High Altitude Alternobaric Facial Palsy: Case Series and Systematic Review of the Literature

Facial nerve baroparesis: a case report

BACKGROUND

Facial nerve baroparesis is a peripheral facial nerve injury resulting from barotrauma during activities such as diving, aviation, and mountain climbing. This condition occurs when increased pressure in the middle ear affects the facial nerve, leading to facial palsy. Despite being documented in otolaryngology literature, facial nerve baroparesis remains underreported and often misunderstood. Enhanced awareness and education about this condition are essential for effectively managing affected patients, helping to mitigate unnecessary panic and procedures during episodes.

CASE PRESENTATION

We present two cases of facial nerve baroparesis that occurred during flights. The first case involves a 25-year-old Arab male with no significant medical history who experienced a transient, one-time episode of right-sided facial nerve baroparesis during a flight from Kuwait to Syria; he reported nasal congestion and a sore throat prior to the flight, with the episode lasting approximately 30 min before resolving spontaneously. The second case is a 30-year-old Arab female with a history of chronic allergic rhinitis, who has experienced recurrent episodes of left-sided facial nerve baroparesis for the past 2 years, occurring during nearly every flight; each episode lasted around 5 min, caused severe facial pain, and also resolved spontaneously. Both patients exhibited varying degrees of Eustachian tube dysfunction. Treatment for the recurrent case included maneuvers to alleviate ear pressure and the use of nasal decongestants, which improved symptoms and decreased the frequency of episodes.

CONCLUSION

Facial nerve baroparesis is frequently underestimated due to its temporary nature, yet it remains a significant cause of facial nerve palsy, especially after changes in pressure. Although the underlying mechanisms are not completely understood, dysfunction of the Eustachian tube is believed to be a contributing factor. Identifying the characteristic features of baroparesis-such as rapid onset, brief duration, and bilateral involvement of facial muscles-is essential for effective management. This highlights the necessity of educating healthcare professionals and flight personnel about this condition to prevent unnecessary treatments. For recurrent cases, management strategies should focus on alleviating Eustachian tube dysfunction.

Facial and trigeminal nerves neuropathy induced by atmospheric pressure changes: A meta-analysis

BACKGROUND

Barometric pressure changes during flight or diving may cause facial barotrauma. Neuropathy of the fifth (CN5) or the seventh (CN7) cranial nerves is a rare manifestation of this condition. The aim of this study was to analyze risk factors for baroneuropathies of CN5 and CN7.

METHODS

A search of PubMed and Cochrane Library databases was conducted to identify all published cases of CN5 and CN7 neuropathies. Only original case reports and series that documented events of neuropathies associated with the trigeminal nerve or facial nerve while flying, diving, or mountain climbing were included. Assessed variables included sex, medical history, age, setting (flight or diving), atmospheric pressure changes, number of episodes, symptoms, treatment, and recovery.

RESULTS

We identified a total of 48 articles described >125 episodes in 67 patients. Mean age was 33.5 ± 12.1 years with a male predominance (76.1 %). Cases were equally distributed between flight and diving (50.7 %, 46.3 %, respectively). CN5 involvement was observed in 77.6 % of patients, with ear pain and facial numbness as the most common symptoms. The latter was correlated with positive otolaryngology medical history. CN7 was involved in 88.1 % of patients. Flying, as opposed to diving was correlated with spontaneous resolution of symptoms (86.7 % vs. 42.3 % of cases resolved spontaneously, respectively, p = 0.001).

CONCLUSIONS

Flight is an equal risk factor to diving with respect to CN5 and CN7 barotrauma. Involvement of CN7 was observed in most cases, but possibly due to report-bias. Positive medical history is a risk factor for facial numbness.

Imaging of Alternobaric Facial Palsy: An Etiologic Hypothesis

OBJECTIVE

To report a case of alternobaric facial palsy (AFP) with a hyperpneumatized temporal bone and to review the relevant literature in order to propose a new facet of AFP pathogenesis.

METHODS

A patient with a hyperpneumatized temporal bone was found to have recurrent episodes of facial palsy associated with air travel. Systematic review of PubMed, Cochrane Library, and Embase characterized all articles related to transient facial palsy associated with altitude changes or diving with a focus on demographics and imaging findings.

RESULTS

A 25 year-old male was referred for recurrent facial palsy associated with commercial air travel. Imaging demonstrated a hyperpneumatized and well-aerated temporal bone. Total air cell volume was calculated to be 8.59 cc on the affected side. A systematic review of the literature identified 49 cases of AFP. Mean age was 34 years old and 80% were male. Twelve cases had imaging of the temporal bone for evaluation, of which 85% demonstrated at least 1 area of hyperpneumatization. Hyperpneumatization was most frequently encountered in the mastoid, zygomatic root, and inferior petrous apex.

CONCLUSION

Hyperpneumatization of the temporal bone is critical to AFP etiology as it predicts higher middle ear pressure, if atmospheric pressure changes cannot be equilibrated, via reduced efficacy of normal tympanic membrane pressure buffering. This hypothesis helps to better account for the rarity of the condition and male preponderance.

Facial nerve baroparesis during airflight: a case report and literature review

BACKGROUND

Facial nerve baroparesis is a rare phenomenon which has been reported during flight. It is thought to occur due to ischaemic neuropraxia on the facial nerve as middle-ear pressure increases in the presence of Eustachian tube dysfunction and force is transmitted through a dehiscent facial nerve canal.

METHOD

This study presents an aviation-associated, right-sided facial nerve palsy as well as presenting the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to discuss presentation, investigations performed and an approach to management of this rare condition.

RESULTS

This study identified 23 cases in the literature (including the case presented in this study) of facial nerve baroparesis.

CONCLUSION

Facial nerve baroparesis is a mostly temporary rare phenomenon that can be managed effectively with ventilation tube insertion. In the event of long-standing facial nerve palsy after descent of the aircraft, urgent myringotomy should be performed to prevent permanent facial nerve damage.