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Acta Neurochirurgica Dec 2017Schwannomas involving the occulomotor cranial nerves (CNs; III, IV and VI), can be disabling, due to the associated diplopia and decreased quality of life and are... (Review)
Review
INTRODUCTION
Schwannomas involving the occulomotor cranial nerves (CNs; III, IV and VI), can be disabling, due to the associated diplopia and decreased quality of life and are extremely rare. We evaluated the role of Gamma Knife surgery (GKS) in these cases.
METHODS
Five patients with CN IV and VI schwannomas (three and two, respectively) were treated in Lausanne University Hospital between 2010 and 2015. Four benefitted from upfront GKS and one from a combined approach (planned subtotal resection followed by GKS), due to a large preoperative tumour volume (size, 3 × 2 × 2.5 cm; volume, 7.9 ml), with symptomatic mass effect and oedema, as well as an entrapement cyst at the brainstem interface, in a young patient. Neuro-ophtalmological evaluation was performed at baseline and during each follow-up time-point. A systematic literature review is presented and compared to the present report.
RESULTS
The mean follow-up was 44.4 months (12-54). Initial clinical presentation was diplopia in four cases and cavernous sinus syndrome in one. The marginal dose was 12 Gy in all cases. The mean target volume was 1.51 cm (0.086-5.8). The mean prescription isodose volume (PIV) was 1.71 cm (0.131-6.7). At last follow-up, all patients presented with disappearance of the baseline symptoms. Tumour control was achieved in 100%, with decrease in volume in all cases. The systematic review analysed 11 peer-reviewed studies, with a total of 35 patients. For uniformly reported CN VI, the mean marginal radiation dose ranged between 12 and 12.5 Gy, with disappearance of symptoms in 12.5%, improvement in 31.25%, stabilisation in 6.25%, worsening in 12.5%. Tumour volume decreased in all cases.
CONCLUSIONS
Our data suggest that first intention GKS is a safe and effective option for patients with small to medium size oculomotor schwannomas, providing a high rate of clinical alleviation and tumour control. When the initial tumour volume is too large for first intention GKS, a combined approach with planned subtotal resection followed by GKS can be performed, with favourable and comparable outcomes as in upfront GKS.
Topics: Abducens Nerve; Adult; Cranial Nerve Neoplasms; Female; Humans; Male; Middle Aged; Neurilemmoma; Quality of Life; Radiosurgery
PubMed: 29022157
DOI: 10.1007/s00701-017-3348-0 -
Asian Journal of Neurosurgery 2021Epidermoid cysts are extra-axial, pearly white avascular lesions mostly found in the cerebellopontine region. They are slow-growing and mostly become symptomatic when... (Review)
Review
BACKGROUND
Epidermoid cysts are extra-axial, pearly white avascular lesions mostly found in the cerebellopontine region. They are slow-growing and mostly become symptomatic when they attain significant size. They do occur at other anatomical locations, but fourth ventricle is a rare location. Three representative cases with their outcomes are described here.
METHODS
The systematic review was done with adherence to predefined criteria. The studied variables were age, gender, duration of symptoms (DOS), clinical features, hydrocephalus (HCP), extent of resection, postoperative complications, outcome, follow-up, and recurrence. Statistical analysis was done to identify predictive factors for outcome.
RESULTS
Final analysis included 58 studies containing 131 patients. The most common clinical feature was cerebellar dysfunction (93%). The most common cranial nerve involved was the abducens nerve ( = 37, 28.46%). Preoperative HCP was present in nearly a third (35%) of patients. The outcomes were not different with age ( = 0.23), gender ( = 0.74), DOS ( = 0.09), and HCP ( = 0.50). Improved outcomes were associated with total resections ( = 0.001), absence of preoperative cranial nerve dysfunctions ( = 0.004), and presentation with features of raised intracranial pressure ( = 0.005). Longer DOS (mean 76.74 months) was associated with significantly increased cranial nerve nuclei involvement ( = 0.03). Aseptic meningitis was reported in 14.5% of cases. Recurrences were infrequently reported ( = 9).
