|Year : 2015 | Volume
| Issue : 4 | Page : 306-308
Sequential pictorial account of results of sealant gel-aided cable nerve grafting in a case of iatrogenic facial nerve palsy
Produl Hazarika, Seema Elina Punnoose, Joyse Zachariah, John Victor
Department of ENT, NMC Specialty Hospital, Abu Dhabi, UAE
|Date of Web Publication||16-Oct-2015|
Department of ENT, NMC Specialty Hospital, P. O. Box 6222, Abu Dhabi
Source of Support: None, Conflict of Interest: None
The uniqueness of this surgical case report is in the use of a stitchless anastomosis of the harvested greater auricular nerve cable graft with the sealant gel to the stump ends of the facial nerve. A liberal use of the gel was done in the full length of the cable graft and a folded hammock support by the temporalis fascia was used to reinforce the stability of the nerve. The restoration of the grafted facial nerve has been documented in different stages in its course of the recovery. Our review of medical literature in PubMed and Medscape search engines failed to show such a sequential pictorial account of documented nerve grafting with the use of sealant gel in the Indian perspective.
Keywords: Graft, Greater auricular nerve, Sealant gel, Stitchless, Stump end of facial nerve
|How to cite this article:|
Hazarika P, Punnoose SE, Zachariah J, Victor J. Sequential pictorial account of results of sealant gel-aided cable nerve grafting in a case of iatrogenic facial nerve palsy. Indian J Otol 2015;21:306-8
|How to cite this URL:|
Hazarika P, Punnoose SE, Zachariah J, Victor J. Sequential pictorial account of results of sealant gel-aided cable nerve grafting in a case of iatrogenic facial nerve palsy. Indian J Otol [serial online] 2015 [cited 2020 Feb 23];21:306-8. Available from: http://www.indianjotol.org/text.asp?2015/21/4/306/165760
| Introduction|| |
The occurrence of facial nerve injury during cholesteatoma surgery though rare still needs to be addressed as a pertinent clinical entity, which requires careful evaluation. Prompt judgment and the appropriate kind of treatment are essential in minimizing or preventing facial disfigurement. Facial disfigurement caused by an iatrogenic facial nerve injury can have a profound psychological effect in addition to the accompanied physical disability. Therefore, the need to treat such a case of facial nerve injury after a mastoid surgery as an emergency becomes a priority rather than following a wait and watch policy. The immediate recognition of the complications, urgent but concise evaluation of the patient with reduced transportation time gap aids in the execution of the appropriate treatment plan. In such case scenarios, the treatment plan is surgical only; where the type of surgical procedure entailed will depend on the extent of injury with or without tissue loss.
This paper deals with such a case of left-sided facial nerve injury with a segment of nerve tissue loss of 2 days duration; repair done with greater auricular nerve cable grafting with sealant gel. We have sequentially documented the pictorial account of the progress made in the recovery of the facial nerve function and in the healing and survival of the graft in this case. To the best of our knowledge, there has been no account of such a case report with pictorial documentation reported earlier in an Indian literature.
| Case Report|| |
A female Afghan National, aged 31 years, had undergone a left radical mastoidectomy on April 03, 2014 for the left atticoantral type of chronic suppurative otitis media with severe sensorineural hearing loss with questionable labyrinthine fistula. The operating surgeon noticed in the immediate postoperative period, the lower motor neuron facial nerve palsy and initiated the patient on steroid therapy. Overnight observation showed deteriorating facial nerve function and the patient was transferred to our center on April 05, 2014 in the morning. On clinical examination, we graded the facial nerve function as House–Brackmann grade IV. After comprehensive preoperative assessment and evaluation, she was undertaken for a mastoid re-exploration on the same day in the evening of April 05, 2014. After removing the residual cholesteatoma and granulation tissue from the middle ear and mastoid, the horizontal segment of the facial nerve was found completely missing from 1st genu to the 2nd genu. Dissection was carried out beyond the 1st and 2nd genu and both the proximal and distal stumps were exposed and freshened [Figure 1]a. The greater auricular nerve was then dissected and harvested out. The epitympanum area was packed with gelfoam in line with the injured bony fallopian canal to have a smooth and level bed for the graft. A temporalis fascia graft was placed over the gelfoam [Figure 1]b. Both the cut end stumps of the facial nerve were laid over the temporalis fascia. The harvested greater auricular nerve was then placed on the temporalis fascia approximating it to both the cut end stumps of the facial nerve [Figure 1]c. A sealant gel was liberally applied to keep the nerves in contact devoid of stitches and tension. Then, the temporalis fascia was folded over it to create a tunnel. Gelfoam was then reapplied. A wide conchomeatoplasty was performed and the postauricular wound was closed in layers. The mastoid cavity was then packed with gelfoam. We performed a series of otoendoscopies to monitor the status of the facial nerve cable graft. Sequential pictorial documentation was done until June 17, 2015 [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. On the last follow-up, the facial nerve function was restored to House–Brackmann grade II score and assessed by electromyoneurography [Figure 3]a,[Figure 3]b,[Figure 3]c.
