- Nerve and Plexus Surgery Program, Division of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
- Department of Neurosurgery, Hospital Regional Universitario Carlos Haya, Málaga, Spain
- Department of Neurosurgery, Catholic University, Rome, Italy
Department of Neurosurgery, Catholic University, Rome, Italy
DOI:10.4103/2152-7806.95391Copyright: © 2012 Socolovsky M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Socolovsky M, Miguel Domínguez Páez, Masi GD, Molina G, Eduardo Fernández. Bell's palsy and partial hypoglossal to facial nerve transfer: Case presentation and literature review. Surg Neurol Int 25-Apr-2012;3:46
How to cite this URL: Socolovsky M, Miguel Domínguez Páez, Masi GD, Molina G, Eduardo Fernández. Bell's palsy and partial hypoglossal to facial nerve transfer: Case presentation and literature review. Surg Neurol Int 25-Apr-2012;3:46. Available from: http://sni.wpengine.com/surgicalint_articles/bells-palsy-and-partial-hypoglossal-to-facial-nerve-transfer-case-presentation-and-literature-review/
Background:Idiopathic facial nerve palsy (Bell's palsy) is a very common condition that affects active population. Despite its generally benign course, a minority of patients can remain with permanent and severe sequelae, including facial palsy or dyskinesia. Hypoglossal to facial nerve anastomosis is rarely used to reinnervate the mimic muscle in these patients. In this paper, we present a case where a direct partial hypoglossal to facial nerve transfer was used to reinnervate the upper and lower face. We also discuss the indications of this procedure.
Case Description:A 53-year-old woman presenting a spontaneous complete (House and Brackmann grade 6) facial palsy on her left side showed no improvement after 13 months of conservative treatment. Electromyography (EMG) showed complete denervation of the mimic muscles. A direct partial hypoglossal to facial nerve anastomosis was performed, including dissection of the facial nerve at the fallopian canal. One year after the procedure, the patient showed House and Brackmann grade 3 function in her affected face.
Conclusions:Partial hypoglossal–facial anastomosis with intratemporal drilling of the facial nerve is a viable technique in the rare cases in which severe Bell's palsy does not recover spontaneously. Only carefully selected patients can really benefit from this technique.
Keywords: Bell's palsy, facial palsy, hypoglossal–facial anastomosis, nerve transfer
Facial palsy is a devastating psychological and social condition. One of the most common procedures for diminishing the consequences of facial palsy is hypoglossal–facial anastomosis.[
Nevertheless, the vast majority of the more than 2500 cases of hypoglossal–facial anastomosis reported in the literature are either traumatic, due to direct cranial trauma, petrous bone fractures, or iatrogenic after resection of a cerebello-pontine angle tumor. Hypoglossal to facial nerve transfer for treating Bell's palsy, a very common cause of acute spontaneous facial nerve palsy, has been exceptionally cited in the literature [
Historical vignette. These Bell's facial palsy cases, unpublished until now, were the only two operated by one of the authors (EF) during a period of more than 30 years (1980–2011), and were included to illustrate the rarity of this severe sequel in spontaneous facial palsy. An unrecovered facial Bell's palsy on the left side (House and Brackmann grade 6) affected a 55-year-old woman and a 54-year-old man. They were operated on employing the classical hypoglossal-facial anastomosis, 12 (July 1984) and 14 (August 1991) months after the beginning of the palsy, respectively. This technique involved complete section of the hypoglossal nerve to reinnervate the mimic muscles. In both patients, the acute event of Bell's palsy was treated shortly by low dosages of corticosteroids. At the time of operation, electromyography confirmed the clinically evident total facial paralysis. One year after operation, a good static and dynamic symmetry was obtained in both patients; the closure of the eye was complete (a–c). The final result was a House and Brackmann grade 3 in both patients
Even though the exact cause of Bell's (idiopathic) facial palsy is not known, many theories exist, including viral (herpes simplex, herpes zoster), immunological, or ischemic.[
In Bell's palsy, another problem for nerve transfer is the surgical timing. On one hand, being a benign condition for which very few patients have severe sequelae, a long waiting period for spontaneous recovery should be preferred before doing any restorative surgery. On the other hand, a long waiting period for performing the nerve transfer favors negative results because of mimic muscle atrophy.
The objective of the present work is: (1) to present a case of Bell's palsy in which the motor deficit remained unrecovered after a congruous waiting period, before an attempt to treat it with a partial hypoglossal nerve transfer was successfully done (to our knowledge, it is the first time this technique has been reported in the literature for Bell's palsy) and (2) to discuss the indications and timing of such reinnervating procedure considering also the other technical options available to treat facial paralysis.