CONCLUSIONS
Although the fourth ventricular epidermoid lesions are difficult to detect in an innocuous stage, when found, they should be extirpated early and totally, as a longer DOS leads to cranial nerve dysfunctions and suboptimal outcomes.
PubMed: 34660356
DOI: 10.4103/ajns.AJNS_539_20 -
World Neurosurgery Feb 2022Metastatic lesions of the clivus are extremely rare, having previously been estimated as representing 0.02% of all intracranial tumors. Owing to its close intracranial... (Review)
Review
BACKGROUND
Metastatic lesions of the clivus are extremely rare, having previously been estimated as representing 0.02% of all intracranial tumors. Owing to its close intracranial relationship with the clivus before entering the cavernous sinus, clinical palsies of the sixth cranial nerve have been classically associated with destructive lesions of this structure.
METHODS
A comprehensive search of PubMed was conducted for studies of patients with metastasis to the clivus from primary cancer at any site. Studies reported in English in the past 20 years from our last search on April 12, 2021 were included. The data collected included patient age, sex, symptoms at presentation, histopathology and treatment timeline of the primary tumor, treatment, follow-up, and mortality.
RESULTS
After the literature review, 46 studies reporting on 58 patients with clivus metastasis were included in the final analysis. The mean age of the patients was 57.5 years, and 39 were male (67.2%). The most common sites of the primary tumor were the prostate (22%), gastrointestinal tract (15%), lung (13%), and kidney (11%). In 43% of patients, symptoms of clivus metastasis had presented before the diagnosis of primary cancer was known, and 71% of the patients had presented with sixth nerve palsy. Of the 58 patients, 53% had undergone surgery, and 37% had received adjuvant radiotherapy. Of the 58 patients, 25% had received radiotherapy alone. The endoscopic transsphenoidal approach to the clivus was almost uniquely used for surgical management. Survival data were available for 31 patients. Death had occurred at a mean of 9.4 months after the presentation of clivus metastasis. A strong correlation was found between the interval from primary cancer to the presentation of clivus metastasis and mortality.
CONCLUSIONS
Although an extremely rare occurrence, clivus metastasis should be considered in patients with a history of malignancy, in particular, prostate malignancy, presenting with new-onset isolated sixth nerve palsy.
Topics: Abducens Nerve Diseases; Cavernous Sinus; Cranial Fossa, Posterior; Endoscopy; Female; Humans; Male; Middle Aged; Skull Base Neoplasms
PubMed: 34861450
DOI: 10.1016/j.wneu.2021.11.105 -
Neurology Feb 2021To describe the spectrum, treatment, and outcome of cranial nerve disorders associated with immune checkpoint inhibitor (Cn-ICI).
OBJECTIVE
To describe the spectrum, treatment, and outcome of cranial nerve disorders associated with immune checkpoint inhibitor (Cn-ICI).
METHODS
This nationwide retrospective cohort study on Cn-ICI (2015-2019) was conducted using the database of the French Refence Center. In addition, a systematic review of the literature (MEDLINE, Scopus, and Web of Science) for records published between 2010 and 2019 was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the search terms cranial nerve or neuropathy or palsy and immune checkpoint inhibitors.
RESULTS
Among 67 cases with ICI-related neurologic toxicities diagnosed in our reference center, 9 patients with Cn-ICI were identified (7 men, 78%, median age 62 years [range 26-82 years]). Patients were receiving a combination of anti-cytotoxic T-lymphocyte antigen 4 and anti-programmed cell death 1 (PD-1)/PD-1 ligand (n = 5, 56%) or anti-PD-1 antibodies alone (n = 4, 44%). Cn-ICI involved optic (n = 3), vestibulocochlear (n = 3), abducens (n = 2), facial (n = 2), and oculomotor (n = 1) nerves. Two patients had involvement of 2 different cranial nerves. Treatment comprised corticosteroids (n = 8, 89%), ICI permanent discontinuation (n = 7, 78%), plasma exchange (n = 2, 22%), and IV immunoglobulin (n = 1, 11%). Median follow-up was 11 months (range 1-41 months). In 3 cases (33%), neurologic deficit persisted/worsened despite treatment: 2 optic and 1 vestibulocochlear. Among cases from the literature and the present series combined (n = 39), the most commonly affected cranial nerves were facial (n = 13, 33%), vestibulocochlear (n = 8, 21%), optic (n = 7, 18%), and abducens (n = 4, 10%). Trigeminal, oculomotor, and glossopharyngeal nerves were less frequently affected (total n = 7).
