J Neurosurg 77:724-731, 1992

Hypoglossal-facial nerve anastomosis for facial nerve palsy following surgery for cerebellopontine angle tumors Luts F. PITT'C, M.D., AND CHARLES H. TATOR, M.D., PH.D., F.R.C.S.(C) Division of Neurosurgeo,, Toronto Western Division, Toronto Hospital, University of Toronto, Toronto, Ontario, Canada u- Hypoglossal-facial nerve anastomosis is one of the procedures frequently performed to restore function after facial palsy secondary to surgery for removal of cerebellopontine angle tumors. The published results of hypoglossal-facial nerve anastomosis have been variable, and there are still questions about the indications, timing, and surgical techniques for this procedure. The goals of the present retrospective analysis of 22 cases of hypoglossal-facial nerve anastomosis were to assess the extent of the functional recovery and to analyze the factors affecting this recovery. The 22 cases of complete facial palsy were gleaned from a series of 245 cases of cerebellopontine angle tumors treated surgically by one of the authors. Twenty patients had an acoustic neuroma (average size 3.5 cm), one patient had a petrous meningioma, and one patient had a facial neuroma. The average age of the patients was 47.3 years (range 19 to 69 years). The average interval from tumor surgery to hypoglossal-facial nerve anastomosis was 6.4 months (range 12 days to 17 months), and the average follow-up period after the procedure was 65 months. The results were graded as good, fair, poor, or failure according to a new method of classifying facial nerve function after hypoglossal-facial nerve anastomosis. The results were good in 14 cases (63.6%), fair in three (13.6%), and poor in four (18.2%); one (4.5%) was a failure. Good and fair results occurred with higher frequency in younger patients who were operated on within shorter intervals, although these relationships were not statistically significant. There were no surgical complications. Good or fair results were achieved in 17 (77.3%) of the 22 cases, and thus hypoglossal-facial nerve anastomosis is considered an effective procedure for most patients with facial palsy after surgery for cerebellopontine angle tumors. KEY WORDS

9 nerve anastomosis

YPOGLOSSAL-FACIAL nerve anastomosis is a technique frequently performed to treat facial nerve palsy associated with the removal of cerebellopontine angle tumors. "-'4-9"~4-LTtg21 23,29,30,32.34, 36,39A4 This procedure has been advocated for patients with loss of the proximal stump of the facial nerve who consequently are not candidates for primary end-toend anastomosis, 4~'~62444 an intracranial-extracranial nerve graft, ~ or an intracranial-intratemporal nerve graft. 33The published results of hypoglossal-facial nerve anastomoses have been variable, ranging from poor to good,~'7-~' E4-16.21,23.27,4(Iand there are still many questions about the indications, timing, and operative techniques for this procedure. The goals of the present retrospective analysis of 22 cases of hypoglossal-facial nerve anastomosis are to assess the extent of the functional recovery, including an analysis of the patients' perception of the results, and to analyze the factors affecting recovery. The present results are compared with those of previous

H

724

9 hypoglossal nerve

facial nerve

facial palsy

series to assess the relative effectiveness of the procedure in terms of the functional and psychological benefit. This report also describes the indications, timing, and surgical technique for the procedure. Clinical Material and Methods Patient Population A total of 245 cases of cerebellopontine angle tumors operated on by the senior author (C.H.T.) were reviewed. Many of the demographic and surgical features of these cases have been reported previously. 37'3g Twenty-five of these patients underwent hypoglossalfacial nerve anastomosis to repair the facial paralysis associated with tumor removal. Three of the 25 patients were excluded from the present study. One of these patients harbored a metastatic adenocarcinoma in an acoustic neuroma and died 4 months following the hypogiossal-facial nerve anastomosis, with the cause of J. Neurosurg. / Volume 77/November, 1992

Hypoglossal-facial nerve anastomosis TABLE

1

Description and outcome of 22 patients treated with hypoglossal-facial anastomosis Case No.

