Facial nerve is a mixed nerve with the origin in pons, consisting predominantly of motor fibers that provide mobility of facial muscles, parasympathetic secretory fibers and sensory fibers, contributing to the sense of taste.Although the constitution and the path of nerve (a bone channel that crosses the petrous bone, the middle ear and the mastoid bone to the stylomastoid foramen which ia also protected by styloid apophysis) seems a very well protected nerve, however it can be affected throughout his path by shock, trauma, bone channel fractures, the pathology is not his own, is of nearby organs: tumors of IAC, middle ear inflammation, infections of geniculate ganglia, middle ear infections with bone channel erosion, tumors of parotid gland. From the brainstem to the exit from the skull, in the three segments, intracranial, intratemporal and extratemporal segments, the nerve pathophysiology is variate according to affected segment. (1,2,3)

This is a retrospective study of 21 patients operated in our clinic during 2000-2009, which presented facial nerve palsy, We included only patients who required surgical treatment. The surgical treatment was decided after a thorough clinical e and imagistic valuation and after a electrophysiological examination. The treatment comprise by nerve decompression, termino-terminal anastomosis, using sural nerve or auricularis magnus nerve.(4)

For anatomical and functional repair was used the nerve graft interposition in 17 cases, in 11 cases in the first 72 hours and in 6 cases later, after 3 months (5 cases) or after 12 months (one case). For the intratympanic or mastoid part we used the great auricular nerve or the sural nerve, when we needed longer graft. The ends of graft were attached to the facial nerve ends using blood droplets and than covering the nerve with pericondrium (in 3 cases) or with temporal muscle fascia (in 4 cases). When we used sural nerve graft the sutures were performed suturing the proximal end of graft to the tympanic segment of the facial nervestrump (app 0.5 mm to the geniculat ganglia) and the distal end of the graft (after being divided into three filaments) to the dissected parotidian branches. Suture was performed using 0.9 monofilament and the the perinervum was sutured in 2 points. In all cases was done the eyelid suture. In cases of iatrogenic injury it was used as binder the blood droplet.

Signs of nerve continuity recovery was observed at 24 weeks in 4 cases, at 26 weeks in 2 patiens and at 28 weeks in 4 cases. Monitoring of restoring nerve was done by electroneuronography (ENoG), in the Neurological Department, and by clinical observation and first recovery signs was seen in the upper eyelid and discrete movements in the buccinator muscle. Nose muscle mobility was observed to occur generally after week 26. Nerve function restore was achieved up to 90% of normal in 3 cases, in which the palsy was obviously during active movements like speech but was absent in resting. Recovery was 75% of normal in 5 cases, being present at rest, from time to time, and in 3 cases was about 60% of normal function, incomplete paralysis being observed in rest. Five patients had the first sign of recovery of nerve function facial muscles spasms, especially in orbicularis muscle. All patients maintained muscle tone by face massage, chewing and for nerve function restore were administrated vasotrope and neuroptrophic medications.

Facial nerve paralysis could be congenital, idiopathic, neoplastic , infectious and traumatic. The most common causes are idiopathic, inflammatory and traumatic.(6)

Treatment of facial nerve inflammatory pathology is usually conservative and if the symptoms does not improve within 3 months of conservative treatment is recommended the nerve decompression with its functional restoration. Fisch and Esslen (7) proposed that surgical solution should be applied before the complete degeneration of the nerve. Electroneuronography is the one that helps to determine the timing of surgery. In the intratympanic and intramasoidian portion cholesteatoma is the most common cause of facial nerve paralysis. Bone wall erosion leads to nerve damage directly by the infectious process. Sometimes the nerve injury is iatrogenic, during the treatment by overheating, thermal trauma, resection, degeneration, etc. If nerve damage is minimal ENoG is recommended and if finds nerve activity than the surgery is delayed. If the activity is absent immediate surgical intervention is recommanded by restoring nerve continuity using nerve graft. The most used grafts in our clinic was the great auricular and the sural nerve. (8)

Best results were achieved in decompression cases comparing to anastomosis and nerve transplant complete recovery is impossible, residual weakness and synkinesis being observed in all the cases.

The obvious facial deformity has an important emotional impact on patient that leads to social isolation and affect the self-esteem so is welcome any solution and effort to enhance patient’s aspect and his quality of life.

44. Spector JG, Lee P, Peterein J, Roufa D. Facial nerve regeneration through autologous nerve grafts: a clinical and experimental study. Laryngoscope. May 1991;101(5):537-545. House JW, Brackmann DE (1985). "Facial nerve grading system". Otolaryngol Head Neck Surg 93: 146–1476. Peitersen E (2002) Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 549:4–307. Fisch U, Esslen E. Total intratemporal exposure of the facial nerve. Arch Otolaryngol 1972;95:3358. Green JD Jr, Shelton C, Brackmann DE. Iatrogenic facial nerve injury during otologic surgery. Laryngoscope. Aug 1994;104(8 Pt 1):922-6

Objectives: The facial nerve is the most susceptible to injury of all the cranial nerves because of its complex course through the temporal bone confined within a prolonged bony canal in some cases not much greater in diameter than the nerve itself. Facial nerve palsy leads to a distorted aspect of the face both at rest and in activity with devastating social consequences for the patient.Material, Methods: We have done a retrospective study of the ten-years materials (2000-2009) of the Cluj-Napoca’s ENT Clinic, 21patiens. After a thorough clinical, imagistic end electromyographic evaluation was decided the surgical treatment which comprise in nerve decompression, termino-terminal anastomosis between the end of intratympanic segment and the distal segment of facial nerve by interposing sural nerve or n. auricularis magnus graft.Results: The interposition of the graft in facial nerve was carried out in the mastoid, in 11 cases in the 72 hours after trauma, in 5 case three months later and in one case twelve months later. Nerve decompression was performed in 4 cases.The nerve graft and the nervous ends were prepared beforehand bycutting a few millimeters of the epineurium sheet. Then the graft was positioned in the bone canal, the ends were put together and theanastomosis was made with autologous fibrin adhesive.Conclusions: Surgical therapy in peripheral traumatic facial palsy gives good functional results. Nerve decompression has statistically better results comparing to anastomosis and nerve transplant.The choice of surgical technique and results directly depend on location and intensity of the lesion and the treatment time.

HBS

Normal, symmetrical function in all areas I

Slight weakness on close inspection, complete eye closure with minimal effort, slight asymmetry of smile with maximal effort, slight synkinesis, absent contracture or spasm

II

Obvious weakness but not disfiguring, unable to lift eyebrow, complete and strong eye closure, asymmetrical mouth movement with maximal effort, obvious but not disfiguring synkinesis, mass movement or spasm

III

Obvious disfiguring weakness, inability to lift brow, incomplete eye closure, and asymmetry of mouth with maximal effort, severe synkinesis, mass movement, spasms

IV

Motion barely perceptible, incomplete eye closure, slight movement corner mouth, synkinesis, contracture, spasm usually absent

V

No movement, loss of tone, no synkinesis, contracture, spasm

V

House-Brackman score to grade severity of facial nerve palsy (5)