CONCLUSION
Cranial nerve disorders can complicate treatment with ICIs. Approximately one-third of the patients had persisting deficits, most frequently involving hearing and vision loss.
Topics: Abducens Nerve Diseases; Adult; Aged; Aged, 80 and over; Cranial Nerve Diseases; Facial Nerve Diseases; Female; Follow-Up Studies; Humans; Immune Checkpoint Inhibitors; Male; Middle Aged; Neoplasms; Oculomotor Nerve Diseases; Optic Neuritis; Retrospective Studies; Vestibulocochlear Nerve Diseases
PubMed: 33318162
DOI: 10.1212/WNL.0000000000011340 -
The Cochrane Database of Systematic... Mar 2017The use of botulinum toxin as an investigative and treatment modality for strabismus is well reported in the medical literature. However, it is unclear how effective it... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The use of botulinum toxin as an investigative and treatment modality for strabismus is well reported in the medical literature. However, it is unclear how effective it is in comparison to other treatment options for strabismus.
OBJECTIVES
The primary objective was to examine the efficacy of botulinum toxin therapy in the treatment of strabismus compared with alternative conservative or surgical treatment options. This review sought to ascertain those types of strabismus that particularly benefit from the use of botulinum toxin as a treatment option (such as small angle strabismus or strabismus with binocular potential, i.e. the potential to use both eyes together as a pair). The secondary objectives were to investigate the dose effect and complication rates associated with botulinum toxin.
SEARCH METHODS
We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2016), Embase (January 1980 to July 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 July 2016. We handsearched the British and Irish Orthoptic Journal, Australian Orthoptic Journal, proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA) and International Orthoptic Association (IOA) (www.liv.ac.uk/orthoptics/research/search.htm) and American Academy of Paediatric Ophthalmology and Strabismus meetings (AAPOS). We contacted researchers who are active in this field for information about further published or unpublished studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTS) of any use of botulinum toxin treatment for strabismus.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies and extracted data. We used standard methods expected by Cochrane and assessed the certainty of the evidence using GRADE. We defined ocular alignment as an angle of deviation of less than or equal to 10 prism dioptres.
MAIN RESULTS
Six RCTs were eligible for inclusion. We judged the included studies as at a mixture of low, unclear and high risk of bias. We did not consider any of the included studies as at low risk of bias for all domains.Two trials conducted in Spain (102 people, number of eyes not specified) compared botulinum toxin with surgery in children that required retreatment for acquired or infantile esotropia. These two studies provided low-certainty evidence that children who received botulinum toxin may have a similar or slightly reduced chance of achieving ocular alignment (pooled risk ratio (RR) 0.91, 95% confidence interval (CI) 0.71 to 1.16), binocular single vision (RR 0.88, 95% CI 0.63 to 1.23), sensory fusion (RR 0.88, 95% CI 0.63 to 1.23) and stereopsis (RR 0.86, 95% CI 0.59 to 1.25) compared with children who received surgery. One trial from Canada compared botulinum toxin with surgery in 30 adults (30 eyes) with horizontal strabismus and reported a reduced chance of ocular alignment with botulinum toxin (RR 0.38, 95% CI 0.17 to 0.85; low-certainty evidence).One trial in the UK suggested that botulinum toxin may result in a similar or slightly improved chance of ocular alignment in people with acute onset sixth nerve palsy compared with observation (RR 1.19, 95% CI 0.96 to 1.48; 47 participants, low-certainty evidence).Very low-certainty evidence from one trial from Brazil suggested that adjuvant botulinum toxin in strabismus surgery may increase the chances of ocular alignment compared with strabismus surgery alone (RR 1.83, 95% CI 0.41 to 8.11; 23 participants).One trial from China of 47 participants (94 eyes) suggested that people receiving botulinum toxin combined with sodium hyaluronate may have a similar or slightly reduced chance of achieving ocular alignment compared with botulinum toxin alone (RR 0.81, 95% CI 0.36 to 1.82; low-certainty evidence).Reported complications in people given botulinum toxin in the included trials included ptosis (range 9% to 41.66%) and vertical deviation (range 8.3% to 18.51%). Ptosis occurred less frequently when treated with botulinum toxin combined with sodium hyaluronate compared to botulinum toxin alone.
