Atlas of Surgery of the Facial Nerve Bachi T Hathiram, DS Grewal
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1Atlas of Surgery of the Facial Nerve
“The authors with Professor William House”
3Atlas of Surgery of the Facial Nerve
DS Grewal MS DORL FACS Professor and Head of the Department President, Association of Otolaryngologists of India (AOI) – 2005–06 Vice Chairman–Indian Academy of Otolaryngology Bachi T Hathiram MS DORL DNB Associate Professor President AOI, Mumbai – 2003–04 Hon. Associate Secretary AOI – 2005–06 Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Ch. Hospital Mumbai, India
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Atlas of Surgery of the Facial Nerve
© 2006, DS Grewal
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First Edition: 2006
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
… My father Prof. Dr. GS Grewal, an ENT Surgeon par excellence
… My mother Daljit Grewal
… Rouble, my wife
…. Dr DS Grewal
… My parents; Adi and Viloo Mistry
… My husband Tempton
… Karishma and Khushi
…. Dr Bachi T Hathiram6
7List of Contributors
It gives me immense pleasure to write a foreword for this Atlas, as I know the authors Dr DS Grewal and Dr Bachi T Hathiram personally. This Atlas has brought up many thoughts about my experience with the surgical management of the facial nerve.
I finished my residency in ENT at the County Hospital in Los Angeles in July 1956. I joined my brother Howard in his busy practice that was mostly otology. A few months later we imported the first Zeiss surgical microscope in the US. To me it provided a wonderful new look at the temporal bone and opened many new surgical possibilities.
At that time many radical mastoids were done for chronic infection and cholesteatoma to open up the mastoid spaces for drainage. Cure of the infection was not an option. Granulation often covered the middle ear and surrounded the facial nerve. I had been taught that if the facial nerve was so much as touched, it was thought a weakness or paralysis would occur. For this reason the granulation was left to continue draining, but at least the infection would not break into the brain.
The microscope, however allowed gentle elevation of the granulation and careful observation of the facial nerve in its the middle ear portion. I learned amazingly, that touching the facial nerve did not cause facial weakness.
Gradually, that rather than staying away from the facial nerve, I began to identify and use it as a landmark to orient to the structures of the middle ear and mastoid. This led to thoughts that if Bell's palsy was due to swelling of the nerve in the bony canal, maybe removing bone over the middle ear and mastoid part of the nerve would relieve the pressure on the nerve. The technique of the microscope combined with continuous suction irrigation and diamond stone bone removal, was developed. The results were not spectacular but sometimes the weakness of the face would improve right after surgery.
At the same time I had begun to develop the middle fossa approach to the internal auditory canal. The problem was to open the internal auditory canal from above without damaging the facial nerve. I found that by identifying the greater superficial petrosal nerve, following it back to the geniculate ganglion, and then uncovering the nerve as it led down to the internal auditory canal, that I could see everything I needed to see. Again the facial nerve was a friendly landmark rather that a feared no man's land.
This book reviews the many aspects of facial nerve pathology and surgery. There are more than 200 intra-operative photographs—the result of their vast experience over several decades of surgery. This Atlas also incorporates the work of several other experienced surgeons in the field. Otologists today must have this knowledge if they are to serve the best interests of their patients. I hope you, the reader, can be inspired to take this knowledge, learn it well, and then extend it further, for the benefit of mankind.
William F House DDS MD
President, AllHear, Inc.10
The Facial Nerve has fascinated and interested almost all Otologists since several decades leading to extensive studies being carried out on the nerve and it's functions. Inspite of this, a comprehensive atlas featuring various intraoperative photographs of the facial nerve and its pathologies is conspicuous by its absence.
My fascination with the facial nerve goes back several decades when I operated more and more cases of carcinoma of the cheek. Earlier, the trend was to functionally reconstruct the face postoperatively and this was achieved by reconstructing the outer and inner lining of the cheek. However, invariably, this was followed by sagging of the face. According to my experience, there was a failure to realize that, with the inner and outer lining of the cheek there is a middle layer, which includes the facial nerve and hence, is most important from the functional and cosmetic viewpoint. This concept got me interested in facial nerve surgery, and slowly and steadily prompted me to study facial nerve in the middle ear.
