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Surgery May Not Be Needed for Posttraumatic Complete Facial Nerve Paralysis

NEW YORK (Reuters Health) – For complete facial nerve paralysis associated with undisplaced temporal bone fracture, nonsurgical treatment leads to “near-universal recovery” and is better than surgery, researchers in India suggest.

“Facial nerve paralysis consequent to a head injury is devastating to patients,” Dr. Alok Thakar of the All India Institute of Medical Sciences, in New Delhi, told Reuters Health. “A half-paralyzed face is disfiguring and embarrassing, and patients often become withdrawn and reclusive.”

“Semi-urgent surgical treatment has traditionally been advocated, and has been found to be reasonably effective in bringing about complete or partial recovery,” he said by email. “Surgery, however, entails minor brain compression with its risks and complications, and also risks damage to the inner ear.”

In some situations, surgery can’t be immediately implemented or patients refuse surgery, he noted. “In our experience, such patients also have had recovery of facial nerve function over time.”

To investigate, Dr. Thakar and colleagues prospectively recruited 28 patients (mean age, 32; 25 men) who had complete facial paralysis after a head injury that occurred less than four weeks before presentation (median time to presentation, 14 days) and who had <5% response on electroneuronography (ENoG) and no response on electromyography. All but two patients had undisplaced temporal bone fractures (24 longitudinal and two transverse).

All participants received prednisolone, 1mg/kg, for three weeks; clinical monitoring every two weeks; and electromyography monitoring every four weeks.

Facial nerve function was assessed by the House-Brackmann grading system and other instruments for 40 weeks.

As reported online February 22 in JAMA Otolaryngology-Head and Neck Surgery, at 40 weeks, 27 patients recovered to House-Brackmann grade I/II and one patient to grade III with conservative treatment alone.

No recovery was seen in any patient at the initial four-week review. The first signs of clinical recovery occurred in four patients by eight weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks, according to the authors.

The 24 patients with longitudinal fractures had grade I/II recovery. No patient required surgical exploration.

Dr. Thakar said, “The recovery rates and recovery quality were as good – if not better! – than the results from previous reports of patients treated with surgery.”

“Patients with head-injury-related facial nerve paralysis need not be routed towards surgery,” he stressed. “Equally good recovery may be anticipated by simply treating with medicines and waiting patiently over the next few months. “

Dr. Nate Jowett of Massachusetts Eye and Ear in Boston told Reuters Health by email, “The authors report that 27/28 recovered to House-Brackmann grade I/II (i.e., recovery to normal function or only mild dysfunction).”

“They also claim that “ENoG criteria of more than 90% to 95% denervation to select patients for surgical exploration is no longer valid,” he added.

“The authors (further) claim that ‘nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results,” he said.

“While I applaud the authors for their efforts on tracing the natural history of facial nerve recovery in this rare subset of patients,” Dr. Jowett said, “I have one important concern: Current standard-of-care ENoG-based indications for urgent surgical decompression of the facial nerve require that 90%-95% denervation be noted on ENoG testing within 14 days of injury.”

“The authors state that the median time to presentation of their cohort of patients in this study was 14 days,” he said, “implying that it was unknown whether half of their cohort would have met current ENoG criteria for surgical decompression of the facial nerve in the first place.”

He noted that pioneering otolaryngologist Dr. Ugo Fisch (often referred to as Professor Fisch) said in 1974 that not only the extent, but also the evolution, of degeneration has to be considered in order to decide whether surgery is indicated in patients with traumatic facial paralysis.

He quoted Professor Fisch, who stated: “An immediate facial paralysis followed by a slow progression of degeneration will have a good prognosis and recover completely, whereas a delayed paralysis with a rapid onset of degeneration should be treated by surgery in order to ensure optimal recovery.”

Dr. Jowett concluded, “The role of acute surgical decompression of the facial nerve in the setting of non-displaced temporal bone trauma resulting in acute facial paralysis in patients meeting electrophysiology criteria . . . within 14 days of injury remains unclear.”

“A prospective controlled trial is needed,” he said, “whereby eligible patients are randomly assigned to non-operative versus operative management within 14 days of injury.”

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