Sex, Age (yrs)

Diagnosis

Interval* Out- Follow-Up (mos) come~ Period (mos)

F, 43 acoumcneuroma 12 fair 61 3 good 42 M, 38 acousticneuroma good 24 M, 45 acousticneuroma 14 4 M, 40 acousticneuroma 0.5 good 169 0.5 good 85 5 M, 22 acousticneuroma 4 poor 30 6 F, 50 acousticneuroma 7 F, 58 acousticneuroma 17 good It4 l good 30 8 M, 19 acousticneuroma 9 F, 36 acousticneuroma 3 good 168 0.5 poor 22 t0 F, 67 aeousttcneuroma poor 7 I1 M, 65 acousticneuroma 15 5 good 33 12 F, 32 acousticneuroma 13 M, 51 acousticneuroma 5 good 85 14 F, 65 acousticneuroma 13 fair 132 0.5 good 33 15 M, 39 acousticneuroma 8 good 109 16 F, 41 acousticneuroma 3 fair 55 17 M, 54 acousticneuroma 4 good 18 18 M, 69 acousticneuroma 0.5 good 79 19 M, 59 acousticneuroma 6 failure 36 20 M, 56 acousucneuroma 11 poor 43 21 F, 32 meningioma 15 good 61 22 M, 60 facialneuroma * Interval from tumor removalto anastomosis. t Outcome accordingto classificationof facial nerve function described in Table 2. 1

2 3

death being metastatic disease unrelated to the surgical procedure. The other two patients underwent hypoglossal-facial nerve anastomosis only 2 months before the time of this review, which was considered an insufficient follow-up period for evaluation of the results. The 22 patients in this study included 13 men and nine women, and the anastomosis procedures were performed between 1973 and 1989. The average patient age was 47.3 years, with a range of 19 to 69 years (Table 1). The cerebellopontine angle tumor was identified as an acoustic neuroma in 20 cases, a facial neuroma in one, and a meningioma of the petrous apex in one (Table 1). For tumor removal, the suboccipital approach was used in nine cases, the translabyrinthine approach in four, a combined translabyrinthine-transtentorial-subtemporal approach in eight, and a combined suboccipital-translabyrinthine approach in one. The interval between tumor surgery and anastomosis ranged from 12 days to 17 months, with a mean of 6.4 months (Table 1). In 14 (64%) of the 22 cases, the anastomosis was performed within 6 months after tumor surgery. The principal criterion determining the timing of surgery was the surgeon's opinion of the status of the facial nerve at the time of extirpation of the tumor. In the 16 patients in whom the nerve was deemed to have been irreparably damaged during removal of the tumor, the anastomosis was performed within 6 months in 13 patients and after 8, 14, and 15 months in the other three. In the remaining six patients,

J. Neurosurg. / Volume 77/November, 1992

the nerve was considered to be anatomically intact and, therefore, the anastomosis was performed 12 to 17 months after tumor surgery because of the expectation that facial nerve recovery would occur. The size of the tumors averaged 3.3 cm in the 22 cases. The 20 acoustic neuromas averaged 3.5 cm in size; 15 of these tumors were 3.0 cm or larger. One patient (Case 21) had a 0.6-cm meningioma at the porus acusticus and another (Case 22) had a 1.0-cm facial neuroma. The facial nerve was lost in the meningioma case because it was markedly thinned and covered with dense, thickened arachnoid. In the facial neuroma case, the nerve had to be excised in order to remove the tumor. This case was treated early in the series; currently, this patient would be managed with an intracranial-intratemporal nerve graft rather than with hypoglossal-facial nerve anastomosis. Prior to t u m o r surgery, 13 patients had normal facial nerve function and nine displayed some degree of facial palsy.

Surgical Technique of Hypoglossal-Facial Nerve Anastomosis With the dissecting microscope, the digastric branch of the facial nerve could usually be identified and followed to the main trunk of the nerve at the stylomastoid foramen. If the facial nerve could not be visualized distal to the stylomastoid foramen, the nerve was identified proximal to the foramen by the technique described by Hitselberger, ~9in which the nerve is localized in the mastoid bone canal by a mastoidectomy approach. The entire diameter of the hypoglossal nerve was used in all cases (Fig. 1). The descendens hypoglossi nerve branch was anastomosed to the distal end of the hypoglossal nerve in 14 cases; in the remaining eight patients, the descendens hypoglossi nerve branch either did not have sufficient length or caliber for the anastomosis or could not be identified.

