Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases

Post-traumatic Delayed Facial Nerve Palsy: Report of 2 Cases and Systematic Review

OBJECTIVE

Delayed facial nerve palsy (dFNP) secondary to head injury is definitely uncommon. Although the mechanism of immediate facial nerve paralysis is well-studied, its delayed presentation remains debated. Given the dearth of available information, we reported herein our experience with 2 cases of posttraumatic dFNP. This systematic review aimed to evaluate all available information on dFNP and to assess treatment outcome also comparing conservatively and surgically approaches.

DATA SOURCES

Pubmed, Scopus, and Web of Science databases were systematically screened.

REVIEW METHODS

The protocol of this investigation was registered on PROSPERO in April 2023 and the systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.

RESULTS

Both patients in the case studies showed a complete recovery within 2 to 3 months after the head trauma. One of them still reported a subjective taste alteration at last control. After the application of the inclusion-exclusion criteria, 9 manuscripts with adequate relevance to this topic were included in the systematic review. The study population consisted of 1971 patients with a diagnosis of posttraumatic facial nerve palsy, of which 128 with a dFNP.

CONCLUSIONS

dFNP due to head trauma is a rarely encountered clinical entity, and optimal treatment still remains to be elucidated. Based on the reported data, it seems rational to propose a conservative approach for dFNP with steroid administration as a first line in most cases, indicating surgery in severe and/or refractory cases.

Temporal Bone Fractures and Related Complications in Pediatric and Adult Cranio-Facial Trauma: A Comparison of MDCT Findings in the Acute Emergency Setting

PURPOSE

The purpose of this study was to analyze the prevalence of and complications resulting from temporal bone fractures in adult and pediatric patients evaluated for cranio-facial trauma in an emergency setting.

METHODS

A retrospective blinded analysis of CT scans of a series of 294 consecutive adult and pediatric patients with cranio-facial trauma investigated in the emergency setting was conducted. Findings were compared between the two populations. Preliminary reports made by on-call residents were compared with the retrospective analysis, which was performed in consensus by two experienced readers and served as reference standard.

RESULTS

CT revealed 126 fractures in 116/294 (39.5%) patients, although fractures were clinically suspected only in 70/294 (23.8%); p < 0.05. Fractures were longitudinal, transverse and mixed in 69.5%, 10.3% and 19.8% of cases, respectively. Most fractures were otic-sparing fractures (95.2%). Involvement of the external auditory canal, ossicular chain and the osseous structures surrounding the facial nerve was present in 72.2%, 8.7% and 6.3% of cases, respectively. Temporal bone fractures extended into the venous sinuses/jugular foramen and carotid canal in 18.3% and 17.5% of cases, respectively. Vascular injuries (carotid dissection and venous thrombosis) were more common in children than in adults (13.6% versus 5.3%); however, the observed difference did not reach statistical significance. 79.5% of patients with temporal bone fractures had both brain injuries and fractures of the facial bones and cranial vault. Brain injuries were more common in adults (90.4%) than in children (63.6%), p = 0.001. Although on-call residents reliably detected temporal bone fractures (sensitivity = 92.8%), they often missed trauma-associated ossicular dislocation (sensitivity = 27.3%).

CONCLUSIONS

Temporal bone fractures and related complications are common in patients with cranio-facial trauma and need to be thoroughly looked for; the pattern of associated injuries is slightly different in children and in adults.

Complications After Pediatric Temporal Bone Fractures by Classification System: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze the rates of complications after pediatric temporal bone fractures (TBF) and the utility of the longitudinal, transverse, and mixed versus the otic capsule sparing (OCS) and otic capsule violating (OCV) classification systems in predicting these complications.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per PRISMA guidelines, studies of children with TBFs were included. Meta-analyses of proportions were performed.

RESULTS

A total of 22 studies with 1376 TBFs were included. Children with TBF had higher rates of conductive hearing loss (CHL) than sensorineural hearing loss (SNHL) (31.3% [95% confidence interval [CI] 23.2-40.1] vs 12.9% [95% CI 8.9-17.5]). No differences in both CHL and SNHL were seen between longitudinal and transverse TBFs; however, OCV TBFs had higher rates of SNHL than OCS TBFs (59.3% [95% CI 27.8-87.0] vs 4.9% [95% CI 1.5-10.1]). Of all patients, 9.9% [95% CI 7.2-13.1] experienced facial nerve (FN) paresis/paralysis, and 13.4% [95% CI 5.9-23.2] experienced cerebrospinal fluid otorrhea. Transverse TBFs had higher rates of FN paresis/paralysis than longitudinal (27.7% [95% CI 17.4-40.0] vs 8.6% [95% CI 5.2-12.8]), but rates were similar between OCS and OCV TBFs.

CONCLUSION

CHL was the most common complication after TBF in children; however, neither classification system was superior in identifying CHL. The traditional system was more effective at identifying FN injuries, and the new system was more robust at identifying SNHL. While these results suggest that both classification systems might have utility in evaluating pediatric TBFs, these analyses were limited by sample size. Future research on outcomes of pediatric TBFs stratified by type of fracture, mainly focusing on long-term outcomes, is needed.

Facial Paralysis Treatment Using Selective Neurectomy: A Comprehensive Review

Facial paralysis can affect patients undergoing full mouth rehabilitation, regardless of what caused their paralysis. A procedure known as modified selective neurectomy of the facial nerve can enhance the movement of facial muscles in individuals with facial synkinesis safely and effectively. This approach is proposed as an alternative to more invasive surgical options when used independently as a treatment for incomplete facial palsy. Selective neurectomy offers a promising surgical option for managing nonflaccid facial paralysis and synkinesis, enhancing patients' quality of life. However, treatment plans should be individually tailored considering the complexity of facial paralysis and the unique needs of each patient, taking into account the timing and type of treatment. The objective of this review is to explore the use of selective neurectomy as a treatment for facial paralysis based on previously published papers.

Totally endoscopic transcanal facial nerve decompression in patients with traumatic facial nerve paralysis: from geniculate ganglion to mastoid segment

OBJECTIVE

The current study evaluated the effectiveness of endoscopic transcanal facial nerve decompression in patients with post-traumatic facial nerve paralysis.

METHODS

This retrospective study included 10 patients with post-traumatic complete facial nerve paralysis who underwent endoscopic transcanal facial nerve decompression. The surgical technique was explained step by step, and the surgical complications, hearing status and facial nerve function 12 months post-operatively were reported.

RESULTS

Endoscopic transcanal facial nerve decompression allowed exposure of the geniculate ganglion to the mastoid segment. The facial nerve function improved from House-Brackmann grade VI to grades I and II in 8 of 10 (80 per cent) patients, and 2 patients experienced partial recovery (House-Brackmann grades III and IV). No severe complication was reported.

CONCLUSION

Endoscopic transcanal facial nerve decompression, involving the nerve from the geniculate ganglion to the mastoid segment, is a safe and effective approach in patients with post-traumatic facial nerve paralysis.

