation between olfactory and gustatory scores and disease severity was assessed with linear regression analysis. Results: At T0, 71 patients (67%) presented with olfactory dysfunction while gustatory impairment was detected in 76 cases (65.6%). Chemosensitive disorders gradually improved over the observation period. No significant correlations were found between T0 chemosensitive scores and final disease severity. The correlation between olfactory scores and fever proved significant at T2 (p = 0.05), while the relationship with gustatory scores was significant at T1 (p = 0.01) and T2 (p < 0.001), however neither was clinically relevant. The correlation between chemosensitive scores and oxygen saturation was significant only for taste at T2 (p < 0.001). Logistic regression analysis found significant correlations between olfactory impairment severity and need for hospitalization at T2 (OR 3.750, p = 0.005). Conclusions: Initial objective olfactory and gustatory scores do not seem to have a significant prognostic value in predicting the severity of the COVID-19 course; however, persistence of olfactory dysfunction at 20 days, associated with a more severe course. Unfortunately, olfactory and gustatory dysfunction do not seem to hold prognostic value at the time of initial diagnosis

Cross-tongue: a clinical answer to long-standing lingual anaesthesia

Lingual nerve (LN) lesions may occur during several oral and maxillo-facial procedures. Prompt surgical nerve repair is mandatory in case of certain LN damage, since the sooner the repair procedure, the better the functional recovery. Furthermore, there is no literature consensus for surgical repairs taking place after 18 months or more, due to extremely variable results. Since employing a motor nerve source other than the proximal stump has proven effective for nerve regeneration in other clinical situations, the Authors proposed using the contralateral healthy LN to add a strong axonal sprouting source to treat 3 patients affected by long standing LN lesion. 30% of the contralateral LN fibres were co-opted by surgical side-to-end neurorrhaphy. Axonal regeneration was achieved on the pathological side of the tongue by a reverse sural nerve graft (cross-tongue procedure). Distal end-to-end neurorrhaphy was accomplished in the free half of the distal stump of the pathological LN.During the postoperative period the sensitivity of the hemi-tongue on the repaired side increased progressively, almost equating normal side levels, as evidenced by sensory and pain-potential registration results. Sensitivity restoration was demonstrated by sensory threshold testing, while improved taste, temperature and static/dynamic two-point discrimination also emphasized good recovery

Surgical treatment of vascular malformations of the facial bones

Purpose To characterize intraosseous vascular malformations and describe the most appropriate approach for treatment according to clinical experience and a review of the published data. Materials and Methods We performed a retrospective review of 11 vascular malformations (7 venous and 4 arteriovenous) of the facial bones treated during a 10-year period using en bloc resection or intraoral aggressive curettage alone or preceded by endovascular embolization. Corrective surgery was planned to address any residual bone deformities. The cases were reviewed at a mean follow-up point of 6 years. Results Facial symmetry was restored in the cases requiring reconstruction. Tooth sparing was possible in the case of jaw and/or maxillary localization. Recanalization occurred in 14% of the venous and 33% of the arteriovenous malformations. Conclusions Facial intraosseous venous malformations can be successfully treated using surgery alone. Facial intraosseous arteriovenous malformations will be better addressed using combined approaches. Aggressive curettage will obviate the need for extensive surgical resection in selected cases

Extraoral approach to mandibular condylar fractures : our experience with 100 cases

Introduction Mandibular condylar fractures are very common. The current literature contains many indications and methods of treatment. Extraoral approaches are complicated by the need to avoid injury to the facial nerve. On the other hand intraoral approaches can make fracture reduction and/or fixation difficult. The mini-retromandibular approach provides an excellent view of the surgical field, minimises the risk of injury to the facial nerve, and allows rapid and easy management of condylar fractures. We have collected and reviewed our first 100 condylar fractures treated by means of a mini-retromandibular approach. Patients and methods Between June 2006 and June 2012, Eighty-seven patients with extracapsular condylar fractures underwent open reduction and rigid fixation for 100 extracapsular condylar fractures via a mini-retromandibular approach. Results Dental occlusion and anatomic reduction were restored in all 100 condylar fractures. Postoperative infection developed in three patients. There was one sialocele and one case of plate fracture. Four patients experienced transient palsy of the buccal branch of the facial nerve. No permanent deficit of any facial nerve branch was observed. No patient showed condylar head resorption. Conclusions Our experience with the treatment of the first 100 condylar fractures using the mini-retromandibular approach has demonstrated that this technique has allowed the Authors to safely manage extracapsular condylar fractures at all levels

Aneurysmal bone cyst: effective nonsurgical treatment based on embolization, percutaneous alcoholization and injection of liquid hydroxyapatite