Classification o f Facial Nerve Function Several classifications have been employed to rate the degree of nerve recovery. 2~ In an attempt to define objective and subjective criteria for comparative analysis, we have developed our own classification (Table 2), modifying those developed by Pensak, et al., 32 Mingrino and Zuccarello, 29 Falbe-Hansen and Hermann, 15 Alexander and Davis, l and others. The outcome was recorded as good, fair, poor, and failure based on the following information: 1) facial muscle contraction of the frontalis, periorbicularis oculi, and periorbicularis oris muscles and the presence of the nasolabial fold; 2) swallowing, speech, and food manipulation in the mouth; 3) abnormal movements, including synkinesis, contractures, or hemifacial spasm; and 4) psychological and emotional aspects, evaluated by asking the patients to assess the degree of psychological benefit offered by the anastomosis on the basis of self-esteem and any limitations in social activity. In addition, the value of using the deseendens hypoglossi nerve branch to restore function of the tongue was assessed. 725

L. F. Pitty and C. H. Tator

FIG. 1. Diagrams showing the method of hypoglossal-faciai nerve anastomosis. Left: The hypoglossal and facial nerves are exposed. Center." The facial nerve is divided at the stylomastoid foramen, the hypoglossal nerve is divided near its entrance into the tongue, and the descendens hypoglossi nerve branch is divided as far distally as possible. Right."The hypoglossal nerve is anastomosed to the distal segment of the facial nerve, and the descendens hypoglossi nerve branch is anastomosed to the distal segment of the hypoglossal nerve. Fifteen of the 22 patients were recently interviewed and photographed in order to assess facial reinnervation prospectively. In the remaining seven patients, there was reliable recorded information from previous visits that allowed retrospective scoring. The follow-up period after hypoglossal-facial nerve anastomosis ranged from 7 to 169 months, with a mean follow-up period of 65 months (Table 1). Tarsorrhaphy was also performed in 17 cases. Operative Results There were no surgical complications related to the hypoglossal-facial nerve anastomosis. In 13 (59%) of the 22 cases, the first evidence of reinnervation was

TABLE 2

Classification offacial nerve function after hypoglossal-facial nerve anaslomosis Outcome Description good goodfacial symmetryat rest complete voluntary eye closure mild to moderate mouth movement minimal or absent synkinesisor mass movement minimal or absent dysfunctionin eating, swallowingor speech, attributable to hypoglossalnerve section feelingof major benefit from the procedure fair fair facialsymmetryat rest unable to obtain satisfactoryclosureof the eye marked synkinesisor mass movement moderate dysfunctionin eating, swallowing,or speech, attributableto hypoglossalnerve section feelingof limited benefit from the procedure poor grossfacial asymmetryat rest total inabilityto closethe eye no mouth movement marked synkinesisor mass movement feelingof no benefit from the procedure failure no evidenceof reinnervation 726

noted between 3 and 6 months after surgery. In the remaining patients with reinnervation, there was evidence of improvement by 8 months. Table 1 shows the final outcome in the 22 cases: 14 (63.6%) had good results, three (13.6%) fair, and four (18.2%) poor; in one patient (4.5%) the operation was a failure. As noted above, these outcomes were measured after a mean follow-up period of 65 months, with a range of 7 to 169 months. Figures 2 and 3 show examples of good results. There was a trend for the poor results to occur in the older patients. In patients aged up to 45 years, the results were good in nine, fair in one, and poor in one; there were no failures. In those aged 46 years or older, however, the results were good in five, fair in two, and poor in three; there was one failure. There was a tendency for better results with shorter time intervals between tumor removal and anastomosis. In patients with intervals of 6 months or less, the results were good in 10, fair in one, poor in two, and failure in one, whereas with intervals of 7 months or greater, the results were good in four, fair in two, poor in two, and no failures. It is noteworthy that there were three patients with good results after intervals of 14, 15, and 17 months. The nasolabial fold returned in 16 patients and was absent in three; this feature was not documented for the other three patients. Forehead movement, although poor, returned in 36% of the cases. The general neurological status of the patient at the time the hypoglossal-facial nerve anastomosis was performed had an effect on the final outcome. Patients with significant morbidity, such as speech dysfunction or multiple cranial nerve deficits secondary to the initial effects of the tumor or to complications from surgical removal, tended to have fair or poor results. For example, in the eight patients with nerve deficits due to damage to the trigeminal nerve, all had significant problems related to eye closure and difficulty with manipulation of food in the mouth. J. Neurosurg. / Volume 77/November, 1992

Hypoglossal-facial nerve anastomosis

FIG. 2. Case 9. This 36-year-old woman underwent hypoglossal-facial nerve anastomosis 3 months after tumor surgery and achieved a good result. A and B: Photographs showing the face in repose (A) and with a minimal smile (B). Unfortunately, a generous lateral tarsorrhaphy was required to provide adequate eye protection. C and D: Closure of the eye could not be accomplished without voluntary forced contraction of the tongue. Note the right hemiatrophy of the tongue (D).

