A question about facial nerve

[beancounter]

I have spent the better part of this day and evening poring over all the questions, answers, concerns, etc., and am convinced that those with AN are a superior race.  It is refreshing, comforting and gratifying to see how articulate, upbeat, compassionate, occasionally irreverent and downright witty the majority of you are.  One question I cannot seem to find a definitive answer to is this:  it appears that, from most of what I read, preserving the facial nerve is a huge issue and often simply cannot be done.  Does anyone know, generally speaking, how likely it is that one who opts for surgery can assume it is almost assured that there will be facial paralysis?  Thanks to all.

[Jim Scott]

Hi, Beancounter:

Preservation of the facial nerve is usually a paramount concern for AN patients.  The tumor often 'sticks' to the nerve or wraps around it to some extent, which weakens the nerve.  When that happens, post-op, facial paralysis or some level of facial malfunction ('droopy eye', sagging lip, etc) may occur, although certainly not always.  Location of the AN as well as the surgeon's skill are major factors is preserving facial functions, post-op. This is why most AN surgeries take anywhere from 6 to 16 hours and demand a very high level of surgical skill and experience.  My neurosurgeon, a fine doctor with over 30 years of experience removing AN tumors, put it best when told me that his operating room (when operating on AN patients) is 'no place for amateurs'. He wouldn't even allow residents or interns to assist him, only his own hand-picked surgical team of AN-experienced physicians and nurses.  He also employs nerve monitoring, which is fairly common, today.  This is the level of skill necessary in removing AN tumors.  Fortunately for me, this all paid off with a successful surgery and radiation treatment.  I experienced no facial problems even with my fairly large (4.5cm) AN.  What little tumor that still remains is shrinking and dying, according to my last MRI (June 2007). 

As we always hasten to say: we're individuals and no AN case is exactly the same or can be expected to have the exact outcome, good or not-so-good.  Knowledge and an experienced surgeon is your best source of comfort when facing AN surgery.  I trust that you'll be able to find one or even both in the weeks to come, as you begin your 'AN journey', as we call it.  I wish you the best.

Jim

[sgerrard]

I don't think it would correct to say that facial preservation "often simply cannot be done." For the smaller tumors, especially with middle fossa or trans-lab approach, many patients on this forum report that they are basically back to normal within two months. For those with larger tumors, or more facial nerve entanglement, there are still quite a few who report recovery of facial nerve function over the following year or so. The number who have to go into further surgeries and the like,to address paralysis, is certainly a minority.

A lot depends on the size and placement of the AN, as Jim said, as well as the surgery team, and what sort of symptoms you already have. There is every reason to be optomistic, as many accounts on this forum will show, even with big problematic tumors.

And yes, we are a motley crew, but full of life and energy and pizazz. You are welcome to join in. 

Steve

[er]

Hi
 I don't know if I am answering correctly.
But like Jim mentioned everyone is different. I am 2 1/2 years old of my AN surgery.  I was left with facial parlaysisation ,my doctor mentioned it would all come back to normal in 6 months. Improvement did come in 6 month but even now I am having nerve feeling coming back.
Here a month ago I saw a young man with the same surgery I had but half of his tumor was cancers and half AN in which shocked me that that could happen. But this young man had no facial paralyasisation or headaches but he did lose his hearing plus the same balance issues that we all have.
eve

[nancyann]

Hi Beancounter:   My feeling is the docs don't really know WHAT shape your facial nerve is in until they get in there.   My preop symptoms were constant tinnitus  & decreased hearing (for years), & for about 6 months very rarely I noticed 'twitching' around my right eye.   My surgeons had lots of experience with ANs.   Unfortunately, once they opened me up, my facial nerve just stopped signaling.  The tumor removed easily from the nerve, but my facial nerve never regained functioning.   The doc decided to cut & reanastamose the nerve,  but I still have facial paralysis 16 months out.   He said my nerve looked like a 'wet noodle'.    I had met someone else who had surgery with the same team & she was fine ( 2 years post op), just some returned balance issues.
So, I feel you never know - thank God facial paralysis is NOT the norm, but there IS a chance of it, albeit small.
Best wishes with your decision.,    Nancy

[leapyrtwins]

beancounter -

doctors can't guarantee anything - they do their best, but they are only human.  However, it IS possible to have surgery and have no lasting facial nerve damage.  I never had facial nerve issues prior to surgery.  Post op I had very slight issues, but after a dose of steroids, the issues were completely gone - only took 2-3 days.  I realize that I am very lucky and I am extremely thankful.  Any doctor well-versed and experienced in AN surgery should be able to give you statistics on any possible side effects - facial nerve issues included.