Temporal Bone Trauma

Temporal bone trauma represents a potentially underrecognized condition during head injuries and remains an important consideration during the evaluation of these patients. The temporal bone contains many critical neurovascular structures in addition to the primary organs of the auditory and vestibular systems that may be violated during these injuries. Despite the lack of consensus guidelines on the management of these injuries, this review highlights the current literature regarding the diagnosis and management of temporal bone trauma and its potential complications.

Long-term outcomes of facial nerve decompression by transmastoid versus middle cranial fossa approach for traumatic facial paralysis

OBJECTIVES

To evaluate and compare the long-term results of patients who underwent facial nerve decompression surgery with either transmastoid-supralabyrinthine (TMSL) or combined transmastoid- middle cranial fossa (MCF) approach for traumatic facial nerve paralysis.

MATERIALS AND METHODS

This is a single-center retrospective case-control study. The medical records of traumatic facial paralysis patients with House Brackmann (HB) Grade 6 who underwent facial nerve decompression surgery at via either TMSL or MCF approach between January 2011 and December 2017 were reviewed. The patients who had otic capsule involvement and total sensorineural hearing loss, therefore underwent translabyrinthine facial nerve decompression, and the patients follow-up period has not yet reached four years were excluded from the study. Postoperative HB score and hearing status were compared.

RESULTS

Eleven patients were operated with MCF approach (group 1), while 9 patients with TMSL approach (group 2). Average age of patients was 20.04 + 15.2 (range:4-47) years. Three (15 %) patients were female, while 17 (85 %) was male. Geniculate ganglion (90 %) was the most affected segment of the facial nerve. Facial nerve edema was observed in all cases, while intraneural hematoma were encountered in 4 (20 %) cases. Statistically significant improvement in median HB scores were reached in both groups, and no significant difference was observed in post-operative HB scores between both techniques. No significant difference in median AC 0,5-4 khZ and BC 0,5-3 kHz thresholds was observed between both techniques.

CONCLUSION

Even middle fossa approach is the best surgical technique to explore geniculate ganglion and labyrinthine segment of facial nerve, the functional results of transmastoid supralabrynthine approach, which is not needed craniotomy with low complication rate are as successful as middle fossa approach in selected patients.

Intraoperative electrical stimulation for persistent, post-traumatic facial paralysis

Approximately 7-10% of temporal bone fractures result in facial nerve paralysis. Treatment is dependent upon the severity of the nerve trauma and can range from conservative medical management to surgical intervention. A study by Hato et al. detailed the relationship between surgical timing and recovery rate for patients with facial nerve palsy secondary to temporal bone trauma. The rates of complete recovery and good recovery decline that the longer surgical intervention is delayed. We present the case of a 14-year-old male with a temporal bone fracture and delayed onset right-sided facial paralysis. This patient was treated with a transmastoid middle cranial fossa (MCF) approach with intraoperative electrical stimulation of the perigeniculate portion of the facial nerve. Despite a 53-day delay between trauma and surgical intervention, the patient's facial function improved from House Brackmann (HB) grade VI to grade II within 6 months. Intraoperative facial nerve stimulation, which we have previously used for unresolved Bell's palsy, may be useful for patients with post-traumatic, persistent facial paralysis.

Improved Prediction of Hearing Loss after Temporal Bone Fracture by Applying a Detailed Classification for Otic Capsule-Violating Fracture: A Wide Scope Analysis with Large Case Series

INTRODUCTION

This study aimed to analyze the predictability of temporal bone (TB) fracture-associated hearing loss by applying a detailed classification separating individual injury of the cochlea, vestibule, and semicircular canals (SCC).

METHODS

In this retrospective study, patients with otic capsule-violating (OCV) fractures were further classified as OCV-C(VS) when the cochlea was involved regardless of vestibule or SCC involvement, OCV-V(S) when the vestibule was involved regardless of SCC involvement, and OCV-S when the fracture only involved SCC. Hearing changes were compared by applying the above-mentioned classification, and TB fracture-induced facial palsy was also analyzed.

RESULTS

A total of 119 patients were included. Patients with OCV fractures had significantly worse bone conduction (BC) and air conduction (AC) thresholds (59.1 ± 25.3 and 87.0 ± 29.5 dB) than those with otic capsule-sparing (OCS) fractures (20.1 ± 17.9 and 36.5 ± 21.9 dB; p < 0.001 for each comparison). The BC and the AC thresholds of OCV-C(VS) (77.5 ± 11.0 and 114.2 ± 14.3 dB) and OCV-V(S) (69.3 ± 27.7 and 98.0 ± 22.2 dB) were significantly higher than OCV-S (40.1 ± 22.9 and 62.1 ± 25.6 dB; p < 0.001 for each comparison). The BC hearing thresholds were not significantly improved in the last pure tone audiometry when compared for total, OCV, or OCS cases. The AC threshold significantly improved in OCS cases. In a considerable number of cases with facial palsy, causative fracture lines involved the geniculate ganglion or tympanic segment without the involvement of the otic capsule. Most cases showed significant improvement; however, recovery was limited in cases with obvious fallopian canal disruption.

CONCLUSIONS

The cases with sole involvement of SCC had significantly better hearing thresholds than those with cochlear or vestibule involvement, even in OCV fracture cases.

Surgical and nonsurgical treatment outcomes in traumatic facial nerve palsy

PURPOSE

Facial nerve decompression surgery is performed on patients with immediate, complete traumatic facial palsy. However, the clinical advantage of the surgical treatment has weak evidence because of lack of control groups in previous studies. Therefore, this study compared facial function outcomes between the patients who underwent surgery and those who did not. Furthermore, in cases of bilateral traumatic facial palsy, the outcomes of the surgical and nonsurgical sides were also discussed.

METHODS

A retrospective medical chart review of immediate and severe (House-Brackman [HB] grade V and VI) traumatic facial palsy was conducted. Twenty-five ears from the surgical group and eight ears from the conservative treatment group were enrolled. Among the patients, three with immediate and severe bilateral facial palsy underwent unilateral surgery.

RESULTS

The average HB grade after 1-year follow-up was 1.7 in the surgical group and 1.5 in the nonsurgical group. Four patients who have definite facial canal disruption in the imaging study have recovered to HB grades I-III without surgical intervention. In patients with bilateral facial palsy, the nonsurgical side showed the same or better facial functions than the surgical side.

CONCLUSIONS

Compared with nonsurgical conservative treatment, facial nerve decompression surgery did not show superior outcomes in immediate HB grade V-VI traumatic facial palsy. The clinical advantage of facial nerve decompression is questionable and should be re-evaluated in a prospectively designed study.

A case of facial nerve palsy caused by severe head injury treated by translabyrinthine approach

Background

Several treatments for traumatic facial paralysis have been reported, but the role of surgery is still controversial.

