OtolaryngologyHead and Neck Surgery (2006) 135, 872-876

ORIGINAL RESEARCH

Systematic facial nerve monitoring in middle ear and mastoid surgeries: Surgical dehiscence and electrical dehiscence
Yun-Hoon Choung, DDS, MD, PhD, Keehyun Park, MD, PhD, Min Jung Cho, MD, PhD, Pill-Hoon Choung, DDS, PhD, You Ree Shin, MD, PhD, and Hison Kahng, MD, Suwon and Seoul, Korea
OBJECTIVES: To evaluate and systemize intraoperative facial nerve monitoring (IOFNM) in middle ear and mastoid surgeries. STUDY DESIGN AND SETTING: A prospective study. METHODS: IOFNM was performed in 100 patients undergoing middle ear and mastoid surgeries. We checked surgical dehiscence under microscopes, and also estimated the minimal threshold of electric current needed to change the electromyography of facial muscles using Nerve Integrity Monitor (NIM)-2 (Xomed, Minneapolis, MN, USA). RESULTS: Forty-three percent of cases showed surgical dehiscence and responded to electric stimulation of 0.7 mA or less. Electrical dehiscence ( 0.7 mA) was presented in 73 (73.0%) cases, and 82.2% of these cases responded to 0.4 mA or less. The mean threshold of minimal electrical stimulation was 0.29 mA for tympanic segments and 0.41 mA for mastoid segments. CONCLUSIONS: We recommend an electrical stimulation of 0.7 mA for the rst screening and 0.4 mA for the second exploration in order to dene the facial nerve using intraoperative NIM-2 monitoring in middle ear and mastoid surgeries. 2006 American Academy of OtolaryngologyHead and Neck Surgery Foundation. All rights reserved.

toidectomies during a 10-year period to be 1.7%. The incidence of facial palsy as a postoperative complication reported in the literature is 1/1000 cases. However, in the clinical community, the incidence may be closer to 1/100 cases.3 Delgado et al4 introduced electromyography as the method for intraoperative FN monitoring in 1979. The benets of routine monitoring of the FN were established by the National Institutes of Health in the United States in 1991.5,6 Intraoperative FN monitoring has long been accepted as the standard of care in surgeries for vestibular schwannomas and other cerebellopontine angle tumors.7-9 In spite of natural FN dehiscence, unusual anatomy, and FN anomalies, the role of intraoperative FN monitoring in chronic ear surgeries is poorly dened.10,11 We tried to prospectively evaluate the role of intraoperative FN monitoring and systematize its application in middle ear and mastoid surgeries.

here are many causes of facial nerve (FN) palsy, but one of the preventable causes is iatrogenic injury. Wiet1 reported the incidence of iatrogenic FN injury to be 0.6% to 3.6% in all otologic cases. These gures increased to 4% to 10% in revision cases. Nissen and Bui2 found the overall incidence of facial palsy for 1024 consecutive mas-

MATERIALS AND METHODS

One hundred patients (male 55, female 45) who underwent middle ear and mastoid surgeries with intraoperative FN monitoring in the Department of Otolaryngology, Ajou University Hospital, Suwon, Korea between April 2003 and December 2004 were enrolled in this study. The study was
Reprint requests: Yun-Hoon Choung, DDS, MD, PhD, Department of Otolaryngology, Ajou University School of Medicine, San 5, Wonchondong, Yeongtong-gu, Suwon 443-721, Republic of Korea. E-mail address: yhc@ajou.ac.kr.

From the Department of Otolaryngology, Ajou University School of Medicine, Suwon (Drs Y-H Choung, Park, Cho, Shin, and Kahng), and the Department of Oral and Maxillofacial Surgery, College of Dentistry, Seoul National University (Dr P-H Choung).