FIG. 3. Case 8. This man was 19 years old when his acoustic neuroma was removed. He underwent hypoglossal-facial nerve anastomosis 1 month after tumor surgery and achieved a good result. The photographs were taken at age 37 years. In repose, there was reasonable facial symmetry (A). Eye closure was almost complete in repose (B). With vigorous tongue movement, there was excellent contraction of the orbicularis oculi muscles (C). Hemiatrophy of the tongue was less marked in this patient (D) than in Case 9 (Fig. 2).

Discussion Preservation of facial nerve function represents a major challenge to the surgeon involved with the removal of acoustic neuromas and other cerebellopontine angle tumors? ~ Unfortunately, intraoperative damage of the facial nerve still occurs, especially with large tumors. As was recognized many years ago, the size of the tumor is a critical factor in the anatomical preservation of the nerve. 3~ Various techniques have been used to restore facial nerve function in these patients.

Literature Review The first surgical attempt to repair the facial nerve to treat facial paralysis was performed in 1879 by Drob-

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nick, who anastomosed the spinal accessory nerve to the facial nerve; however, the first published report of this technique is attributed to Sir Charles Ballance in 1895. ~3 The first hypoglossal-facial nerve anastomosis was performed by Korte in Berlin in 1901; since then, there have been many reports of this surgical approach being used to treat facial paralysis secondary to surgery for cerebellopontine angle tumors and other lesions. 1,2,6,7,9,10,14-16,18,19,21,23~25.28-30,32,34,36,39,40,44 n y poglossal-facial nerve anastomosis has also been used in the management of traumatic lesions of the facial nerve 5'"'3-''44and in treating surgical damage of the facial nerve following operations for hemifacial spasm ~ or for tumors at the base of the skull, 5'32 in the ear, 5 or 727

L. F. Pitty and C. H. Tator involving the parotid gland or mandible ~ or the temporal bone. 44 Bell's palsyT M and post-herpetic palsf 444 have also been treated with this procedure. Although primary anastomosis or nerve grafting is preferable for surgical reconstruction of the facial nerve,12'24 functional recovery using a donor nerve technique, such as hypoglossal-facial nerve anastomosis, tends to be similar. For example, Stennert 36 reported similar results for hypoglossal-facial nerve anastomosis and nerve grafts within the mastoid or tympanum. However, such donor nerve techniques have the major disadvantage that a normal nerve has to be sacrificed, leaving the patient with some functional loss. The indications for donor nerve techniques are the complete and irreversible paralysis of the facial muscles and lack of availability of the proximal stump of the injured nerve. Loss of the proximal stump excludes both primary end-to-end suture of the facial nerve and the interposition of a graft. Prerequisites for donor nerve techniques include intact facial mimetic muscles and the availability of a suitable donor nerve.2-~6In addition to the hypoglossal nerve, other donor nerves include the spinal accessory nerve, 28'29"44the phrenic nervefl and the glossopharyngeal nerve. ~3 The undesirable side effects of using either the glossopharyngeal or the phrenic nerve have almost eliminated the utilization of these nerves for anastomosis to the facial nerve? The spinal accessory nerve as a donor, especially when the branch to the trapezius muscle is preserved, has been highly recommended by Migliavacca, 2s who reported good results in 76% of his 25 cases. Conversely, Alexander and coworkers, ~'27 Zini, et al., 44 and Mingrino and Zuccarello 29 reported better results with hypoglossalfacial nerve anastomosis. The latter authors suggested that this is because the cortical representation of the tongue and face are closer than those of the shoulder and face, as originally suggested by Ballance. The larger size of the cortical representation of the tongue may also account for the better results with hypoglossalfacial nerve anastomosis. The cross-facial nerve graft anastomosis utilizes the contralateral facial nerve with interposition grafts between the two facial nerves. 9'-~5'39Lee and Terzis 24 preferred this procedure over the donor nerve techniques, but provided no further details of their cases. Conley and Baker9 reported a poor result with this approach in 10 cases. Tran Ba Huy, et at., 39 pointed out that the cross-facial nerve anastomosis is more complicated technically and requires a longer operation. Furthermore, it has the disadvantage of a decreased axonal input for reinnervation compared with procedures such as hypoglossal-facial nerve anastomosis. Synkinesis and mass movements are seen as frequently after cross-facial nerve anastomosis as other anastomoses. 9 The experience of Tran Ba Huy, et al., with the cross-facial nerve anastomosis was rather disappointing, with satisfactory results in only 25% of their 20 cases, compared to better results in 16 cases of hypoglossal-facial nerve anastomosis. Zini, et at., 44 have abandoned the cross-facial 728