Case Description

A 57-year-old man was admitted to our hospital with head trauma due to a fall injury. A total body computed tomography (CT) scan showed a left frontal acute epidural hematoma associated with a left optic canal and petrous bone fractures with the disappearance of the light reflex. Hematoma removal and optic nerve decompression were performed immediately. The initial treatment was successful with complete recovery of consciousness and vision. The facial nerve paralysis (House and Brackmann scale grade 6) did not improve after medical therapy, and thus, surgical reconstruction was performed 3 months after the injury. The left hearing was lost entirely, and the facial nerve was surgically exposed from the internal auditory canal to the stylomastoid foramen through the translabyrinthine approach. The facial nerve's fracture line and damaged portion were recognized intraoperatively near the geniculate ganglion. The facial nerve was reconstructed using a greater auricular nerve graft. Functional recovery was observed at the 6-months follow-up (House and Brackmann grade 4), with significant recovery in the orbicularis oris muscle.

Conclusion

Interventions tend to be delayed, but it is possible to select a treatment method of the translabyrinthine approach.

Total Transcanal Endoscopic Approach for Selective Facial Nerve Decompression in Traumatic Facial Nerve Palsy

Facial nerve palsy is one of the complications of temporal bone fracture. Several approaches can be used for facial nerve decompression which include the middle cranial fossa approach, transmastoid approach and translabyrinthine approach. When the site of injury is identified at the tympanic segment and perigeniculate area, total transcanal endoscopic approach (TTEA) is an excellent surgical option. This approach is safe and less invasive avoiding external incision and mastoid drilling. Our patient showed recovery to House-Brackmann grade II facial function and reduction of the air-bone gap 6 months after the surgery.

[Traumatology of the lateral skull base]

The most common cause of lateral skull base fractures are still road traffic accidents, followed by falls. The radiologic classification into otic capsule-sparing or otic capsule-violating fractures correlates well with an increased risk of injury to the sensitive structures of the middle ear with otic capsule-violating fractures. In case of immediate onset complete facial nerve paralysis, decompression surgery is generally recommended if bony impingement can be demonstrated on high-resolution CT of the temporal bone. For many other facials nerve complications, recent publications have achieved good to excellent facial nerve recovery rates with watchful waiting under conservative treatment with prednisolone administration.

A Study of Otological Manifestations of Temporal Bone Fractures

The aim of study was to evaluate various otological manifestations of temporal bone fractures and to suggest their management. This prospective observational study was conducted in a tertiary care hospital of Armed Forces over 2.5 years in 57 cases of temporal bone fracture in patients of age group of 12-59 yrs comprising 49 males and 8 females. Radioimaging was done for diagnosing the fracture, mapping its extent and for clinical correlation. Hearing was assessed by tuning forks, free field hearing and pure tone audiogram as per the fitness of patient. Majority of patients were in the age group 20-40 years who had met with road accidents. Important otological features included Battle sign (24.6%), ear canal laceration (53%), tympanic membrane perforation (7%), haemotymanum (40%), ear discharge (66.7%), hearing loss (63%), vertigo (16%), tinnitus (21%), facial paralysis (68%) and cerebrospinal fluid otorrhea (3.5%). Otic capsule sparing fracture was three times more common than violating ones. Facial palsies were treated with oral steroid with complete recovery in 56.41% cases but three required decompression surgery. 4 patients underwent tympanoplasty. Both the cerebrospinal fluid leaks stopped in 2 weeks time. Facial palsy is as common as hearing loss. TM perforation is as rare as CSF leak. Otic capsule violating fracture line is less common. Hearing loss shows recovery in most of the cases. Delayed onset positional vertigo is more common than acute vertigo. Large numbers of immediate onset complete facial palsy do recover from injury without surgery.

[Facial nerve-sublingual nerve parallel bridge anastomosis for facial nerve injury caused by closed temporal bone fractures]

Objective

To investigate the effectiveness of facial nerve-sublingual nerve parallel bridge anastomosis for facial nerve injury resulting from closed temporal bone fractures.

Methods

Between January 2017 and December 2019, 9 patients with facial nerve injury resulting from closed temporal bone fracture caused by head and face trauma were treated. Among them, 5 patients were treated with facial nerve-sublingual nerve parallel bridge anastomosis (operation group), and 4 patients were treated with neurotrophic drugs combined with rehabilitation exercise (conservative group). There was no significant difference in gender, age, side, cause of injury, duration of facial nerve injury before surgery, House-brackmann grading (hereinafter referred to as HB grading) of facial nerve injury, and other general information between 2 groups ( P>0.05). HB grading was used to evaluate the improvement of facial nerve function before and after treatment. At the same time, facial nerve neuroelectrophysiological test was performed to evaluate the electrical activity of facial muscles before and after treatment. Tongue function, atrophy, and tongue deviation were evaluated after nerve anastomosis according to the tongue function scale proposed by Martins et al.

Results

Patients in both groups were followed up 12-30 months, with an average of 25 months. None of the 5 patients in the operation group showed symptoms such as tongue muscle atrophy, tongue extension deviation, hypoglossal nerve dysfunction (mainly including slurred speech, choking with water), postoperative infection, bleeding, lower limb muscle atrophy or lower limb motor dysfunction after sural nerve injury. Postoperative skin sensory disturbance in lateral malleolus area was found, but gradually recovered to normal. During the follow-up, facial nerve and sublingual motor neurons were innervated to paralyzed facial muscle in the operation group. At last follow-up, the HB grading of 5 patients in the operation group improved from preoperative grade Ⅴ in 2 cases, grade Ⅵ in 3 cases to grade Ⅱ in 3 cases, grade Ⅲ in 1 case, and grade Ⅳ in 1 case. And in the conservative group, there were 1 patient with grade Ⅴ and 3 patients with grade Ⅵ before operation, facial asymmetry continued during follow-up, and only 2 patients improved from grade Ⅵ to grade Ⅴ at last follow-up. There was significant difference in prognosis HB grading between the two groups ( t=5.693, P=0.001). In the operation group, the amplitude and frequency of F wave were gradually improved, and obvious action potential could be collected when the facial muscle was vigorously contracted. On the contrary, there was no significant difference in neuroelectrophysiological results before and after treatment in the conservative group.

Conclusion

Facial nerve-sublingual nerve parallel bridge anastomosis can effectively retain the integrity of the facial nerve, while introducing the double innervation of the sublingual nerve opposite nerve, which is suitable for the treatment of severe incomplete facial nerve injury caused by closed fracture.

Facial Nerve Hematoma After Penetrating Middle Ear Trauma: A Cause of Delayed Facial Palsy

ABSTRACT

Penetrating middle ear injury may cause hearing loss, vertigo, or facial nerve injury, although facial nerve paralysis followed by head trauma is a rare condition. In this study, we report a case of a 3-year-old patient with delayed facial palsy on the left side that developed 4 days after an accidental tympanic membrane perforation caused by a cotton-tipped swab. Otoendoscopic examination revealed a perforation in the posterosuperior quadrant of the tympanic membrane. Audiometry revealed no hearing loss on the injured side, and eye movement examination did not reveal spontaneous or positional nystagmus. Pre- and postcontrast T1-weighted magnetic resonance imaging demonstrated high signal intensity along the tympanic portion of the fallopian canal, which suggested that hemorrhage within the facial canal may be a cause of delayed facial palsy. It can be assumed that traumatic injury at the dehiscent facial nerve in the tympanic portion caused hematoma within the fallopian canal, resulting in delayed facial nerve palsy.