0194-5998/$32.00 2006 American Academy of OtolaryngologyHead and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.04.008

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Figure 1 Surgical dehiscence of the facial nerves was noted in 43 (43.0%) of 100 cases (A). All surgically dehiscent facial nerves responded to 0.7 mA or less of electrical stimulation (B).

approved by the Institutional Review Boards of the Ajou University School of Medicine (Suwon, Korea). We used Nerve Integrity Monitoring (NIM)-2 (Xomed, Minneapolis, MN, USA) for intraoperative FN monitoring. One of the authors dened FN dehiscence with inspection and palpation under a microscope (surgical dehiscence). The same person checked the location and length of the dehiscent FNs. The FN was divided into three parts: the geniculate ganglion, tympanic segment, and mastoid segment. The tympanic segment was subdivided into three parts, with the central part being around the stapes. The mastoid segment was also subdivided into three equal parts. Two sterile needle electrodes were placed in the ipsilateral orbicularis oculi and orbicularis oris muscles, and a constant, unipolar, current stimulus was used. The impedance of each electrode was less than 5 K, and the imbalance between the two electrodes was less than 0.5 K. Muscle relaxants were avoided during the operations to facilitate the monitoring of electromyographic (EMG) activity. We stimulated the FNs with a constant, unipolar current with a frequency of 4 pulses/second for 100 s. We estimated the minimum threshold of electric currents to make the FN show the rst response of EMG change on NIM-2. We observed the FN dehiscence by surgical microscope and dened surgical dehiscence. In this study, all dehiscent FNs responded to stimulation of 0.7 mA or less. Stimulation greater than 0.7 mA resulted in nonspecic responses of FNs irrespective of dehiscence. Therefore, we dened the response to electrical stimulation within 0.7 mA as electrical dehiscence.

and 5 were for revision surgeries (5.0%). The cause of surgery in 71 cases (71.0%) was middle ear cholesteatomas, and in 29 cases (29.0%) was noncholesteatomatous otitis media.

Surgical Dehiscence of the FN

Surgical dehiscence under a microscope was found in 43 (43.0%) cases (Fig 1A). Thirty (69.8%) of the 43 cases were dehiscent in the middle portion of the tympanic segment. Nine (20.9%) were dehiscent in the mastoid segment, and 5 (11.6%) were dehiscent in the geniculate ganglion (Table 1). In 71 cases with middle ear cholesteatomas, 38 cases (53.5%) showed FN dehiscence. However, in 29 cases with chronic otitis media, 5 (17.2%) showed FN dehiscence. All 43 cases that showed surgical dehiscence responded to electrical stimulation of 0.7 mA or less. Fifteen cases (34.9%) of all surgically dehiscent FNs responded to minimal electrical stimulation between 0.25 and 0.3 mA, followed by 14 cases (32.6%) responding to 0.15 to 0.2 mA, 5 cases (11.6%) to 0.35 to 0.4 mA, 4 cases (9.3%) to 0.05 to 0.1 mA, 3 cases (7.0%) to 0.65 to 0.7 mA, and 2 cases (4.7%) to 0.45 to 0.5 mA (Fig 1B). Three cases that responded to electrical stimulation of 0.7 mA showed thick-

Table 1 Surgical dehiscence of the facial nerves according to location Location Geniculate ganglion Tympanic segment Proximal Middle Distal Mastoid segment Number (%) 5 39 21 30 16 9 (11.6) (90.7) (48.8) (69.8) (37.2) (20.9)

RESULTS
The mean age of the patients was 40.4 (range: 4-65) years old. Ninety-ve cases were for primary surgeries (95.0%),

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Figure 2 Electrical dehiscence of the facial nerves was noted in 73 (73.0%) of 100 cases (A). Distribution of the minimum electrical stimulation for facial nerves (B).

ened nerve sheaths and surrounding granulations due to chronic inammation.

Electrical Dehiscence of the FN

Since all surgically dehiscent FNs responded to electrical stimulation of 0.7 mA or less, we dened the FNs that responded to electrical stimulation of 0.7 mA or less as electrical dehiscence. Actually, if the stimulation was over 0.7 mA, nonspecic responses were occasionally observed, regardless of the location of FNs. Electrical dehiscence was found in 73 cases (73.0%) (Fig 2A). Most of them responded between 0.2 and 0.4 mA (Fig 3B). Twenty-three (31.5%) of all electrically dehiscent FNs responded to minimal electrical stimulation between 0.25 and 0.3 mA, followed by 20 (27.4%) FNs responding to 0.15 to 0.2 mA, 13 (17.8%) to 0.35 to 0.4 mA, 6 (8.2%) to 0.65 to 0.7 mA, 5 (6.8%) to 0.45 to 0.5 mA, 4 (5.5%) to 0.05 to 0.1 mA, and 2 (2.7%) to 0.55 to 0.6 mA (Fig 2B). The electrically dehiscent FNs were noted in 30 (52.6%) cases among 57 surgically nondehiscent FNs. About 73%