nerve anastomosis due to the technical difficulties and relatively poor results. Thus, hypoglossal-facial nerve anastomosis remains the preferred surgical approach if intracranial primary anastomosis or grafting is not possible.8.9,sz44 Despite the general consensus that hypoglossal-facial nerve anastomosis produces considerable functional recovery, many patients are still left with disabilities such as an incompletely protected eye, unsightly mass facial movements, and other cosmetic deficits. Therefore, some patients will require additional procedures, including cosmetic procedures 42 and tarsorrhaphy, to diminish the physical and psychological disabilities of facial palsy. Table 3 summarizes the reported series of hypoglossal-facial nerve anastomoses performed to treat various conditions from 1954 to the present. A total of 562 cases have been reported, assuming that the 137 cases reported by Conley and Baker9 in 1979 were included in the 200 cases reported in 1985 by Baker.: The patients' ages ranged from 6 months to 75 years, although patients younger than 15 years were found in tWO r e p o r t s . 9"44 The time between facial paralysis due to the nerve lesion and anastomosis ranged from immediate surgery to 55 years; most procedures were performed within the first 1 to 2 years. The follow-up period ranged from 4 months to 16 years. Good results were achieved in approximately 65% of the patients, fair results in about 22%, and poor results (including total failures) in about 13%. Unfortunately, significant variations in the criteria used for the classification of results limit the usefulness of these comparisons. We agree with Iansek, et al., 2j that the lack of a uniform classification of recovery of facial nerve function atter hypoglossal-facial nerve anastomosis accounts for much of the difficulty in comparing the results of various series. In our 22 cases, good results were achieved in 14 (63.6%), which is similar to the average in the literature. S t u d y Results

The most striking achievement in our series was the restoration of facial muscle tone leading to the reappearance of the nasolabial fold and recovery of complete symmetry of the face at rest in 14 patients. All 14 patients achieved complete closure of the eye, which sometimes required active tongue movement. These patients considered that the benefit was substantial and that their quality of social life was enhanced. They had minimal synkinesis or mass movement and moderate perioral movement, giving a satisfactory cosmetic appearance. There was minimal or no functional loss in terms of speech or food manipulation in the oral cavity after section of the hypoglossal nerve. Thus, our study supports the view of others that there is minimal or no dysfunction due to sacrifice of the hypoglossal nerve. All patients continued to use topical medication to lubricate the eye, and most also required tarsorrhaphy, indicating that hypoglossal-facial nerve anastomosis does not eliminate the problem of eye protection. NorJ. Neurosurg. / Volume 77/November, 1992

Hypoglossal-facial nerve anastomosis TABLE 3 S u m m a r y of reports of hypoglossal-facial nerve anastomoses*

Authors & Year

No. of Cases

Patient Age (yrs)

Sex (M/F)

Time to Anastomosist

Outcome

Alexander & Davis, 1954 Kessler, eta[., 1959 Falbe-Hansen & Hermann, 1967 Evans, 1974 Conley & Baker, 1979 Hitselberger, 1979 Stennert, 1979 Mingrino & Zuccarello, 1981 Ylikoski, et al., 1981 Chang & Shen, 1984 Gavron & Clemis, 1984 Baker, 1985 Cannoni, et al., 1985 Kanzaki, et al., 1985 Zini, el al., 1985 Iansek, et al., 1986 Pensak, et al., 1986 Hammerschlag, et aL, 1987 Moffat, et al., 1989 Pitty & Tator, 1992

33 14 23 13 137:~ 22 20 5 5 12 30 200z~ 31 25 12 13 61 16 5 22

-20-55 25-64 46-70 0.5-75 22-61 15-61 -28-47 20-55 20-68 ---4-60 ----19-69

-6/8 14/9 3/10 ----1/4 5/7 ------38/23 --13/9

0-42 mos 3 wks-21 mos 17 days-6 yrs -2-55 yrs 4 mos-4.5 yrs 0-13 yrs --1 mo-2 yrs 0-2 yrs -0-42 mos 3 mos-1 yr 6 mos-1 yr --3-21 mos -0.5-17 mos

26 good, 7 fair, 0 poor 11 good, 0 fair, 3 poor 12 good, 8 fair, 3 poor 4 good, 8 fair, 1 poor 89 good, 25 fair, 23 poor 22 satisf 20 satisf 3 good, 2 fair, 0 poor 4 good, 1 poor 10 good, 2 fair, 0 poor 22 good, 4 fair, 2 poor, 2 failures 77% good 30 good, 1 fair, 0 poor 25 satisf 11 good, 1 fair, 0 poor 0 good, 6 fair, 7 poor 26 good, 29 fair, 6 poor -0 good, 3 fair, 2 poor 14 good, 3 fair, 4 poor, 1 failure