Outcomes and prognostic factors of facial nerve repair: a retrospective comparative study of 31 patients and literature review

PURPOSE

To evaluate functional results of facial nerve repair by direct nerve suture or grafting, compare results between a traumatic and a tumoral group and identify prognostic factors.

METHODS

A retrospective monocentric cohort study was studied in a university ENT department. Thirty-one patients who benefited from facial nerve suture or grafting, with at least 12 months postoperative follow-up were included. Patients were divided into two groups according to the lesion type: traumatic (accident of the public road or iatrogenic) and tumoral. Preoperative data studied were sex, side, etiology documented by CT and/or MRI, facial palsy duration and grade according to House Brackmann grading system. Intraoperative data included: surgeon, age of patient, surgical technique, graft type, use of biological glue, facial nerve derivation, lesioned site. Postoperative data included: histological diagnosis, radiotherapy history, time to onset of the first signs of reinnervation, follow-up duration, and final facial function.

RESULTS

Success rate, including grade III and IV, was 68% in the whole cohort, 79% in the traumatic group and 59% in the tumoral group. Patients presenting with facial palsy evolving less than 6 months had better recovery results than those evolving longer than 6 months (p = 0.02). No other prognostic factors were identified.

CONCLUSIONS

The best outcome that can be achieved by suture or grafting of the facial nerve in traumatic or tumoral lesions is a grade III. Preoperative facial palsy duration is a prognostic factor and must be considered when establishing an operative indication.

Effectiveness of Surgical Treatment in Traumatic Facial Paralysis

INTRODUCTION

In the etiology of facial nerve palsy, trauma is the most important. Our aim was to present our experience gained by evaluating the surgical approaches we have used in extratemporal and intratemporal facial nerve injuries and their long-term results, also to contribute to the consensus that will be formed on this subject.

MATERIALS AND METHODS

Thirteen patients among 24 patients who underwent surgery with a diagnosis of traumatic facial paralysis were evaluated in this study. The clinical response of these patients to treatment was examined by classifying them according to the House-Brackmann classification in the preoperative and postoperative periods.

RESULTS

Of the 13 patients, 9 had fractures due to temporal bone trauma, and 4 had nerve damage in the extratemporal part of the facial nerve. In the treatment, facial nerve decompression was performed using the middle fossa approach in 9 patients with temporal bone fractures. In the 4 patients with extratemporal facial nerve injury, graft repair or primary suturing was performed. In the postoperative period, the stages of the patients were III or below in 12 patients (92%), and only 1 (8%) patient remained in stage IV.

DISCUSSION

When the postop conditions of the patients were examined according to House-Brackmann staging, it was observed that surgical treatment caused a significant improvement in the functions of the facial nerve.

CONCLUSIONS

Our results showed that surgery was an effective treatment method in patients with indications for traumatic facial paralysis.

Endoscopic Decompression of the Labyrinthine Segment of the Facial Nerve

OBJECTIVE

To describe the outcome and feasibility of an exclusive endoscopic transcanal transpromontorial approach (ETTA) for decompression of the labyrinthine segment of the facial nerve (LSFN).

PATIENT

A 60-year-old man with a left-sided transverse fracture of temporal bone involving the LSFN, resulting in a grade VI House-Brackmann (HB) facial palsy, associated with ipsilateral total sensorineural hearing loss.

INTERVENTION

Surgical decompression of the LSFN by ETTA.

MAIN OUTCOME MEASURE

The patient underwent ETTA which allowed complete exposure and decompression of the LSFN.

RESULTS

One year postoperatively, the patient had recovered with House-Brackmann grade II facial function.

CONCLUSION

ETTA can be considered a valuable and appropriate technique for posttraumatic decompression of LSFN, associated with unilateral total sensorineural hearing loss. The procedure resulted in significant facial nerve function improvement. ETTA should be considered both a scarless, mastoid conserving and less invasive surgical technique for posttraumatic LSFN decompression associated with pre-existing cochlear impairment.

CT of Skull Base Fractures: Classification Systems, Complications, and Management

As advances in prehospital and early hospital care improve survival of the head-injured patient, radiologists are increasingly charged with understanding the myriad skull base fracture management implications conferred by CT. Successfully parlaying knowledge of skull base anatomy and fracture patterns into precise actionable clinical recommendations is a challenging task. The authors aim to provide a pragmatic overview of CT for skull base fractures within the broader context of diagnostic and treatment planning algorithms. Laterobasal, frontobasal, and posterior basal fracture patterns are emphasized. CT often plays a complementary, supportive, or confirmatory role in management of skull base fractures in conjunction with results of physical examination, laboratory testing, and neurosensory evaluation. CT provides prognostic information about short- and long-term risk of cerebrospinal fluid (CSF) leak, encephalocele, meningitis, facial nerve paralysis, hearing and vision loss, cholesteatoma, vascular injuries, and various cranial nerve palsies and syndromes. The radiologist should leverage understanding of specific strengths and limitations of CT to anticipate next steps in the skull base fracture management plan. Additional imaging is warranted to clarify ambiguity (particularly for potential sources of CSF leak); in other cases, clinical and CT criteria alone are sufficient to determine the need for intervention and the choice of surgical approach. The radiologist should be able to envision stepping into a multidisciplinary planning discussion and engaging neurotologists, neuro-ophthalmologists, neurosurgeons, neurointerventionalists, and facial reconstructive surgeons to help synthesize an optimal management plan after reviewing the skull base CT findings at hand. Online supplemental material is available for this article. ^©RSNA, 2021.

Is Early Traumatic Facial Nerve Surgery a Priority during the COVID-19 Pandemic?

As otolaryngologists are exposed to high risk of coronavirus disease 2019 (COVID-19) infection, logic and evidence-based prioritization for surgeries is essential to reduce the risk of infection amongst healthcare workers. Several clinical guidelines and surgery prioritizing recommendations have been published during the COVID-19 pandemic. They recommended the surgery in the setting of immediate facial nerve paralysis within 72 hours after trauma, but none of the previous studies in the literature suggests that the optimal timing of operation should be less than 2 weeks from injury.

Complete laceration of motor branches of facial nerve and its successful repair: A case report from Afghanistan

INTRODUCTION

Facial nerve (the seventh cranial nerve) injury causes functional, aesthetic, and psychological difficulties. The second most common cause of facial nerve palsy is trauma.

PRESENTATION OF CASES

A previously healthy 21-year-old worker, was brought to emergency room after car accident, with complete paralysis of all muscles of the left side of his face. He was transferred to operating room. After anatomical determining the nerve, end-to-end manner was done. After nine month of follow up an excellent repair was seen.

DISCUSSION

Traumatic facial nerve injury is usually accompanied by temporal bone fracture (up to 70 percent) but in some cases facial nerve is damaged without any fractures, and damage of facial nerve branches can happen due to laceration. Management of an injured facial nerve depends on its etiology. There are three main options for facial nerve repair; direct end-to-end coaptation, coaptation with an interposition graft and nerve transfer. Surgery exploration is indicated in patients with complete and immediate facial nerve paralysis and denervation more than 90 % electrophysiological findings.