of these electrically dehiscent but surgically nondehiscent FNs responded to electrical stimulation of 0.4 mA or less (Fig 3). Figure 4 showed a cumulative distribution of electrical dehiscence according to minimal stimulation thresholds. The cumulative frequency of electrical dehiscence increased to 0.4 mA (82.2% of the electrical stimulation) along the primary curve. Beyond 0.4 mA, the cumulative frequency formed a plateau. The minimal electrical threshold according to the location of FNs was, on average, 0.29 mA 0.12 mA in the tympanic segment and 0.41 mA 0.24 mA in the mastoid segment (Table 2). The frequency of electrical dehiscence, according to cause of surgery, was 58 (81.7%) of 71 cases with cholesteatomas and 15 (51.7%) of 29 cases with noncholesteatomatous otitis media.

Figure 3 Distribution of the minimum electrical stimulation in electrically dehiscent but surgically nondehiscent facial nerves.

Figure 4 Cumulative distribution of electrical dehiscence according to minimum stimulation thresholds. Electrical stimulations of 0.7 mA for the rst screening and 0.4 mA for the second exploration are appropriate.

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Table 2 Minimum threshold of electrical stimulation for facial nerves during middle ear and mastoid surgeries Second genu (n 5) Minimal threshold of electrical stimulation (mA) 0.31 0.17 Tympanic segment (n 68) 0.29 0.12 Mastoid segment (n 15) 0.41 0.24

DISCUSSION
Iatrogenic FN injury is one of the most severe complications among temporal bone surgeries. FN injury can be increased when the normal anatomic landmarks of the temporal bone are altered.12,13 Previous surgery, granulation tissue, and cholesteatomas can distort the normal anatomy and complicate the surgery.13,14 It is very difcult for the surgeon to predict before surgery variations of the FN, such as congenital bony dehiscence or abnormal course of the facial canal. Therefore, intraoperative FN monitoring should be required for temporal surgeries including congenital aural atresia, cerebellopontine angle (CPA) tumor surgeries, cochlear implantation, the infratemporal fossa approach, and middle ear and mastoid surgeries. However, the role of intraoperative FN monitoring in middle ear and mastoid surgeries has not been well established.10,11 There are some differences in rates of FN dehiscence according to the kind of detection method used and disease present. Li et al15 found FN dehiscence of 11.4% by microscope use during surgeries. Baxter16 reported a dehiscence rate of 55% based on temporal bone histopathology. Sheehy et al17 reported a surgical dehiscence of 44% including congenital dehiscence of 15% and cholesteatomaderived dehiscence of 17%. Harvey et al18 found that signicant facial nerve dehiscence was present in 6% of mastoid surgeries. In our study, surgical dehiscence was 43.0%, which is a little higher than those in any previous report. This different result was thought to be because of the higher portion (71%) of cholesteatomas in this study as well as the prospective design. The most common site of dehiscence was the tympanic segment (90.7%) (Table 1), which was similar to Baxters results (85%).16 This result suggests that the most risky portion is the tympanic segment of the FN, and more caution is needed during manipulation of the FN around the stapes. In this study, most (76.7%) FNs with surgical dehiscence responded to electrical stimulation of 0.3 mA or less (Fig 1B). This result is consistent with the known fact that the response threshold of healthy nerves is about 0.1 to 0.5 mA.19 Three cases that responded to electrical stimulation of 0.7 mA showed thickened nerve sheaths and surrounding granulations due to chronic inammation. That is, chronic inammation can result in histopathologic change of tissues around a FN and can increase the minimal threshold of electrical stimulation in intraoperative FN monitoring.