* Abbreviations: satisf = satisfactory result; - - = data not available. t Time belween paralysis and hypoglossal-faeialnerve anastomosis. ~:It is assumed that the 137 cases reported by Conley and Baker9 in 1979 were included in the 200 cases reported by Baker: in 1985.

mally, eye protection is provided by lacrimation and automatic blinking of the eye, both o f which are abolished by damage of the facial nerve. Indeed, eye problems were the m a i n concern voiced by the patients during their follow-up interviews. Recovery of the frontalis branch of the facial nerve was very p o o r in our experience, which is similar to the findings in most other series. 7'~5'16'4~ We concur with Chang and Shen 6 that the relatively small n u m b e r of fibers passing to the frontalis branch from the trunk o f the postgeniculate portion o f the facial nerve accounts for the p o o r reinnervation o f the frontalis muscle. We are unable to identify specific clinical or technical differences to account for the five cases with poor results or failure. However, the severe nerve atrophy observed at the t i m e of anastomosis in two of these patients (Cases 6 and 20) m a y account for the poor outcomes. H e m i a t r o p h y o f the tongue on the side ipsilateral to the anastomosis was present in all 22 patients, although the severity varied considerably (Figs. 2 and 3). In the 17 patients in w h o m the degree of atrophy was assessed specifically, there was no definite evidence that the atrophy was less severe in the 12 patients who underwent descendens hypoglossi branch-hypoglossal stump anastomosis than in the five in w h o m this anastomosis was not performed. In our opinion, the usefulness of this anastomosis has not been established. ~'~6"~8'44 The reason for the trend toward better results in younger patients is not known. A better o u t c o m e in younger patients was also found by Falbe-Hansen and H e r m a n n t5 and Clemis and Gavron. 7"~6We did not find J. Neurosurg. / V o l u m e 7 7 / N o v e m b e r ,

1992

that the o u t c o m e was better in females as had been found by Chang and Shen. 6 The effect o f dysfunction o f other cranial nerves on the o u t c o m e of hypoglossal-facial nerve anastomosis is an i m p o r t a n t issue. T w o o f our three patients with a fair result (Cases 1 and 17) had multiple cranial nerve deficits involving the fifth, ninth, and 10th nerves, plus evidence o f brain-stem dysfunction. Although s y m m e try of the face was achieved by the anastomosis, there was significant dysfunction in eating, swallowing, talking, and coordination in one of these patients, and mild functional difficulties involving several cranial nerves in the other. It is i m p o r t a n t to note that both patients judged the procedure as beneficial. However, as indicated by Clemis and Gavron, 7 the additional hypoglossat palsy may add further difficulties to pre-existing swallowing or speech dysfunction secondary to t u m o r removal. Perhaps an alternative surgical approach such as spinal accessory-facial nerve anastomosis might be considered in these particular cases. In patients with damage o f the first division o f the trigeminal nerve, there is a predisposition to corneal ulceration. This occurred in three o f our patients. In this circumstance, p e r m a n e n t tarsorrhaphy is usually required. Patients were encouraged to train their tongues for better facial performance. Training in front o f a m i r r o r to achieve fine, discrete m o v e m e n t was probably useful. We have begun to use electromyographic ( E M G ) biofeedback techniques after hypoglossal-facial nerve anastomosis. Hammerschlag, et al., ~s evaluated E M G biofeedback and found evidence that it leads to greater 729

L. F. Pitty and C. H. Tatar function. Balliet, et al.) reported improvement in selective motor control of facial muscles with behavioral training methods.

Surgical Technique Identification of the branch of the facial nerve supplying the posterior belly of the digastric muscle was helpful in identifying the main trunk of the facial nerve. Mastoidectomy, as recommended by Hitselberger, j9 was necessary in a minority of cases. In two recent cases not included in the present series, mastoidectomy was very helpful in visualizing an atrophic facial nerve operated on after a very long delay. In these patients the nerve could only be identified when the mastoidectomy was performed. It should be noted that mastoidectomy in patients who have had previous posterior fossa or translabyrinthine surgery may produce a cerebrospinal fluid fistula. Exploration of the intraparotid portion of the nerve was also difficult, especially after long delays between t u m o r surgery and anastomosis.