A 53-year-old woman presented to us after she had a spontaneous left facial palsy on waking up from sleep. Some days before, she had a complaint of pain in her left ear, but an otological exam was completely normal, including the absence of vesicles at the external ear examination,. She received steroids and started physiotherapy that continued for the following months without positive results. Ten months later, she was seen for the first time at the Nerve Surgery Center of the University of Buenos Aires School of Medicine with a complete left facial palsy requiring special care of the cornea to avoid ulcers, which were not present. The physical exam showed at that moment a complete palsy of the upper, lower, and middle left hemi-face [House and Brackmann (HB) grade 6]. She was incompetent to close the left eye, the facial symmetry was lost, and she could not make any kind of active movement on the left side of the mouth. Signs of mimic muscle atrophy were evident on the affected side of the face [
Classical and partial direct hypoglossal-facial anastomosis technique. The classical technique was employed in the historical cases presented in
The surgical technique is described elsewhere.[
Some active contraction of the facial muscles was seen 5 months after the procedure. At 12 months, the patient showed a complete facial symmetry at rest, active movements under voluntary control with mild eye–tongue synkinesia, adequate eye closure – which prompted her to abandon the artificial tears – and no signs of tongue atrophy or asymmetry (grade 1 tongue atrophy in the scale describing the grade of tongue dysfunction after hypoglossal-facial neurorrhaphy).[
Spontaneous evolution of Bell's palsy
According to The Copenhagen Facial Nerve Study, spontaneous facial nerve palsy (Bell's palsy) is a benign condition which implies an acute unilateral partial or total facial motor deficit of undetermined etiology, having an incidence of 32/100,000, without seasonal, side, or gender variations, and is more frequent between 15 and 60 years,.[
In a Switzerland study of 196 patients suffering from idiopathic facial palsy (Bell's and herpes zoster), the results were similar and the prognosis was significantly different between individuals having at the onset a total facial deficit compared to those having a partial one; all but one patient had a normal functional recovery in the latter group, compared to one third remaining with deficits, including synkinesias, in the former).[
On the other hand, Finester concluded in an extensive review that 15–20% of cases experience permanent damage to the nerve, 5% being severe.[
The absence of complete (HB grade 6) long-term facial palsy in Bell's patients, as described by the Denmark group, has been contested. Terzis et al. describe many patients with severe idiopathic facial sequelae on whom they performed a series of different procedures.[
Classical treatment of Bell's palsy facial sequelae
Facial palsy can be treated by static and dynamic techniques. The natural evolution of Bell's palsy, as mentioned, is very good, with a minor proportion of the patients with sequelae, this deficit being mild in the vast majority. Therefore, many patients benefit from partial procedures, mainly static, to minimize this problem. This includes eyelid weight placement, lateral tarsorrhaphy, upper eyelid blepharoplasty, and static facial suspension, among others.
Many surgeons usually prefer dynamic procedures, even in patients with partial deficit. Examples of these partial techniques have been frequently reported in the literature. Terzis et al. presented five cases of Bell's palsy, in which blinking was ameliorated by a nerve transfer or a free vascularized functional muscle transfer.[
Bell's palsy and hypoglossal–facial anastomosis: Pros and cons
Nowadays, hypoglossal to facial nerve transfer still remains as the preferred means to surgically minimize the effects of facial palsy.[
Some reasons could explain the lack of popularity of hypoglossal transfer to facial nerve in Bell's palsy. Probably the most important reason is the fact that most of the cases recover completely, and if not, sequels can be generally classified as grades 2, 3, or 4 in HB scale. Therefore, it sounds not logical to perform a surgery in a patient with a certain grade, to end up in the same grade months later. In this scenario, it is preferable to adopt some of the classical alternate techniques described before.
However, hypoglossal nerve transfer to the facial nerve should be considered, obviously, only in patients with HB 5 or 6, which as stated before are infrequent. The apparently lengthy nerve affection in Bell's palsy raises the question regarding the viability of the receptor nerve and the eventual result of such a nerve transfer. The results shown in this case and also in the scarce earlier reported ones with the classical technique demonstrate that those very rare cases of unrecovered Bell's palsy, of severe grade, can be successfully treated by hypoglossal–facial anastomosis. Furthermore, perhaps the indications of such nerve transfer could be extended also to those cases showing severe syncinesias, where botulin toxin injections do not work. If a hypoglossal nerve transfer is considered, the authors believe that at present the procedure of choice is the direct partial hypoglossal to facial nerve transfer, used in the patient presented in this case report, which avoids severe tongue sequels.
Finally, the surgical timing of such a nerve transfer is another issue to be considered. Mantsopoulos et al., studying retrospectively 44 patients from Greece for a long term, also concluded, as many others, that if no recovery is seen after 1 year of palsy, no further improvement is to be expected later on.[
Partial hypoglossal–facial anastomosis with intratemporal drilling of the facial nerve is a viable technique in the rare cases in which severe Bell's palsy does not recover spontaneously. Only carefully selected patients can really benefit from this technique.
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