CONCLUSION

Traumatic facial nerve paralysis management is challenging considering operation in low resources countries. In this case early repair of facial nerve is beneficial and has a good to excellent prognosis in immediate complete damage of facial nerve even without accessibility to electroneurography or electromyography to estimate the severity of injury.

Evaluation of Clinical Outcome in Traumatic Facial Nerve Paralysis

Introduction  The facial nerve is the most commonly paralyzed nerve in the human body, resulting in far-reaching functional, aesthetic and emotional concerns to the patient.

Objective  Evaluation of the clinical outcome of 47 patients with traumatic facial nerve paralyses, with respect to clinical recovery and audiological sequelae.

Methods  A descriptive longitudinal study was conducted over 24 months between January 2017 and December 2018 at a tertiary center with detailed clinical, topodiagnostic, audiometric and radiological evaluation and regular follow-up after discharge.

Results  Road traffic accidents constituted 82.98% of the trauma cases, out of which 76.60% were found to be under the influence of alcohol.

Delayed facial paralysis was observed in 76.60% cases. Temporal bone fracture was reported in 89.36%, with otic capsule (OC) sparing fractures forming 91.49% of the cases. Topologically, the injury was mostly at the suprachordal region around the second genu. The majority of the patients (65%) attained full recovery of facial nerve function with conservative medical management. Audiometrically, 77.27% of the patients had hearing loss at the time of presentation, of which 64.71% were conductive in nature; 51.22% attained normal hearing at follow-up visits.

Conclusion  Early initiation of steroid therapy, concurrent eye care and physiotherapy are the cornerstones in the management of traumatic facial nerve paralysis.

Our Experience on Temporal Bone Fractures: Retrospective Analysis of 141 Cases

Temporal bone fractures are a common lesion of the base of the skull. The diagnosis and management of temporal bone fractures require a multidisciplinary approach. Variable clinical presentations may arise from such fractures, ranging from an asymptomatic course to very serious consequences. The aim of this study was to report our experience with a series of patients with temporal bone fractures and to propose a diagnostic/therapeutic algorithm. This study enrolled 141 patients, 96 (68.1%) males and 45 (31.9%) females, ranging in age from 20 to 60 (average age: 39 ± 4.1 years), with temporal bone fractures who were referred to Cardarelli Hospital between 2006 and 2018. The present paper presents a classification of temporal bone fractures and typical clinical sequelae and provides an illustration of their prognosis and treatment.

Bilateral Traumatic Facial Paralysis with Hearing Impairment and Abducens Palsy

The temporal bone is often affected in basilar skull fractures. Fractures involving the petrous portion are particularly significant, as they may be associated with neurovascular sequelae. Bilateral facial paralysis secondary to bilateral temporal bone fracture is a rare clinical entity, even more so when associated with other cranial nerve damage such as abducens nerve paralysis and hearing impairment. Only 4 similar cases have been reported in the literature to date. In this paper, we describe a 28-year-old male patient with bilateral facial paralysis, unilateral abducens palsy, and bilateral hearing loss due to bitemporal fractures that developed after a motor vehicle accident. Conservative management was preferred. The 6-month follow-up showed remarkable improvement. This report highlights the effectiveness of conservative management in posttraumatic complete facial and abducens palsy.

Simultaneous bilateral traumatic facial palsy with different treatment protocols

INTRODUCTION

Bilateral simultaneous facial palsy is a rare clinical entity. Traumatic origin is even rarer. Long-term sequelae are disabling. Therefore, rapid and adequate management is crucial.

CASE PRESENTATION

Herein we present a case report of a traumatic bilateral facial palsy in a 43 years old male treated with surgery in one side and conservative treatment in the other side. He achieved eye closure at his 10 months follow up.

DISCUSSION

Electroneurography showing more than 90 % of facial nerve degeneration and electromyography revealing no regeneration potentials are identified as surgical indications. The perigeniculate region is the most commonly injured portion of the facial nerve with temporal bone fractures. Surgical approach to this area remains controversial; transmastoid, middle fossa craniotomy or a combination of both.

CONCLUSION

It is important to discuss expectations with the patient as it might take 12 months to regain maximal nerve function.

Tapia Syndrome After Cervical Laminoplasty: A Case Report and Review of the Literature

BACKGROUND

Tapia syndrome is a rare complication of surgical positioning with resulting unilateral cranial nerve X and XII deficits that may provide diagnostic challenges in the perioperative period. Timely diagnosis will facilitate obtaining the necessary supportive care while preventing unnecessary workup and procedures.

CASE DESCRIPTION

The following case report illustrates a patient that developed Tapia syndrome immediately after a posterior cervical laminoplasty with eventual resolution of symptoms. A review of the literature was also undertaken for comparison.

CONCLUSIONS

Tapia syndrome can occur with a variety of surgeries, but appear to be most common in surgeries of the posterior cervical spine in the neurosurgical literature. It is theorized that flexed head position common among posterior cervical procedures makes patients more prone to Tapia syndrome in these cases. The ideal management remains poorly defined in the literature. The time course and resolution of neurologic deficits support a transient neuropraxic mechanism in most cases, though some patients do suffer permanent deficits.

A large case series of temporal bone fractures at a UK major trauma centre with an evidence-based management protocol

OBJECTIVE

To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol.

METHODS

A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention.

RESULTS

Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients.

CONCLUSION

Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.

Nonsurgical Treatment for Posttraumatic Complete Facial Nerve Paralysis

Importance

Current recommendations envisage early surgical exploration for complete facial nerve paralysis associated with temporal bone fracture and unfavorable electrophysiologic features (response to electroneuronography, <5%). However, the evidence base for such a practice is weak, with the potential for spontaneous improvement being unknown, and the expected results from alternative nonsurgical treatment also undefined.

Objective

To document the results of nonsurgical treatment for posttraumatic complete facial paralysis with undisplaced temporal bone fracture and unfavorable electrophysiologic features.

Design, Setting, and Participants

Prospective cohort study recruiting from April 2010 to April 2013 at a tertiary care university hospital. Follow-up continued until 9 months or until complete recovery if earlier. Study group included 28 patients with head injury-associated complete unilateral facial nerve paralysis with unfavorable results of electroneuronography (<5% response) with or without undisplaced temporal bone fracture. Undisplaced temporal bone fractures were documented in 26 patients (24 longitudinal fractures and 2 transverse fractures).

Interventions

Patients received prednisolone, 1 mg/kg, for 3 weeks combined with clinical monitoring every 2 weeks and electromyography monitoring every 4 weeks. As per study protocol, surgical exploration was limited to patients demonstrating motor end plate degeneration on results of electromyography, or having no improvement until 18 weeks.

Main Outcomes and Measures

Facial nerve function was evaluated by the House-Brackmann grading system; Forehead, Eye, Mouth, and Associated defect grading system; and the modified Adour system. Observations were completed at 40 weeks.

