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Rehabilitation of Non-facial Cranial Nerve Dysfunction Following Skull Base Surgery
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
11 sections · 107 slides
Overview
- Scope of this topic
- Acute versus gradual cranial nerve loss
- Trend towards neural preservation
- Lower cranial nerve innervation of the upper aerodigestive tract
Trigeminal Nerve (Cranial Nerve V)
- Course of the trigeminal nerve
- Operative exposure that endangers CN V
- Sensory consequences of trigeminal loss
- Corneal risk from V1 loss
- Motor division of V3
- Compensation for V3 motor loss
- Temporalis and masseter atrophy
- Trigeminal neuropathy in vestibular schwannoma
- Outcome of surgery and radiation on trigeminal symptoms
Nerves of Extraocular Movement
- Which extraocular nerves are actually at risk
- Trochlear nerve course and injury
- Presentation of trochlear nerve weakness
- Abducens nerve course
- Management of abducens nerve palsy
Glossopharyngeal Nerve (Cranial Nerve IX)
- Course of the glossopharyngeal nerve
- Functional components of the glossopharyngeal nerve
- Branchial motor function of CN IX
- Visceral motor function and the parotid gland
- Somatic sensory territory of CN IX
- Carotid sinus nerve and baroreceptor function
- Long-term control after bilateral baroreflex loss
- Assessment of glossopharyngeal function
Vagus Nerve (Cranial Nerve X)
- Why vagal injury dominates skull base morbidity
- Course of the vagus nerve to the neck
- Functional consequences of a high vagal injury
- General sensory territory of the vagus
- Visceral sensory and visceral motor functions
- Consequences of bilateral vagal loss
- The three branchial motor branches of CN X
- Velopharyngeal insufficiency after vagal injury
- Loss of pharyngeal constrictor function
- Superior and recurrent laryngeal nerve injury patterns
- Upper oesophageal sphincter dysfunction
- Intraoperative vagal nerve monitoring
- Role of tracheostomy in vagal injury
- How tracheostomy impairs swallow compensation
Preoperative Evaluation and Non-surgical Care
- Preoperative flexible laryngoscopy
- Radiographic swallow assessment and team preparation
- Non-surgical care as first-line treatment
Management of Postoperative Velopharyngeal Insufficiency
- Assessment and grading of VPI
- Timing and temporising measures in VPI
- Adynamic lateral pharyngeal wall in high vagal injury
- Surgical options for velopharyngeal insufficiency and why most fail
- Why standard pharyngoplasties fail here
- Unilateral palatal adhesion: principle and origin
- Exposure and incision for palatal adhesion
- Unilateral transpalatal incision in the palatal crease
- Posterior pharyngeal wall preparation
- Approximation of the hemipalate to the nasopharyngeal surface
- Closure and immediate postoperative course
- Adhesion obliterating the incompetent hemi-nasopharynx
- Nasopharynx before and after unilateral adhesion on transnasal endoscopy
- Complications and outcomes of palatal adhesion
Surgical Management of Unilateral Vocal Fold Paralysis
- Swallow and voice therapy in unilateral vocal fold paralysis
- Postoperative baseline assessment of voice and swallow
- Timing of injection laryngoplasty
- Injection materials and complications
- Outcome measures after medialisation
- Progression from repeated injection to definitive surgery
- Implant materials for type 1 thyroplasty
Type 1 Thyroplasty and Arytenoid Adduction
- Anaesthesia and set-up for type 1 thyroplasty
- Exposure of the thyroid cartilage
- Releasing strap muscles to reveal the thyroid cartilage
- Subperichondrial dissection with the window measured out
- Dimensions of the cartilage window
- Marked rectangular window in the thyroid ala
- Creating the window and the paraglottic pocket
- Sizing and carving the Silastic implant
- Beveled medialisation implant in position
- Confirming voice and securing the implant
- Indications and exposure for arytenoid adduction
- Exposing the posterior cricoarytenoid muscle
- Kerrison rongeur removing posterior thyroid cartilage
- Prolene suture placed through the muscular process of the arytenoid
- Routing and tensioning the adduction suture
- Regulating suture tension while sizing the implant
- Complications of medialisation surgery
- Allowing for intraoperative oedema
- Laryngeal reinnervation procedures
Spinal Accessory and Hypoglossal Nerves
- Course of the spinal accessory nerve
- Function and testing of the spinal accessory nerve
- Shoulder morbidity and its rehabilitation
- Course of the hypoglossal nerve
- Function and monitoring of the hypoglossal nerve
- Consequences of hypoglossal weakness
Summary
- Key principles of cranial nerve rehabilitation
- Key operative numbers and endpoints
- Operations that work and operations that do not
- References
- References (continued)
- References (continued)
- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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