HSC Section 8_April 2017

Reprinted by permission of Otol Neurotol. 2016; 37(6):799-804.

Otology & Neurotology 37 :799–804 2016, Otology & Neurotology, Inc.

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

Richard B. Cannon, Rhett S. Thomson, Clough Shelton, and Richard K. Gurgel

Division of Otolaryngology–Head and Neck Surgery, The University of Utah School of Medicine, Salt Lake City, Utah

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 electro- myography (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, hear- ing results, and surgical complications. Results: At MF decompression, 11 patients had an anatomi- cally intact facial nerve. Of these patients with intact nerves, 72.7% obtained normal to near normal facial function (HB I Traumatic facial nerve paralysis can result from many blunt and penetrating injuries to the temporal bone. The most common causes of temporal bone fractures are motor vehicle accidents, recreational activities, falls, or assaults and can result in stretching, compression, or transection of the facial nerve (1,2). These patients with significant skull base trauma caus- ing facial nerve paralysis often have multiple, complex medical issues, which makes their management challenging. One of the most devastating aspects of temporal bone trauma is paralysis of the facial nerve, which occurs in 7 to 10% of cases (3). Some patients with posttraumatic facial paralysis may recover normal or near normal facial function with observation or medical management alone, including steroids to minimize posttraumatic neural Address correspondence and reprint requests to Richard K. Gurgel, M.D., The University of Utah, Otolaryngology Head and Neck Surgery, 50 North Medical Dr., SOM 3C-120, Salt Lake City, UT 84132, U.S.A.; E-mail: Richard.Gurgel@hsc.utah.edu No sources of support or funding were received for this work.- Presented at the 2015 AAO-HNSF Annual Meeting and OTO EXPO. None of the authors has a conflict of interest.

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 þ 2.9 dB and þ 3.3%, respectively ( p ¼ 0.44; p ¼ 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 decompres- sion and repair of the facial nerve. Key Words: Facial nerve decompression — Facial nerve repair — Long-term outcomes — Middle fossa approach — Surgical criteria — Temporal bone fracture — Traumatic facial nerve paralysis. edema. If the onset of facial nerve dysfunction was delayed from the traumatic incident, then the prognosis is excellent (4–6). However, a subset of patients who have immediate-onset, complete facial nerve paralysis after a skull base trauma are at risk for a poor long-term outcome. The long-term consequences of facial paralysis result in functional limitations, are emotionally distress- ing, and have significant psychosocial implications (7). Patients who are high risk for poor outcomes, as deter- mined by electrodiagnostic testing, may benefit from surgical management (8–10). Appropriate surgical candidates after temporal bone trauma have poor long-term prognosis of their facial nerve function. Coupling a function-based clinical evalu- ation, the House-Brackmann (HB) facial nerve grading system, with electrodiagnostic testing has been effective in determining long-term prognosis (11,12). Specifically, electroneurography (ENoG) and voluntary electromyog- raphy (EMG) can provide prognostic information when there is complete paralysis (HB VI) on clinical exam (13). Patients with any posttraumatic facial movement rarely need surgical intervention and several studies show that patients with < 90% degeneration on their ENoG testing have excellent long-term outcomes, with Otol Neurotol 37: 799–804, 2016.

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