Results

Among the 28 patients in the study (3 women and 25 men; mean [SD] age, 32.2 [8.7] years), facial nerve recovery with conservative treatment alone was noted in all patients. No recovery was seen in any patient at the initial 4-week review. The first signs of clinical recovery were noted in 4 patients by 8 weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks. No patient required surgical exploration. At 40 weeks, 27 patients recovered to House-Brackmann grade I/II and 1 patient to grade III. All 24 patients with longitudinal fractures had grade I/II recovery.

Conclusions and Relevance

For undisplaced temporal bone fractures, nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results. Recovery is delayed and usually first manifests at 8 to 12 weeks after the fracture. In the current era of high-resolution computed tomography, surgical exploration should not be first-line treatment for undisplaced longitudingal temporal bone fractures associated with complete facial nerve paralysis and unfavorable electrophysiologic features.

Facial Nerve Trauma: Clinical Evaluation and Management Strategies

The field of facial paralysis requires the reconstructive surgeon to apply a wide spectrum of reconstructive and aesthetic principles, using a comprehensive array of surgical tools, including microsurgery, peripheral nerve surgery, and aesthetic facial surgery on the road to optimize patient outcomes. The distinct deficits created by different anatomical levels of facial nerve injury require a fundamental understanding of facial nerve anatomy. Palsy duration, followed by location and mechanism, will determine mimetic muscle salvageability, by means of either direct repair, grafting, or nerve transfers, whereas longer palsy durations will necessitate introducing a new neuromuscular unit, whether by muscle transfer or free functional muscle transplant. A thorough history, physical examination, and basic understanding of ancillary studies, emphasizing palsy duration, location, and mechanism of injury, are critical in evaluation, prognostication, and treatment strategies in traumatic facial palsy patients. The importance of ancillary and aesthetic procedures cannot be overstated. Although these do not provide motion, they constitute essential tools in the treatment of facial paralysis, providing both protective and improved aesthetic outcomes, yielding the highest impact in final surgeon and patient satisfaction, bringing our patients to smile not only on the outside, but also on the inside.

Conservative versus Surgical Therapy in Managing Patients with Facial Nerve Palsy Due to the Temporal Bone Fracture

Facial nerve paralysis is classified into immediate or delayed-onset palsy, and affected patients should be treated through conservative or surgical therapy. Appropriate treatment is somewhat debated as well as proper time for performing surgery. This study aimed to assess treatment outcome between conservatively and surgically treated groups and to determine the appropriate time of surgery in selected patients for surgery. Twenty-four patients from April 2008 to July 2015 were included. Performing decompression surgery within the first 2 months following the trauma accompanies a better prognosis ( p -value < 0.05). Eleven patients were managed conservatively, and 4 of them demonstrated immediate onset and 7 indicated delayed onset. Nine patients obtained normal nerve function, one patient had partial palsy, and one of them had complete palsy. There was no significant difference in the rate of recovery between types of the treatment ( p -value > 0.05). Decompression surgery is recommended in the first 2 months after the trauma for immediate onset and also complete degeneration on electroneuronography.

The Outcome Analysis of Traumatic Facial Nerve Palsy Treated With Systemic Steroid Therapy

PURPOSE

Although facial nerve palsy is uncommon after a blunt craniofacial injury, it will result in functional and aesthetic disability if full recovery is not achieved. Currently, the management is still controversial and mainly through systemic steroid therapy or surgical decompression. However, current studies mainly focus on the surgical intervention, and only a few of these studies discuss the details of the steroid treatments. Thus, the purpose of this study is to analyze possible prognosis factors of systemic steroid in managing traumatic facial nerve palsy after a blunt craniofacial injury retrospectively.

METHODS

During the period from May 2005 to April 2015 at Chang Gung Memorial Hospital, a total of 26 patients who suffered from post-traumatic facial nerve palsy receiving steroid therapy were enrolled in the study. All the patient's charts were reviewed, recorded, and analyzed including the general data, temporal bone fracture type, hospital courses, trauma-related data from emergency room records, and initial and final facial nerve palsy grading. The facial nerve palsy was graded using the House-Brackmann (HB) system; the final HB grade I was set as full recovery.

RESULTS

The outcome showed steroid therapy onset within 24 hours (odds ratio [OR] = 10.111; 95% confidence interval [CI] = 1.597-64.005; P = 0.014) and steroid therapeutic duration for longer than 14 days (OR = 11.571; 95% CI = 1.172-114.262; P = 0.036) possessed a significantly better recovery rate.

CONCLUSION

This study recommends to apply steroids within 24 hours once post-traumatic facial palsy occurs and the therapy should persist longer than 14 days.

Comparison of the application of artificial ossicles and autologous ossicles in the reconstruction of a damaged ossicular chain

OBJECTIVE

To evaluate the therapeutic effect that the titanium partial ossicular reconstruction prosthesis and autologous ossicles have on hearing loss after reconstruction of a damaged ossicular chain.

METHODS

Forty-two medical records of treatments carried out from 2013 to 2015 for ossicular chain damage with facial nerve paralysis due to temporal bone fractures were reviewed. The study assessed: causes of damage, pre-operative pure tone audiometry findings, types of intra-operative ossicular chain damage, intra-operative ossicular chain repair methods (titanium partial ossicular reconstruction prosthesis or autologous ossicles) and post-operative pure tone audiometry results.

RESULTS

The titanium partial ossicular reconstruction prosthesis was used in 26 cases; the average air-bone gap was 32.3 ± 5.3 dB pre-operatively and 12.8 ± 5.3 dB post-operatively. Autologous ossicles were used in 16 cases; the average air-bone gap was 33.4 ± 4.5 dB pre-operatively and 17.8 ± 7.8 dB post-operatively.

CONCLUSION

Ossicular chain reconstruction is an effective way of improving hearing in patients with ossicular chain damage. The results suggest that repair with either the titanium partial ossicular reconstruction prosthesis or autologous ossicles can improve hearing following ossicular chain injury with facial nerve paralysis caused by a temporal bone fracture.

Stem Cells from Human Exfoliated Deciduous Teeth (SHED) Differentiate in vivo and Promote Facial Nerve Regeneration

Post-traumatic lesions with transection of the facial nerve present limited functional outcome even after repair by gold-standard microsurgical techniques. Stem cell engraftment combined with surgical repair has been reported as a beneficial alternative. However, the best association between the source of stem cell and the nature of conduit, as well as the long-term postoperative cell viability are still matters of debate. We aimed to assess the functional and morphological effects of stem cells from human exfoliated deciduous teeth (SHED) in polyglycolic acid tube (PGAt) combined with autografting of rat facial nerve on repair after neurotmesis. The mandibular branch of rat facial nerve submitted to neurotmesis was repaired by autograft and PGAt filled with purified basement membrane matrix with or without SHED. Outcome variables were compound muscle action potential (CMAP) and axon morphometric. Animals from the SHED group had mean CMAP amplitudes and mean axonal diameters significantly higher than the control group (p < 0.001). Mean axonal densities were significantly higher in the control group (p = 0.004). The engrafted nerve segment resected 6 weeks after surgery presented cells of human origin that were positive for the Schwann cell marker (S100), indicating viability of transplanted SHED and a Schwann cell-like phenotype. We conclude that regeneration of the mandibular branch of the rat facial nerve was improved by SHED within PGAt. The stem cells integrated and remained viable in the neural tissue for 6 weeks since transplantation, and positive labeling for S100 Schwann-cell marker suggests cells initiated in vivo differentiation.