In addition, the number of FNs with electrical dehiscence was 73 (73.0%) out of 100 cases. This was 30 more than the number with surgical dehiscence. That is, 30 FNs showed both surgical nondehiscence and electrical dehiscence. This result may have been due to partial micro-dehiscence, which cannot be inspected by microscope, or a very thin bony covering that can easily conduct with low electrical current. In these cases, the possibility of FN injury is increased with heat created by surgical drills and tough manipulations of operating instruments. Therefore, electrical dehiscence provides for a greater margin of safety to preserve FNs than surgical dehiscence in intraoperative FN monitoring in middle ear and mastoid surgeries. Cumulative distribution of electrical dehiscence according to minimal stimulation thresholds (Fig 4) showed that 0.7 mA is a very useful criterion for the rst stimulating threshold, and 0.4 mA is a useful criterion for the detailed second exploration of an FN in intraoperative FN monitoring. This means that we can detect the exposed FNs almost completely under electrical stimulation of 0.7 mA (rst threshold), even with thickened nerve sheaths. We can also easily nd normal FNs under 0.4 mA (second threshold), decreasing the possibility of a nonspecic response. The average minimal electrical threshold was 0.29 mA for the tympanic segment and 0.41 mA for the mastoid segment (Table 2). This difference is thought to be from the different thicknesses of myelin sheath around the FNs. To explore a more detailed location of FNs in intraoperative FN monitoring, 0.3 mA is appropriate for the tympanic segment and 0.4 mA is appropriate for the mastoid segment. Of course, for more precise exploration of FNs, we need to decrease the threshold of electrical stimulation to under 0.3 mA. Intraoperative FN monitoring is considered to have a great role, not only in vestibular schwannoma surgeries, but also in middle ear and mastoid surgeries. A systematic application is required in clinical elds. Therefore, we need objective clinical studies to nd the optimal threshold for FN stimulation according to type of operation, location of FNs, and thickness of facial canals.

CONCLUSIONS
Electrical dehiscence, based on responses of electrical stimulation, is safer to use than surgical dehiscence,

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8. Soldner F, Papavero L, Wallenfang T, et al. Intraoperative NIM-2 monitoring for facial nerve preservation in acoustic neurinoma surgery. Eur Arch Otorhinolaryngol 1994;3113. 9. Colletti V, Fiorino FG. Advances in monitoring of seventh and eighth cranial nerve function in posterior fossa surgery. Am J Otol 1997;19: 50312. 10. Noss RS, Lalwani AK, Yingling CD. Facial nerve monitoring in middle ear and mastoid surgery. Laryngoscope 2001;111:831 6. 11. Jason SG, Spiros M, Michel GS, et al. Facial nerve monitoring in chronic ear surgery. Otolaryngol Head Neck Surg 2002;126: 108 14. 12. Samuel HS, Alastair GL. The incidence of facial nerve dehiscence at surgery for cholesteatoma. Otol Neurotol 2001;22:129 32. 13. Green JJ, Shelton C, Brackmann D. Iatrogenic facial nerve injury during otologic surgery. Laryngoscope 1994;104:922 6. 14. Green JJ, Shelton C, Brackmann D. Surgical management of iatrogenic facial nerve injuries. Otolaryngol Head Neck Surg 1994;111: 606 10. 15. Li D, Cao Y. Facial canal dehiscence: a report of 1,465 stapes operations. Ann Otol Rhinol Laryngol 1996;105:46771. 16. Baxter A. Dehiscence of the fallopian canal. J Laryngol Otol 1971; 85:58794. 17. Sheehy J, Brackmann D, Graham M. Cholesteatoma surgery: residual and recurrent disease: a review of 1,024 cases. Ann Otol Rhinol Laryngol 1977;86:451 62. 18. Harvey S, Fox M. Relevant issues in revision canal-wall-down mastoidectomy. Otolaryngol Head Neck Surg 1999;121:18 22. 19. Yingling CD. Intraoperative monitoring of cranial nerves in neurotologic surgery. In: Cummings CW, Fredrickson JM, editors. Otolaryngology head and neck surgery. 3rd ed. St. Louis: Mosby Year Book; 1993. p. 333155.

based on surgical observations in middle ear and mastoid surgeries. Electrical stimulations of 0.7 mA for the rst screening and 0.4 mA for the second exploration are considered appropriate to dene an FN using intraoperative NIM-2 monitoring in middle ear and mastoid surgeries.

REFERENCES
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