Surgical Management of Acute Facial Palsy

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Key points

  • Bell palsy and traumatic temporal bone fracture are common causes of acute facial palsy.

  • Patients with complete facial paralysis (House-Brackmann 6/6) should undergo electrophysiologic testing (electroneurography [ENoG], electromyography [EMG]).

  • Patients with complete paralysis (House-Brackmann 6/6) within 14 days of symptom onset, greater than 90% degeneration on ENoG testing, and absent EMG activity may benefit from surgical decompression.

  • The return of facial nerve should not be expected for

Rationale for Middle Cranial Fossa Approach for Bell Palsy

The surgical approach for Bell palsy has evolved as the understanding of its pathophysiology has changed. Historically, the stylomastoid foramen and chorda-facial junction have both been proposed as the sites of disorder in Bell palsy.7, 8, 9, 10 Consequently, transmastoid decompression was initially advocated, but later found to be ineffective when performed alone.11, 12

Increased knowledge regarding the site of nerve compression and conduction blockade in Bell palsy became available following

Principles of Electrophysiologic Testing

Electrophysiologic testing provides an objective means of assessing nerve function and is indicated for patients with complete paralysis. Those with incomplete paralysis carry a favorable prognosis and electrophysiologic testing is not indicated. Electrophysiologic testing offers prognostic value for the likelihood of poor recovery (House-Brackmann [HB] grade 3 or higher) in patients with complete paralysis, thereby identifying those who may be candidates for surgical decompression. ENoG and

Facial Nerve Decompression via Middle Cranial Fossa Approach

All patients undergo bone and air conduction audiometry as well as electrophysiologic testing before surgical intervention. MRI or temporal bone CT imaging may be obtained but is not necessary. A preoperative Stenver view plain radiograph may aid in determining the depth of the semicircular canal from the MCF floor.42 The anesthesia team should be informed that long-acting paralytic agents may not be used. Endotracheal intubation is performed and the bed is rotated 180°. An arterial line,

Postoperative Care

Postoperatively, patients should be cared for in the intensive care unit overnight with frequent neurologic examinations. The pressure dressing should be changed every day to assess the skin and check for hematoma or CSF effusion. Oral narcotics usually provide adequate pain control, but intravenous narcotics may be used judiciously for breakthrough pain. Patients are kept nil per os until postoperative day 1. Eye care should be continued through the postoperative period (discussed later).

Summary

Bell palsy or traumatic facial nerve injury are two common causes of acute facial palsy. Bell palsy accounts for most acute facial palsy cases, and most patients with Bell palsy completely recover with medical therapy alone. However, patients with complete paralysis who meet electrophysiologic criteria have a poor prognosis with medical therapy alone and may benefit from facial nerve decompression via an MCF approach. Patients with acute facial palsy from traumatic injury may be candidates for

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    Disclosure: The authors have no conflicts of interest to disclose.

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