Bilateral Post-Traumatic Facial Paralysis That Contains Longitudinal and Transverse Temporal Fracture

Acute bilateral post-traumatic facial paralysis is rare in the literature. Post-traumatic facial paralysis is frequently accompanied transverse fractures of temporal more. The incidence of acute bilateral post-traumatic facial paralysis has been reported as 1 to 5 per million in the literature. Trauma and concurrent facial paralysis are usually in the same subsite (right temporal bone fracture and right facial paralysis). There is one pathophysiological pattern for a single temporal bone fracture in a subsite. The authors present a bilateral isolated different pathophysiological pattern sudden onset facial paralysis in a patient herein.

Hypoglossal-facial nerve "side-to-side" neurorrhaphy for facial paralysis resulting from closed temporal bone fractures

BACKGROUND

Closed temporal bone fractures due to cranial trauma often result in facial nerve injury, frequently inducing incomplete facial paralysis. Conventional hypoglossal-facial nerve end-to-end neurorrhaphy may not be suitable for these injuries because sacrifice of the lesioned facial nerve for neurorrhaphy destroys the remnant axons and/or potential spontaneous innervation.

OBJECTIVE

we modified the classical method by hypoglossal-facial nerve "side-to-side" neurorrhaphy using an interpositional predegenerated nerve graft to treat these injuries.

METHODS

Five patients who experienced facial paralysis resulting from closed temporal bone fractures due to cranial trauma were treated with the "side-to-side" neurorrhaphy. An additional 4 patients did not receive the neurorrhaphy and served as controls.

RESULTS

Before treatment, all patients had suffered House-Brackmann (H-B) grade V or VI facial paralysis for a mean of 5 months. During the 12-30 months of follow-up period, no further detectable deficits were observed, but an improvement in facial nerve function was evidenced over time in the 5 neurorrhaphy-treated patients. At the end of follow-up, the improved facial function reached H-B grade II in 3, grade III in 1 and grade IV in 1 of the 5 patients, consistent with the electrophysiological examinations. In the control group, two patients showed slightly spontaneous innervation with facial function improved from H-B grade VI to V, and the other patients remained unchanged at H-B grade V or VI.

CONCLUSIONS

We concluded that the hypoglossal-facial nerve "side-to-side" neurorrhaphy can preserve the injured facial nerve and is suitable for treating significant incomplete facial paralysis resulting from closed temporal bone fractures, providing an evident beneficial effect. Moreover, this treatment may be performed earlier after the onset of facial paralysis in order to reduce the unfavorable changes to the injured facial nerve and atrophy of its target muscles due to long-term denervation and allow axonal regrowth in a rich supportive environment.

Surgery for post-traumatic facial paralysis: are we overdoing it?

PURPOSE

Early facial nerve decompression is recommended for cases of post-traumatic facial palsy on the basis of ENoG with degeneration > 95%. There is still a dispute in the literature concerning the role and timing of surgery versus conservative treatment in such cases. This study has been planned to evaluate the outcome of conservative management in traumatic facial paralysis with regard to type of trauma, onset, and electrodiagnostic tests.

METHODS

A prospective cohort study included 39 patients with post-traumatic facial palsy. All patients underwent ENoG, nerve stimulation test, HRCT temporal bone and Schirmer's test. The patients received intravenous methylprednisolone 1 gm/day for 5 days or oral prednisolone 1 mg/kg in tapering doses for 3 weeks. Follow-up was done at 4, 12 and 24 weeks after the treatment. Surgical exploration was limited to patients showing no improvement after 12 weeks. Facial nerve function was evaluated by the HBFNS and FEMA grading systems.

RESULTS

Among the 39 patients in the study [5 women and 34 men; mean (SD) age, 33.5 (11.37) years], facial nerve recovery with conservative treatment alone was noted in 31 patients. The first signs of clinical recovery were noted in 27 patients by 4 weeks, in 31 patients by 12 weeks. Seven patients required surgical exploration. At 24 weeks, 31 patients recovered to House-Brackmann grade I/III and 1 patient to grade IV. 19 of 26 patients with longitudinal fractures had grade I/III recovery, whereas all 6 patients with transverse fracture recovered on conservative treatment.

CONCLUSIONS

Patients with incomplete facial palsy are candidates for conservative management. It is justified to try conservative management in patients with complete facial paralysis for up to 3 months even in cases where ENoG and NET suggest poor prognosis. The presence of sensorineural hearing loss or transverse fracture at presentation does not suggest a poor prognosis for improvement.

Total Transcanal Endoscopic Facial Nerve Decompression for Traumatic Facial Nerve Palsy

A few approaches can be used to decompress traumatic facial nerve paralysis including the middle cranial fossa approach or transmastoid approach depending on the site of injury. In some specific situation of treating traumatic facial nerve palsy whose injured site was confined from the geniculate ganglion to the second genu, transcanal endoscopic approach for facial nerve decompression can be used. We performed two cases of total endoscopic transcanal facial nerve decompression in patients with traumatic facial nerve palsy. After a six month follow-up, both patients showed improvement in facial function by 2 grades according to House-Brackmann grade system. In terms of treatment outcomes, total transcanal endoscopic facial nerve decompression for traumatic facial nerve palsy is an alternative for lesions limited to the tympanic segment I, and has an advantages of being minimally invasive and is cosmetically acceptable without an external scar or bony depression due to drilling.

Post Temporal Bone Fracture Facial Paralysis: Strategies in Decision Making and Analysis of Efficacy of Surgical Treatment

Management of traumatic facial nerve injuries after temporal bone fractures is both challenging and controversial. The dilemma is whether to operate or not and if operating, when to operate and how much of the nerve to decompress. The aim of this study is to review our criteria for decision making in management of patients with temporal bone fracture induced facial nerve palsy, and analyze outcome of patients selected for surgical management. Review of 28 cases of temporal bone fracture between 2012 and 2016 was carried out. Patient assessment included clinical, audiological, computer tomography scans and electromyography (EMG) examinations. All 28 cases were initially started on conservative medical treatment. Based on criteria of complete clinical paralysis at onset, no improvement with conservative treatment and fibrillation potential in EMG, 10 cases underwent surgical decompression through the transmastoid approach. Among the 10 surgically-treated patients, lesions were predominantly found in geniculate ganglion area. Analysis of results after 12 months revealed 70% of cases who underwent surgery had House Brackmann (HB) Grade I-II recovery. Good recovery was achieved in all 18 medically treated patients (HB Grade I-II). Candidate selection based on accurate clinical judgment and judicious use of electrodiagnostic tests plays a vital role in outcomes in the treatment of post traumatic facial injury. Early surgical intervention gave better results in our study.

Is Serial Electroneuronography Indicated Following Temporal Bone Trauma?

