HSC Section 3 - Trauma, Critical Care and Sleep Medicine

O

skull base with risk to adjacent neural and cranial structures. The facial nerve is the cranial nerve most commonly involved. Patients usually present with auricular pain, otorrhea, and hearing loss. Risk factors include diabetes mellitus, previous radiation therapy, advanced age, and an immunocompromised state. The white cell count may be normal or raised but the ESR (erythrocyte sedimentation rate) is always raised. Ear culture is positive for Pseudomonas aeruginosa in most cases. If squa- mous carcinoma of the temporal bone is suspected, a biopsy should be done. Imag- ing should include a computed tomography (CT) scan of the temporal bones and an MRI. If results are equivocal, technetium or gallium scans may also aid diagnosis. Treatment includes control of the diabetes, antibiotic ear drops, long-term intrave- nous antibiotics, and debridement. Progress may be followed clinically, as well as with serial ESR. It is not clear whether pregnancy increases the risk of FP over the general population; however, it occurs more frequently during the third trimester in pregnant patients. The etiology is likely the same as in typical BP with viral reactivation. 28 Most cases are unilateral FP; however, bilateral may also be possible. BP during the third trimester carries a worse prognosis compared with a cohort of nonpregnant women of the same age. 29 Medical treatment is the same as for BP. Steroids and antivirals are recommended. The risk-to-benefit ratio in conjunction with the age of the fetus should be weighed and discussed with the patient. It is believed that steroids have higher risk for the fetus in the first trimester, including adrenal suppression, low birth weight, and developmental defects. 28 However, a recent literature review showed that these risks were taken from long-term administration of the drug in cases such as rheumatoid arthritis, whereas the dosing for acute FP is short. 30 The conclusion is that steroids for acute FP are safe in pregnancy, especially in the third trimester. 30 Antiviral medications are low risk to the mother and fetus and are used during late pregnancy. Vestibular schwannomas are the most common benign intracranial tumors. FP is typi- cally caused by treatment of these lesions; resection or radiation, both of which can result in facial nerve injury. A very large vestibular schwannoma can also cause FP, although less likely acute FP. Facial nerve schwannomas may also cause FP, as they slowly grow and expand, and may rarely present with acute FP (see Drs Alicia M. Quesnel and Felipe Santos’ article, “ Evaluation and Management of Facial Nerve Schwannoma ,” and Drs Vivian Kaul and Maura K. Cosetti’s article, “ Management of Vestibular Schwannoma (including NF2) - Facial Nerve Considerations ,” in this issue, for further details.) Malignant Head and neck tumors, such as parotid malignancies, can present with acute or slowly progressive FP. MRI with contrast will delineate the tumor and any facial nerve involve- ment. Treatment of the tumor will depend on the clinical and pathologic stage. Acute management focuses on eye care and antibiotic and steroid medical therapy. Planned surgical extirpation with facial nerve (FN) reconstruction will depend on the extent of the tumor as well as patient factors. PREGNANCY-ASSOCIATED BELL PALSY TUMORS Benign

53