The conception of the “Atlas” however was not only because of my keen interest in the facial nerve but also in the art of photography for which I received professional training from the Indo-American Society, Bombay in 1976. The magic of photography is that it allows you to capture a moment before it is gone. I personally believe that a photograph should be such that once the audience sees it, they should be able to visualize the mind of the photographer, and actually feel the pulse of the subject. Pondering over a photograph later may also help a surgeon to observe something new that was previously unnoticed and give him ideas to improvise on his technique.
In my experience, the facial nerve can be considered as the most photogenic structure in the middle ear due to its long and tortuous course. It is best captured on a photograph as it does not reflect light but absorbs it. Its exact intraoperative color is best seen in the light of the operating microscope, photographed without the use of a flash. All these features of facial nerve along with a good surgical exposure make the facial nerve an interesting subject for an atlas. The constant use of Zeiss operating microscopes have significantly contributed to the quality and precision of my photography.
Also, I would like to emphasize that the facial nerve should be considered very much as a part of mainstream ENT surgical practice and should be dealt with confidence by trainee and budding otologists, rather than being scared of it and avoiding it. The purpose of this atlas is to achieve this through exhaustive photographic depiction of the nerve and it's various features (anatomical and pathological), which will allow the young otologist to visualize and indeed understand this so called complex structure as a thing of beauty, and fall in love with the facial nerve. Surgery of facial nerve has proven to increase the chance of cure and hence the perspective towards surgical treatment needs to be changed.
I would like to thank our Dean, Dr Sanjay Oak and our ex-Dean Dr G V Koppikar for giving me all the facilities for facial nerve surgery. I would also like to thank Dr L H Hiranandani, my constant source of inspiration as well as Dr N L Hiranandani my colleague and friend; Prof William House, a legend in Otoneurosurgery for writing the foreword; Prof John Ballantyne one of our senior colleagues and a renowned otologist who has always guided me; Dr David Moffat, Cambridge; Dr Johannes J Manni, Netherlands; and Dr Narendra Pandya, Dr Ashok Shah, Dr CM Deshpande, and Dr AN Modi, India; for their contribution. I am thankful to Dr Mohammed Hashmi for drawing the diagrams for the Atlas. I also would like to thank my lecturer, Dr Nilam Sathe and my past and present residents – Dr Manoj Bhaskaran, Dr Trupti Manjrekar, Dr Neha Shah, Dr Paresh Tankwal, Dr Rahul Mehta, Dr Ashwin Dwivedi, Dr Shobhit 12Srivastava, Dr Ritu Agarwal, Dr Lovneesh Kumar, Dr Santhosh Davis, Dr Minal Shroff, Dr Rajeev T, Dr Mukesh Kumar, Dr Vijay Prakash, Dr Palak Shroff, Dr Prashant Sharma and Dr Mitul Chamadia, as they were associated during various stages of preparation of the Atlas. My special thanks to Dr Alok Mohorikar and Dr Vicky Khattar who have not only contributed a chapter, but have worked tirelessly with us throughout the making of this Atlas. Dr Sonal Saraiya was a great help in the proofreading of the Atlas. I would also like to thank Dr Rohan Walvekar and Dr Kaushal Sheth, my past residents for all their help in the basic stages of the Atlas.
I sincerely hope that this Atlas serves its purpose of enlightening the readers about the various aspects of the facial nerve and the photographs capture the essence of facial nerve surgery, which is important for maintaining the normalcy of the face – truly the index of man.
The facial nerve is considered as a “friend of the otologist” and through our experience, we feel that the facial nerve sheath is a boon to the otologist as it is not only a barrier in limiting the spread of disease to the facial nerve but, also prevents iatrogenic trauma to the nerve. This firm belief of mine forms the principle of unhesitant atraumatic facial nerve surgery.
I am indeed grateful to my colleague and co-author of this atlas, Dr Bachi T Hathiram for making this belief a reality.
Jointly through this Atlas, we have made an effort to familiarize you with our concepts of facial nerve surgery.
Dr DS Grewal