AUTHORS' CONCLUSIONS
Most published literature on the use of botulinum toxin in the treatment of strabismus consists of retrospective studies, cohort studies or case reviews. Although these provide useful descriptive information, clarification is required as to the effective use of botulinum toxin as an independent treatment modality. Six RCTs on the therapeutic use of botulinum toxin in strabismus, graded as low and very low-certainty evidence, have shown varying responses. These include a lack of evidence for effect of botulinum toxin on reducing visual symptoms in acute sixth nerve palsy, poor response in people with horizontal strabismus without binocular vision, similar or slightly reduced achievement of successful ocular alignment in children with esotropia and potential increased achievement of successful ocular alignment where surgery and botulinum toxin are combined. Further high quality trials using robust methodologies are required to compare the clinical and cost effectiveness of various forms of botulinum toxin (e.g. Dysport, Xeomin, etc), to compare botulinum toxin with and without adjuvant solutions and to compare botulinum toxin to alternative surgical interventions in strabismus cases with and without potential for binocular vision.
Topics: Abducens Nerve Diseases; Adult; Botulinum Toxins, Type A; Child; Humans; Neuromuscular Agents; Randomized Controlled Trials as Topic; Strabismus; Vision, Binocular
PubMed: 28253424
DOI: 10.1002/14651858.CD006499.pub4 -
World Neurosurgery Nov 2023Abducens nerve (AN) schwannomas are extremely rare tumors. Clinical characteristics and factors that influence postoperative outcomes are not well defined. (Review)
Review
BACKGROUND
Abducens nerve (AN) schwannomas are extremely rare tumors. Clinical characteristics and factors that influence postoperative outcomes are not well defined.
OBJECTIVE
To characterize clinical features of AN schwannomas and predictors of surgical outcomes.
METHODS
PRISMA-guided systematic review of the literature on AN schwannomas was performed. Subsequently, univariate and multivariate regression analyses were performed to identify the predictive value of variables that influence postoperative outcomes.
RESULTS
A total of 42 studies with 55 patients were evaluated. The mean age at presentation was 43.9 ± 14.6 years. The most common presenting symptom was cranial nerve VI palsy (69.1%). Cavernous sinus (49.1%) and prepontine cistern (36.3%) were the most commonly involved locations. Complete recovery after surgery was seen in 36.3% at a median follow-up of 28.4 ± 25.8 months. Preoperative AN palsy (P < 0.001), suboccipital approach (P = 0.007), and subtotal resection of tumor (P = 0.044) were significant protective factors for postoperative complications. Prepontine location and postoperative complications were poor prognostic indicators of AN recovery (odds ratio [OR], 0.10, P = 0.030 and OR, 0.10, P = 0.028, respectively). Subtotal resection was significantly correlated with higher odds of AN recovery (OR, 6.06; P = 0.040).
CONCLUSIONS
AN schwannomas are rare but serious tumors that can cause significant morbidity, with only approximately one third of patients showing complete recovery after surgery. The suboccipital approach was a protective factor for postoperative complications, especially when combined with subtotal resection. Knowledge of these factors along with tumor characteristics helps optimize surgical planning and preoperative counseling.
Topics: Humans; Adult; Middle Aged; Abducens Nerve; Cranial Nerve Neoplasms; Abducens Nerve Diseases; Neurilemmoma; Postoperative Complications; Treatment Outcome; Retrospective Studies
PubMed: 37652133
DOI: 10.1016/j.wneu.2023.08.100 -
Strabismus Jun 2023The aim of this systematic review is to identify cases of neurogenic ocular palsy in the presence of COVID-19 and to document patient characteristics, type of palsy and...