|Figure 1: (a) Proximal end of the cut nerve, (b) temporalis fascia graft in position, (c) cable nerve graft in position|
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|Figure 2: Otoendoscopic view (a) April 14, 2014, (b) May 17, 2014 (c) June 21, 2014 (d) June 27, 2015|
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|Figure 3: Facial muscle improvement House–Brackmann grading. (a) Corrugator supercili, (b) Eyes closed, (c) Eyes open|
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| Discussion|| |
The presence of extensive cholesteatoma and granulation tissue in the atticoantral type of chronic suppurative otitis media is known to cause erosion of the bony fallopian canal, bony semicircular canal creating difficulties in the identification of the facial nerve during mastoid surgery. Han et al. mentioned in their case series that the tympanic and pyramidal segment was more prone to injury during the mastoid surgery whereas Green et al. quoted their incidence as lower tympanic segment as the most common injury position (55%) followed by descending segment (32%). The management of iatrogenic facial nerve injury poses a considerable challenge for the otolaryngologist. The restoration process of the facial nerve function depends on the factors such as type of injury with or without tissue loss, availability of viable proximal and distal ends of the facial nerve stumps, the status, viability of the facial muscle, donor site morbidity and the time gap between injury and treatment, and tissue healing based on age of the patient. The optimal timing of the repair has been debated extensively in literature. The commonly accepted belief today is that an injured nerve should be repaired as soon as possible and not in a delayed fashion. Delay in the repair of nerve 3 weeks after injury was a concept advocated in 1970 on the basis of experimental data. Subsequent data, however, proved that the best long-term results are achieved when the repair is performed as soon as possible (Medscape).
Various surgical procedures have been mentioned in the literature such as decompression, end to end anastomosis, facial-hypoglossal anastomosis, end to end anastomosis after nerve transfer, interposition, or cable nerve grafting with greater auricular nerve. The landmark work of facio-hypoglossal anastomosis by Conley and Baker  describing their 30 years of experience, highlights the utility and success of this operation. Then, the concept of neural rehabilitation of the facial nerve paralysis typically involved neurorrhaphy from donor motor nerve. In a series  of 42 patients of iatrogenic facial nerve palsy, 24 patients had decompression, 10 patients had cable nerve grafting with greater auricular nerve, 2 patients had end to end anastomosis after nerve transfer, 2 patients had end to end anastomosis, and another 4 patients had facial-hypoglossal anastomosis. Recoveries in these patients were charted based on the House–Brackmann grading. Seventeen patients out of 24 were followed up to a year wherein 4 patients showed recovery to grade I, 11 patients of decompression group to grade II, and 2 patients to grade III. Five cases out of 10 who had undergone interposition cable grafting with greater auricular nerve were available for follow-up for a year of which 3 cases recovered to grade II and 2 cases to grade III. In a recently published report  of 4 cases of iatrogenic facial nerve injury, 3 of the patients were treated with cable nerve grafting and 1 with end to end anastomosis. Their study found better results with end to end anastomosis. In our personal experience in New Medical Centre Specialty Hospital, Abu Dhabi from 2007 to 2015, we have performed 4 facial nerve decompressions for traumatic facial nerve palsy secondary to temporal bone fracture but this is our lone case of a cable nerve grafting where segment of facial nerve was missing. Facial nerve injury with tissue loss is not a very common clinical entity here in our center. By and large, decompression and greater auricular nerve cable nerve grafting are the commonly done surgical procedures for facial nerve injury. Cable or interposition nerve grafting is frequently used in facial nerve injury where loss of any part of the segment of the nerve is encountered. The surgeon is required to identify the proximal and distal facial segment for anastomosis. The most popular choice of graft is the greater auricular nerve. The ongoing argument in cable nerve grafting, however, exists whether it can be stitched or stitchless between the perineural and epineural technique. Some authors claim that the perineural stitched repair improves regeneration and relieves synkinesis. Others speculate that the perineural stitches cause trauma and vascular damage with ensuing endoneural fibrosis with no obvious functional advantages over the stitchless epineural repair. In our case, we avoided the perineural stitches and opted for the stitchless sealant gel aided facial nerve grafting over the temporalis fascia which was folded into a tunnel to get an additional stable support to the cable graft. The status of the graft has been documented with otoendoscopy until the present recovery stage. Functional recovery of the facial muscle in our case has been recorded as House–Brackmann II from IV. Sealant glue and temporalis fascia used in the present case has helped in the stability and continuity of the cable graft to its near normal recovery. This shows that the recovery of the facial nerve function can also be gained by motor and sensory nerve assembly and not alone by the mentioned motor to motor nerve assembly.
Sealant glue is composed of a two solution polyethylene glycol ester solution and polyethylenimine. These two solutions when mixed together will form a gel that has adhesive properties and can be used as a stitchless approach in the repair of nerve as well as dura in skull base surgeries. The absorption of the gel postusage occurs in approximately 90 days which gives adequate time in healing of the nerve.
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[Figure 1], [Figure 2], [Figure 3]