OBJECTIVE

Contemporary guidelines advise facial nerve (FN) decompression within 2 weeks of temporal bone trauma if a single electroneuronography (ENoG) demonstrates more than 90% degeneration of the FN. We report a case series demonstrating the potential of serial ENoG to guide FN management more than 2 weeks following injury.

PATIENTS

Adults with traumatic temporal bone fractures and resultant ipsilateral FN paresis.

INTERVENTION

Serial ENoG followed by observation or decompression of the FN.

MAIN OUTCOME MEASURE

House-Brackmann (HB) graded FN function.

RESULTS

Nine cases of blunt temporal bone trauma resulting in ispilateral FN paralysis were identified and reviewed. Two patients were women, and average age at the time of trauma was 30 years (range, 17-52). Immediate paralysis occurred in four cases, while five were delayed. A single ENoG was performed in seven patients and was predictive of final function in six, while one patient had an initially reassuring ENoG but did not obtain full recovery of FN function (HB 4). Two patients underwent serial ENoG on a weekly basis which, while initially reassuring, demonstrated declining FN function on subsequent testing. Decompression was performed in both patients with excellent recovery of FN function (HB1 and HB2).

CONCLUSIONS

The majority of ENoGs performed within 2 weeks of temporal bone trauma provide sufficient prognostic data for treatment decisions; however, in selected cases, a single ENoG may not adequately predict long-term FN outcomes. For patients failing to improve with observation alone, serial ENoG may capture declining FN function, identifying patients that may benefit from late decompression.

Long-term Outcomes After Middle Fossa Approach for Traumatic Facial Nerve Paralysis

OBJECTIVES

Controversy exists regarding the role of surgery for patients with skull base trauma and facial paralysis. Our goal is to report the long-term outcomes of early facial nerve decompression and repair via the middle fossa (MF) approach for patients with traumatic paralysis.

STUDY DESIGN

Retrospective case series.

SETTING

Academic medical center.

PATIENTS

There were 18 patients who met surgical criteria: immediate complete paralysis, greater than 90% degeneration on electroneurography (ENoG), and no voluntary electromyography (EMG) potentials within 14 days after trauma and 1 year minimum follow-up.

INTERVENTION

MF approach for traumatic facial paralysis and for irreversible injuries nerve grafting was performed.

MAIN OUTCOME MEASURE

Long-term facial function, hearing results, and surgical complications.

RESULTS

At MF decompression, 11 patients had an anatomically intact facial nerve. Of these patients with intact nerves, 72.7% obtained normal to near normal facial function (HB I or II) at 1 year: 27.3% to HB I, 45.5% to HB II, and 27.3% to HB III. At surgery, seven patients were found to have injuries that required nerve grafting and 100% improved to HB III. For all patients, facial nerve function significantly improved after surgery (p < 0.01). The average difference in pure tone average and word recognition after surgery was +2.9 dB and +3.3%, respectively (p = 0.44; p = 0.74). Minor, transient complications occurred in three patients and an abscess required drainage in one patient, but no other major complications.

CONCLUSION

In our series, all patients with traumatic complete paralysis and poor facial prognosis achieved a long-term outcome of HB III or better after MF approach for decompression and repair of the facial nerve.

Bilateral traumatic abducens nerve avulsion: A case series and literature review

Although abducens nerve palsy is an established sequela of head trauma - given the prolonged intracranial course of the nerve - bilateral injury is rare. Here, we present two cases of bilateral traumatic abducens nerve avulsion, in the absence of regional fractures, one of which presented two months following the initial trauma. Additionally, we review the current literature on bilateral abducens nerve palsy secondary to trauma, discussing the anatomy of the nerve's course and potential mechanisms of injury.

Surgical timing for facial paralysis after temporal bone trauma

OBJECTIVES

To explore surgical timing of facial paralysis after temporal bone trauma.

METHODS

The clinical data of the patients with facial paralysis after temporal bone trauma who underwent subtotal facial nerve decompression were retrospectively collected, and 80 cases followed-up for one year were enrolled in the study. They were divided into different subgroups according to the age, onset, and interval between facial paralysis and surgery, and the outcomes of facial nerve between different subgroups were compared.

RESULTS

The number of patients who achieved good recovery of HB Grade I or II was 52 of 80 (65.0%). 43 of 66 cases (65.2%) in the younger group had good recovery of facial nerve in contrast to 9 of 14 cases (64.3%) in the elderly group, without significant difference (p>0.05). 9 of 13 cases (69.2%) in the delayed onset group had good recovery, while 43 of 67 cases (64.2%) in the immediate onset group had good recovery, without significant difference (p>0.05). The good recovery rate of the <1month group was statistically higher compared to the 3-6months group or the >6months group (P<0.05), while the good recovery rate of the <1month group was not statistically higher than that of the 1-2months group or the 2-3months group (P>0.05).

CONCLUSION

This study demonstrated that the good recovery rate of facial paralysis after temporal bone trauma was uncorrelated with age and onset. It was better to perform surgical decompression within 3months after facial paralysis.

Clinical features and radiological evaluation of otic capsule sparing temporal bone fractures

Objective:

To evaluate the clinical and radiological aspects of otic capsule sparing temporal bone fractures.

Methods:

Using medical records, 188 temporal bones of 173 patients with otic capsule sparing temporal bone fractures were evaluated. Otoscopic findings and symptoms, facial paralysis, and hearing loss were assessed.

Results:

Using regional analysis, 7 fractures were classified as type I, 85 as type II, 169 as type III and 114 as type IV. Fourteen of the 17 facial paralysis cases improved to House–Brackmann grade II or lower at an average of 57.6 days after the initial evaluation. Thirty-one patients underwent initial and follow-up pure tone audiometry examinations. The air–bone gap closed significantly from 27.2 dB at an average of 21.8 days post-trauma to 19.6 dB at an average of 79.9 days post-trauma, without the need for surgical intervention.

Conclusion:

Initial conservative treatment for facial paralysis or conductive hearing loss is possible in otic capsule sparing fracture cases after careful evaluation of the patient.

The timing of surgical treatment of traumatic facial paralysis: a systematic review

CONCLUSIONS

Surgical decompression performed within 2 weeks yields the best clinical prognosis for patients with TFP. This study also demonstrated that surgical exploration performed within 2 months results in acceptable outcomes.

OBJECTIVES

The ideal timing for surgical intervention of traumatic facial paralysis (TFP) is still controversial. A systematic review was performed to appropriately determine the timing of surgical decompression.

METHODS

Related studies were identified by searching Pubmed, EMBASE, and Cochrane and reviewing the relevant reference lists until 1 March 2016. Surgical timing was classified into four sub-groups: <2 weeks, 2 weeks-1 month, 1-2 months, and >2 months.

RESULTS

Six studies including 119 patients (119 cases) fulfilled the study requirements. The number of patients who achieved perfect recovery of House-Brackmanm (H-B) grade 1 was 40 of 119 patients (33.6%). Good results were demonstrated in 94.4% (17/18) of patients managed with surgical decompression within 2 weeks vs 63.4% (64/101) of patients undergoing surgical intervention at >2 weeks (p = 0.009).