Jan   

[john twoffer]

This is very important. We all want to save our facial nerves. From talking with several neurosurgeons I found out that there is a facial nerve branch called the nervus intermedius. It's a branch that goes along with the facial nerve. This nerve is probably too hard to see during surgery and is probably cut the majority of the time because it can't be isolated. In fact, apparently little branches of the facial nerve are always cut.
Maybe I am wrong about this. Could someone explain it better? I know that post surgery people often have dry eye, numbness of the ear, or strange tongue sensations, but yet can have an intact facial nerve. Little branches somewhere must be getting damaged. I would like to know more about this from everyone.

[satman]

Hi John,
All I know about this is: I had an 8 cm AN,my facial nerve was not cut , but due to the size and
location of mine the nerve was severly damaged. I ended up with all of the post-op problems
but with P.T and diligence these problems can be overcome.
I had the Translab approach and have no hearing on left side,but that has been the least of my problems.
What tends to get to me is the dry-eye thing,but now I have a gold weight in my left eye.
At least I got a piece of jewelry [bling ,bling] out of the deal.
I hope all of my rambling helped in some sort of way.

[nancyann]

John:  I think the 3 branches branch out to the different areas of the face: 1 to the eye area, 1 to the cheek area, & 1 to the mouth/chin area.  Of course, the furthest branch out from where the facial nerve generates is the eye area, which is why this is USUALLY the last area to have movement return.

[john twoffer]

John:  I think the 3 branches branch out to the different areas of the face: 1 to the eye area, 1 to the cheek area, & 1 to the mouth/chin area.  Of course, the furthest branch out from where the facial nerve generates is the eye area, which is why this is USUALLY the last area to have movement return.

I'm still confused on whether the nervus intermedius is always cut or not. It apparently does the eye dryness, "postganglionic neurons send axons that provide parasympathetic innervation to the lacrimal gland" according to one source. It apparently also provides innervation to the submandibular and sublingual glands. Being cut can also mess up sensation "from the skin of the external auditory meatus, from the mucous membranes of the nasopharynx and nose, and taste from the anterior two-thirds of the tongue, floor of the mouth, and the palate." It seems like being without a nervus intermedius messes up a lot of things. So, I'm wondering if all people who have surgery are messed up a little bit in all these areas? Or maybe the nerve is not always cut. I'm confused about this.

[nancyann]

Hi John:  Well, I'm no neurologist;  I know there are sensory & motor pathways.  I don't think the nerve has to get 'cut', but symptoms are also due to how 'damaged' the nerve is, what 'area' of the nerve is damaged.   Some people can't 'feel' (sensory) certain areas, some can't 'move' (motor) certain areas.  Funny, I have total paralysis on the right side, yet I can feel my eye burning when I need more lubricant - there are some here who can move their face but don't have feeling....
Sorry, I'm not specifically answering your questions - but this is just how I look at what happened to me.....

[sgerrard]

I'm sure it is way more information than you want, and is certainly more than I can make sense of, but this article explains all the anatomy of the facial nerve in full medical jargon, and provides some illustrations that show that the facial nerve is, to put it mildly, complicated.

http://www.emedicine.com/ent/topic8.htm

This picture from the article seems to say it all (facial nerve = cranial nerve VII):




Not light weight reading by any means, but informative even if you just skim it and look at the pictures.

Steve

[nancyann]

Hi Steve:  WOW - Table 2 says it all - Hey John, looks like this is what you were talking about.....  thanks Steve.  (with my decreased concentration s/p surgery, Table 2 is as far as I go!).   

[OTO]

beancounter

Size and location of the AN plus impact to the facial nerve is used to determine the surgical technique.   Translabyrinthe give the surgeron the best view of the facial nerve, but they will have to cut the hearing nerve.   Retrosigmoid and middle fossa give a better chance to save the hearing nerve.   I think preventing damage to the facial nerve is the major consideration in all the surgeries.   They will leave tumor material alone rather than risk additional damage to the facial nerve.  Skill and experience is key.   In my case (10mm AN using middle fossa), they had to leave behind tumor because it was stuck to the facial nerve.  They assure me that the tumor should not grow back (they cut the blood supply to the tumor), and my face although I had some numbness, is very good.  I can close my eyelid, and most of the motion and feeling has returned.   I will go for my six month MRI in two or three weeks.... 

[Obita]

Hi there beancounter228:

I had the translab approach done in May '04.  I could smile and close my eye right after surgery.  My face felt numb, but everything was working. My surgeons warned me that I could have some late onset weakness a few weeks later.  Sure enough, about day 12, my eye quit closing at night.  It was closing normally again somewhere between 2 and 3 months post op.

Kathy