Aneurysmal bone cysts (ABCs) are rare and poorly understood bony lesions. ABCs are intensely vascularized by both high flow vessels and low flow \u201cvascular lakes\u201d.Owing to this features treating an ABC can often be difficult and perilous since abrupt hemorrhages can occur. Besides, enucleation or courettage are frequently blemished by local recurrence.Resection with reconstruction (often after previous embolization) is an option that yields higher cure rate but at the price of disfigurement or donor site morbidity.Here we report a preliminary analysis of a new technique that consist on endovascular embolization followed by percutaneous alcoholization and obliteration by injecting liquid hydroxylapathite into the vascular chambers. Two patients, who were previously treated with conservative surgical removal of mandibular ABC, presented with vast recurrences.Under general anesthesia an endovascular procedure was undertaken. Here facial and inferior alveolar arteries were closed by means of cyanoacrilic glue. Then by percutaneous direct puncture the remaining \u201cvascular lakes\u201d were injected with absolute alcohol. Ten minutes after, when a fluoroscopic examination demonstrated no contrast leakage, liquid hydroxylapathite was injected into the chambers.No perioperative complications were recorded.Six months after the procedure no disease relapse was detectable.5 more patients with ABC outside the facial skeleton were treated with the same technique.Endovascular treatment followed by percutaneous injection of calcium hydroxylapathite seems to be a valid alternative to safely and conservatively manage ABCs.However longer follow up and higher number of treated patients are needed to deem this approach superior to the \u201cstandard\u201d resection

Comprehensive surgical management of cocaine-induced midline destructive lesions

Purpose This article presents a review of the literature and proposes a protocol for managing acute and chronic midfacial cocaine-induced injuries. Materials and Methods This report describes a series of 4 patients affected by cocaine-induced midline destructive lesions. Three patients came to the authors' attention after 18 months of drug withdrawal and underwent surgical treatments to restore nasal and palatal morphology and function, and the fourth patient was referred because of acute cocaine-induced destructive lesions and was treated by aggressive debridement. An 18-month drug-free period is planned before beginning any reconstructive procedures in this latter patient. Results Long-term follow-up showed stable results without relapse of palatal fistulas and good esthetic nasal appearance in all 3 patients undergoing reconstruction. The fourth patient did not show any disease progression and will be monitored for drug withdrawal. Conclusion Chronic cocaine consumption may cause multiple types of damage to the soft and hard tissues of the midface. Acute lesions must be addressed with aggressive debridement. As a result of chronic injury, the palate and nose are deformed in a very complex way and the vascularity of the remaining local tissues may be compromised or inadequate for flap harvesting. Palatal and nasal reconstructions are very delicate operations and should be addressed separately to maximize the predictability of the result

La placca sovraplatismatica: una nuova soluzione nel trattamento delle fratture mandibolari da difosfonati

La necrosi dei mascellari in seguito a trattamento con difosfonati \ue8 oramai divenuta una situazione clinica di frequente riscontro. Spesso i pazienti affetti presentano scadenti condizioni generali e pertanto il loro trattamento \ue8 di tipo conservativo, che nelle prime fasi \ue8 limitato alla rimozione del sequestro osseo. Negli stadi avanzati della malattia la necrosi pu\uf2 portare alla formazione di fistole cutanee ed alla frattura mandibolare, con conseguente deterioramento delle condizioni di vita dei pazienti. Presentiamo un\u2019utile soluzione tecnica per la stabilizzazione delle fratture mandibolari causate dalla necrosi ossea nei pazienti che assumono difosfonati ,al fine di ridurre il dolore e consentire la ripresa dell\u2019alimentazione. Previa cervicotomia, su un piano superficiale al muscolo platisma, una placca mandibolare ricostruttiva autobloccante dello spessore di 2,4 mm viene modellata e successivamente posizionata, con l\u2019impiego di viti corticali posizionate lontano dalla frattura. Il sito di frattura \ue8 invece approcciato per via endorale, e la chirurgia \ue8 limitata al courettage, con la rimozione di un eventuale sequestro osseo presente ed al lavaggio abbondante con soluzione fisiologica. I vantaggi di lavorare su un piano extraplatismatico sono molteplici. Si tratta di un piano sicuro nei confronti del n. marginalis mandibulae che si trova profondamente. Non essendoci interruzione del periostio, l\u2019apporto ematico ai monconi residui della mandibola non viene compromesso. Inoltre questa tecnica consente di evitare il contatto diretto tra il sito di frattura spesso infetto e la placca ricostruttiva. Sebbene la guarigione della frattura non venga ottenuta , la fissazione della placca con questa tecnica \ue8 stabile nel tempo, i pazienti non hanno pi\uf9 dolore e possono riprendere ad alimentarsi, con un conseguente grande miglioramento della loro qualit\ue0 di vita. Riteniamo che questa tecnica sia veloce, semplice ed efficace, in grado di offrire ai pazienti un lungo periodo libero da malattia