Mediterr. J. Otol 2007; 3:(3) 150-159

Consensus on Treatment Algorithms for Traumatic and Iatrogenic Facial Paralysis

O. Nuri Ozgirgin, Carlos Cenjor, Roberto Filipo, Mislav Gjuric, Jacques Magnan, Anestis Psifidis

Bayındır Hospital, otolaryngology Dept. Ankara - Turkey, ozgirgin@politzersociety.org

The frequency of head trauma has increased in parallel with the number of high performance vehicles on the road. The 1980s showed the highest frequency of accidents, and thereafter, the frequency of head traumas fortunately decreased as a result of the use of seatbelts. Temporal bone fractures are associated with intracranial injuries in 22% of all head trauma cases.

The initial effect of trauma to the facial nerve is ischemia. This leads to neural edema, which increases pressure in the closed space of the fallopian canal. Decompression surgery is a preventive procedure designed to curtail progression of neural injury due to edema. Approximately 50% of patients who undergo facial nerve decompression surgery achieve excellent functional outcome.

The axis of the fracture line closely affects the hearing, as transverse fractures cross the longitudinal axis of the temporal bone and the labyrinth. In this situation, sensorineural hearing loss is inevitable. The site of the injury in these cases is generally in the middle ear portion of the nerve

The panel concluded that in case of complete, immediate paralysis, the presence of clear cut fracture line in high resolution tomography has been the main indication to decide for the decompression and/or repair of the facial nerve. In delayed cases EMG will be the final and most reliable tool on deciding for the surgery. In contrast ENoG is still very helpful but not descriptive in every case.

For the delayed referrals with complete paralysis, there has been a consensus that the cases should preferably be operated before three months.

In traumatic cases, hematoma, transection and the injury by the bone spicules were found to be frequent causes of the nerve injuries.

Because of the geniculate ganglion which has been the mostly injured portion of the nerve, surgical approach to this area has been frequently required the middle fossa approach. However in some cases with wide access through the attic, transmastoid approach has also been used by some of the panelists. Beneath the previously described landmarks for the middle fossa approach, marking the tegmen with drill was proposed to be helpful on locating the geniculate ganglion. Additionally following the fracture line to find the injured portion of the nerve was also recommended.

The incidence for the gun shot traumas was mentioned to be low.

For the cases with nerve tissue loss, the panel agreed that grafting with cable nerve tissue is advantageous as compared with rerouting. Rerouting technique was blamed to damage the vascular supply of the nerve.

Especially for the injuries nearby the brainstem, anastomosis with the hypoglossal nerve has been the preferred technique. All the panelists mentioned that they are used to perform end to end anastomosis. With this technique it was suggested that more nerve fibers are supplied for the facial nerve. The functional loss of the tongue movements has not been found to handicap the patient.

For the iatrogenic cases the presence of cholesteatoma and granulation tissue was mentioned to be he main risk factors to injure the nerve during surgery. And the second genu of the nerve was the most injured portion.