Timing of Hypoglossal-Facial Nerve Anastomosis In the present series, the longest delay between tumor removal and anastomosis was 17 months (Table 1). Several authors have performed the anastomosis after even longer delays (Table 3), but most agree that very late cases have less chance of recovery due to atrophy of the facial nerve and muscles. In our series, there was a trend toward better results when the operation was performed earlier. It would appear that there is no definite delay beyond which hypoglossal-facial nerve anastomosis becomes ineffective. McKenzie and Alexander 27 reported a patient in whom the anastomosis was carried out 289years after section of the facial nerve with a good result. Hitselberger ~9 mentioned one case with a good result after a delay of 489 years. One of our patients with a poor result was a young woman with severe nerve atrophy only 11 months after the removal o f a meningioma in the posterior fossa. Ylikoski, et al., 43 reported a similar case of a 28-yearold woman who underwent removal of a cerebellopontine angle meningioma and had hypoglossal-facial nerve anastomosis 7 months later. The histopathological finding was a major fibrotic change in the nerve.

References 1. Alexander E Jr, Davis CH Jr: Correction of peripheral paralysis of the facial nerve by hypoglossal-facial anastomosis. South Mefl d 47:299-303, 1954 2. Baker DC: Hypoglossal-faeial nerve anastomosis. Indications and limitations, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 526-528 3. Balliet R, Shinn JB, Bach-Y-Rim P: Facial paralysis rehabilitation: retraining selective muscle control. Int Rehabil Med 4:67-74, 1982 4. Brackmann DE, Hitselberger WE, Robinson JV: Facial nerve repair in cerebellopontine angle surgery. Ann Otol Rhinol Laryngol 87 (Suppl 6 Pt 1):772-777, 1978 5. Cannoni M, Pech A, Thomassin JM, et al: A consistently reliable technique for facial reanimation: hypoglossalfacial nerve anastomosis, in Portmann M (ed): Facial 730

Nerve. New York: Masson, 1985, pp 529-534 6. Chang CGS, Shen AL: Hypoglossofacial anastomosis for facial palsy after resection of acoustic neuroma. Surg Neural 21:282-286, 1984 7. Clemis JD, Gavron JP: Hypoglossal-facial nerve anastomosis: report on 36 cases with posterior fossa facial paralysis, in Graham MD, House WF (eds): Disorders af the Facial Nerve. Anatomy, Diagnosis, and Management. New York: Raven Press, 1982, pp 499-504 8. Coleman CC: Results of facio-hypoglossal anastomosis in the treatment of facial paralysis. Ann Surg 111:958-970, 1940 9. Conley J, Baker DC: Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed face. Plast Recnnstr Surg 63:63-72, 1979 10. Crumley RL: Innovations in hypoglossal-facial anastomosis, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 516-518 I 1. Dott NM: Facial paralysis - - restitution by extra-petrous nerve graft. Prne R Sac Med 51:900-902, 1958 12. Drake CG: Acoustic neuroma. Repair of facial nerve with autogenous graft. J Neurosurg 17:836-842, 1960 13. Duel AB: Advanced methods in the surgical treatment of facial paralysis. Ann Otol Rhinni Laryngol 43:76-88, 1934 14. Evans DM: Hypoglosso-facial anastomosis in the treatment of facial palsy. Br J Plast Snrg 27:251-257, 1974 15. Falbe-Hansen J Jr, Hermann S: Hypoglosso-facial anastomosis. A follow-up study of 25 patients. Acta Neural Stand 43:472-478, 1967 16. Gavron JP, Clemis JD: Hypoglossal-facial nerve anastomosis: a review of forty cases caused by facial nerve injuries in the posterior fossa. Laryngoscope 94: 1447-1450, 1984 17. Givr6 A, Olivecrona H: Surgical experiences with acoustic tumors. J Neurosurg 6:396-407, 1949 18. Hammerschlag PE, Brudny J, Cusumano R, et al: Hypoglossal-facial nerve anastomosis and electromyographic feedback rehabilitation. Laryngoscope 97:705-709, 1987 19. Hitselberger WE: Hypoglossal-facial anastomosis, in House WF, Luetje CM (eds): Acoustic Tumors, Vol II: Management. Baltimore: University Park Press, 1979, pp 97-103 20. House JW: Facial nerve grading systems. Laryngoscope 93:1056-1069, 1983 21. lansek R, Harrison MJG, Andrew J: Hypoglossal-facial nerve anastomosis: a clinical and electrophysiological follow-up. J Neural NenrosurgPsychiatry49:588-590, 1986 22. Kanzaki J, O-Uchi T, Shiobara R, et al: Management of facial nerve and facial paralysis in acoustic neuroma surgery, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 439-441 23. Kessler LA, Moldaver J, Pool JL: Hypoglossal-facial anastomosis for treatment of facial paralysis. Neurology 9: 118-125, 1959 24. Lee KK, Terzis JK: Management of acute extratemporal facial nerve palsy. Cliu Plast Surg 11:203-210, 1984 25. Lodge WO, Gueukdjian SA: De la paralysie faciale; modifications des nitrations d'anastomose facio-hypoglosse et de plastie faciale. Presse Med 63:1025-1026, 1955 26. Lye RH, Dutton J, Ramsden RT, et al: Facial nerve preservation during surgery for removal of acoustic nerve tumors. J Neurosurg57:739-746, 1982 27. McKenzie KG, Alexander E Jr: Restoration of facial function by nerve anastomosis. Ann Snrg 132:411-415, 1950 28. Migliavacca F: Facial nerve anastomosis for facial paralysis following acoustic neurinoma surgery. Acta Neuro-

