HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Sun et al

performed under the operating microscope with atraumatic technique. The ends of the nerve or graft should be freshened sharply using microscissors. Nerve ends are joined using 8-0 to 10-0 monofilament (eg, nylon or polypropylene) sutures in the epineurium at 6 and 12 o’clock positions. 26 If grafting of an intracranial portion of nerve is required, only 1 or 2 sutures are placed. Following suture approximation, a fibrin sealant may be applied.

POSTOPERATIVE CARE AND POTENTIAL COMPLICATIONS 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). Steroids (hy- drocortisone or dexamethasone) are continued for 48 hours. Eye Care Ocular complications are the greatest source of morbidity in facial nerve palsy. Facial nerve palsy results in decreased lacrimation, upper eyelid retraction, lower eyelid paralytic ectropion, and lagophthalmos. Together these deficits result in decreased tear film and an inability to close the eye, leading to corneal exposure keratopathy that may lead to corneal ulceration and ultimately loss of vision in the affected eye. Ophthalmologic consultation is recommended if ocular symptoms are present, there is concern for decreased corneal sensation, or prolonged facial nerve paralysis is expected. Conservative management may be divided into 5 categories: lubrication, retaining moisture, obstruction of tear outflow, improvement of tear quality, and bandage or scleral contact lenses. 47 Aggressive lubrication should be performed using artificial tears for mild cases and thicker lubricating ointments for more severe cases. The retention of moisture is aided by air humidifiers, removing fans from the environment, wearing humidification goggles, moisture release eye flow, or taping the affected eye shut. Obstruction of tear outflow is accomplished by placement of silicone punctal plugs or permanent thermal cautery in the punctum. Tear quality can be improved by increasing the lipid component of tears with warm compresses, lipid-enhanced artificial tears, oral omega-3 fatty acids, or doxycycline. 48 Bandage soft contact lenses can be placed to protect the corneal surface from exposure, but they require antibiotic prophylaxis and close follow-up to prevent infectious complications. Scleral hard lenses may also be used if a long-term solution is desired. Temporary interventions focus on mechanically lowering the upper eyelid or tempo- rarily sealing the eye shut. The upper eyelid may be lowered with adhesive stick-on weights, protective ptosis with botulinum toxin injection to the levator muscle, or hy- aluronic acid gel injection into the upper eyelid. The eyelids may be temporarily closed using suture tarsorrhaphy. Permanent intervention most commonly includes lateral tarsorrhaphy but may also include medial or pillar tarsorrhaphy. Further surgical reha- bilitation may include lifting the brow and static or dynamic interventions to rehabilitate the upper eyelid. Static interventions include the placement of a gold or platinum up- per eyelid weight. Dynamic eyelid closure may be attained with a palpebral spring that attaches between the lateral orbital rim and the tarsus and forces the eyelid closed during levator inaction.

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