BACKGROUND
The aim of this systematic review is to identify cases of neurogenic ocular palsy in the presence of COVID-19 and to document patient characteristics, type of palsy and possible aetiologies.
METHODS
A systematic search of PubMed, Medline and CINAHL databases was conducted on the 6th of January 2023 to identify cases of neurogenic ocular palsy in patients with current or previous COVID-19 infection. Data were pooled to summarise the neurogenic palsy, patient clinical characteristics and proposed palsy mechanisms.
RESULTS
The combined database search yielded 1197 articles. Of these, 23 publications consisting of 25 patients met the inclusion criteria. Most patients were male (68%) and ranged in age from 2 to 71 years (median=32.7, SD=21.4). Seven patients (28%) were children aged 2 to 10 years old. Abducens palsies were most common (68%) and the most common ocular presentation was diplopia (76%) with an average time of onset 15 days from testing positive to COVID-19 or having symptoms of the virus. Proposed mechanism of development of a neurogenic palsy secondary to COVID-19 infection was classified into one of three categories: vascular/thrombotic, a viral neuro-invasive or inflammatory virus-mediated immune response.
DISCUSSION
This study suggests that COVID-19 infection may be linked to oculomotor, trochlear and abducens nerve palsies and the underlying mechanisms may vary but are difficult to definitively establish. Further studies investigating the onset of neurogenic palsy secondary to COVID-19 infection is required.
Topics: Child; Humans; Male; Child, Preschool; Adolescent; Young Adult; Adult; Middle Aged; Aged; Female; COVID-19; Oculomotor Nerve Diseases; Abducens Nerve Diseases; Diplopia; Paralysis
PubMed: 37448224
DOI: 10.1080/09273972.2023.2232419 -
Journal of Neuro-ophthalmology : the... Jun 2022A worldwide mass vaccination campaign against the coronavirus disease 2019 (COVID-19) pandemic is currently underway. Although the safety data of the clinical trials did...
BACKGROUND
A worldwide mass vaccination campaign against the coronavirus disease 2019 (COVID-19) pandemic is currently underway. Although the safety data of the clinical trials did not report specific concerns regarding neuro-ophthalmological adverse events, they involved a limited number of individuals and were conducted over a relatively short time. The aim of the current review is to summarize the available postmarketing data regarding the occurrence of neuro-ophthalmological and other ocular complications of the COVID-19 vaccines.
EVIDENCE ACQUISITION
Electronic searches for published literature were conducted using Ovid MEDLINE, Embase, Web of Science, Google Scholar, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search strategy incorporated controlled vocabulary and free-text synonyms for the concepts of COVID, vaccines, and visual and neuro-ophthalmologic diseases and symptoms.
RESULTS
A total of 14 case reports and 2 case series have been selected for inclusion in the final report, reporting 76 cases of post-COVID-vaccination adverse events. The most common adverse event was optic neuritis (n = 61), followed by uveitis (n = 3), herpes zoster ophthalmicus (n = 2), acute macular neuroretinopathy (n = 2), optic disc edema as an atypical presentation of Guillain-Barré syndrome (n = 1), (arteritic anterior ischemic optic neuropathy; n = 1), abducens nerve palsy (n = 1), oculomotor nerve palsy (n = 1), Tolosa-Hunt syndrome (n = 1), central serous retinopathy (n = 1), acute zonal occult outer retinopathy (n = 1), and bilateral choroiditis (n = 1). Most cases were treated with high-dose steroids and had a favorable clinical outcome.
CONCLUSION
Since the implementation of the COVID-19 vaccination campaign in the past year, several post-COVID-vaccination neuro-ophthalmological complications have been described. However, considering the number of individuals that have been exposed to the vaccines, the risk seems very low, and the clinical outcome in most cases is favorable. Therefore, on a population level, the benefits of the vaccines far outweigh the risk of neuro-ophthalmological complications.