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Hypoglossal-facial nerve anastomosis chir 17:274-279, 1967 29. Mingrino S, Zuccarello M: Anastomosis of the facial nerve with accessory or hypoglossal nerves, in Samii M, Jannetta PJ (eds): The Cranial Nerves. Berlin: SpringerVerlag, 1981, pp 512-514 30. Moffat DA, Croxson GR, Baguley DM, et al: Facial nerve recovery after acoustic neuroma removal. J Laryngol Otol 103:169-172, 1967 31. Olivecrona H: Acoustic tumors. J Neurosurg 26:6-13, 1967 32. Pensak ML, Jackson CG, Glasscock ME, III, et al: Facial reanimation with the VII-XII anastomosis: analysis of the functional and psychologic results. Otolaryngol Head Neck Surg 94:305-310, 1986 33. Samii M: Facial nerve grafting in acoustic neurinoma. Clin Plast Surg 11:221-225, 1984 34. Sargent P: Four cases of facial paralysis treated by hypoglosso-facialanastomosis. Proe R Soe Med 5:69-70, 1911 35. Smith JW: Treatment of facial palsy by cross-face nerve grafting, in Buchheit WA, Truex RC Jr (eds): Surgery of the Posterior Fossa. New York: Raven Press, 1979, pp 173-179 36. Stennert E: 1. Hypogiossal facial anastomosis: its significance for modern facial surgery. II. Combined approach in extratemporal facial nerve reconstruction. Clin Plast Surg 6:471-486, 1979 37. Tator CH: Acoustic neuromas: management of 204 cases. Can J Neurol Sei 12:353-357, 1985 38. Tutor CH, Linden RD, Duncan EG: Management of acoustic neuromas in 212 patients, in Fraysse B, Lazorthes Y (eds): Neurinomes de rAcoustique, Acquisitions et Controverses, Tome 2. Paris: Pierre Fabre, 1988, pp 11-19

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39. Tran Ba Huy P, Monteil JP, Rey A: Results of twenty cases of transfacio-facial anastomosis as compared with those of XII-VII anastomosis, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 85-87 40. Vacher S, Hadjean E, Monteil JP, et al: Anastomoses hypoglosso-faciales. Analyse et r&ultats (sur une srrie de 12 cas) et comparaison avec les r&ultats des anastomoses facio-faciales. Ann Otolaryngol Chlr Cervicofae 99: 303-312, 1982 41. Yanagihara N: Grading system for evaluation of facial palsy, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 41-42 42. Yanagihara N, Okamura H: Multiple facial suspension operation in long-standing facial palsy: concept and technique, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 537-539 43. Ylikoski J, Hitselberger WE, House WF, et al: Degenerative changes in the distal stump of the severed human facial nerve. Acta Otolaryngo192:239-248, 1981 44. Zini C, Sanna M, Gandolfi A: Hypoglosso-facial anastomosis in the rehabilitation of irreversible facial nerve palsies, in Portmann M (ed): Facial Nerve. New York: Masson, 1985, pp 519-522

Manuscript received May 18, 1991. Accepted in final form March 23, 1992. Address reprint requests to: Charles H. Tator, M.D., The Toronto Hospital, Toronto Western Division, Suite 2-435, McLaughlin Pavilion, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.

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Hypoglossal-facial nerve anastomosis for facial nerve palsy following surgery for cerebellopontine angle tumors.

Hypoglossal-facial nerve anastomosis is one of the procedures frequently performed to restore function after facial palsy secondary to surgery for rem...
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