Topics: COVID-19; COVID-19 Vaccines; Herpes Zoster Ophthalmicus; Humans; Pandemics
PubMed: 35427282
DOI: 10.1097/WNO.0000000000001537 -
World Neurosurgery Aug 2017Limited or no literature exists identifying factors associated with functional nerve recovery in patients undergoing resection of sixth cranial nerve (CN VI) schwannomas. (Review)
Review
BACKGROUND
Limited or no literature exists identifying factors associated with functional nerve recovery in patients undergoing resection of sixth cranial nerve (CN VI) schwannomas.
METHODS
A systematic review of literature was performed on CN VI schwannomas that were treated surgically. Synthesizing the findings pooled from the literature, we investigated associations of patient demographics and clinical characteristics with postsurgical CN VI functional recovery in multivariable regression models. In addition, we present the findings of an adolescent woman surgically managed for intracavernous CN VI schwannoma. Complete encasement of the cavernous segment of the internal carotid artery is unique to our case.
RESULTS
We synthesized data of 32 patients from 29 studies, and our index case. Overall, the mean age of the patients was 44.0 ± 16.5 years, and approximately 52% (n = 17) were female. Most tumors were left-sided (n = 18; 54.5%), with an average size of 3.46 ± 1.71 cm. The most common location was cisternal (n = 11; 33%), followed by cavernous sinus (CS) proper (n = 9; 27%), cisterocavernous (n = 8; 24%), orbital (n = 4; 12%) and caverno-orbital (n = 1; 3%). CN VI recovery was reported in less than half the cohort (n = 14; 45%). Tumor extension in the CS was significantly associated with lesser likelihood (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-0.98; P = 0.048) of postsurgical CN VI recovery. Although female gender (OR, 0.86; 95% CI, 0.07-10.09; P = 0.906), large tumor size (>2.5 cm) (OR, 0.45; 95% CI, 0.07-2.89; P = 0.397), and solid consistency (OR, 0.37; 95% CI, 0.03-4.19; P = 0.421) were associated with lesser odds for recovery, these were not statistically significant. Likewise, although gross total resection (OR, 6.28; 95% CI, 0.33-118.25; P = 0.220) was associated with higher odds of nerve recovery, the estimates were statistically insignificant.
CONCLUSIONS
CS involvement is associated with lesser odds for functional nerve recovery in patients undergoing surgical resection for CN VI schwannoma.
Topics: Abducens Nerve; Abducens Nerve Diseases; Adolescent; Adult; Aged; Cavernous Sinus; Child; Cranial Nerve Neoplasms; Female; Humans; Male; Middle Aged; Neurilemmoma; Odds Ratio; Postoperative Complications; Prognosis; Radiosurgery; Recovery of Function; Young Adult
PubMed: 28465275
DOI: 10.1016/j.wneu.2017.04.146 -
International Journal of Oral and... May 2019The aim of this systematic review was to describe the anatomical and surgical factors related to cranial nerve injuries in Le Fort I osteotomy. The protocol of this...
The aim of this systematic review was to describe the anatomical and surgical factors related to cranial nerve injuries in Le Fort I osteotomy. The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO). Two independent reviewers performed an unrestricted electronic database search in the MEDLINE/PubMed, LILACS, Scopus, Web of Science, and Cochrane databases up to and including August 2018. Thirty-two articles were selected for data extraction and synthesis: 30 studies were identified in the main search and two by a manual search. The level of agreement between the reviewers was considered excellent (κ=0.779 for study selection and κ=0.767 for study eligibility). This study revealed that the main nerve affected was the trigeminal nerve, followed by the oculomotor, abducens, optic, facial, and vagus and accessory nerves. Cleft lip and palate patients presented the highest incidence of cranial nerve damage. Cranial nerve damage after Le Fort I osteotomy is not rare. Anatomical and structural knowledge of the patient are necessary in order to minimize the risks of cranial nerve injury in Le Fort I osteotomy.
Topics: Cleft Lip; Cranial Nerve Injuries; Humans; Maxilla; Maxillary Osteotomy; Osteotomy, Le Fort; Prospective Studies
PubMed: 30598335
DOI: 10.1016/j.ijom.2018.11.012