Transmastoid decompression as a treatment of Bell palsy

Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research

OBJECTIVE

The "Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research" aims to review the latest evidence regarding the treatment of Bell's palsy and to provide appropriate recommendations.

METHOD

Regarding the treatment of Bell's palsy, a guideline panel identified key clinical questions using an analytic PICO framework. The panel produced recommendations following the standards for trustworthy guidelines and the GRADE approach. The panel considered the balance of benefits, harm, and preferences when making recommendations.

RESULTS

The panel identified nine key clinical questions: systemic (high/standard dose) corticosteroids, intratympanic corticosteroids, systemic antivirals, decompression surgery, acupuncture, physical therapy, botulinum toxin, and reanimation surgery.

CONCLUSION

These guidelines strongly recommend systemic standard-dose corticosteroids for the clinical management of Bell's palsy. Other treatments are weakly recommended due to insufficient evidence. The absolute risk reduction of each treatment differed according to the disease severity. Therefore, physicians and patients should decide on treatment based on the disease severity.

A New Surgical Option For Patients with Unresolved Bell's Palsy

PURPOSE

This paper describes a new surgical procedure with electrical stimulation of the facial nerve for unresolved Bell's palsy and compares the facial nerve recovery with another group who underwent traditional middle cranial fossa decompression.

RECENT FINDINGS

All patients with total unilateral facial paralysis had surgery by the senior author 3 months from onset of Bell's Palsy. Surgical decompression was performed in 13 patients between 1992-2012 (Group 1). Surgical exposure with intraoperative electrical stimulation of the facial nerve in the peri-geniculate region was performed in 47 patients between 2012-2022 (Group 2). The facial recovery at 1 month and 3 month were significantly better in Group 2. The degree of synkinesis was significantly less in Group 2. The trans-mastoid electrical stimulation of the facial nerve is less invasive, requires no hospital stay, and less time off work compared to the middle cranial fossa approach. The earlier facial movement at one month results in less long-term unwanted faulty regeneration or synkinesis.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Intact Transmastoid Ossicle Swaying Technique to Preserve Hearing in Pediatric Facial Nerve Decompression Surgery: A Case Report

When pharmacological treatments are inadequate, facial nerve paralysis from various etiologies, including Bell's palsy, Hunt syndrome, and trauma, often requires surgical intervention. Facial nerve decompression surgery aims to relieve nerve compression and restore function, with preserving hearing function, especially in pediatric cases, being crucial. Conventional methods, like the transmastoid approach, risk affecting auditory function due to ossicle manipulation. Herein, we describe the case of a 12-year-old boy with left facial palsy diagnosed with zoster sine herpete (ZSH) syndrome. Despite medical treatment, the patient's condition did not improve, prompting facial nerve decompression surgery. Employing the intact transmastoid ossicle (ITO) swaying technique, we minimized ossicular manipulation, preserving auditory function while effectively achieving facial nerve decompression. The patient demonstrated improvement postoperatively in auditory and facial nerve functions. Furthermore, audiometric assessments demonstrated no substantial deterioration in hearing thresholds, and the facial nerve function improved from Grade V to Grade II on the House-Brackmann scale. The ITO technique provides a less invasive alternative compared to conventional approaches, lowering the chance of the ossicular chain and the risk of postoperative hearing loss. This case highlights the significance of customized surgical approaches in pediatric facial nerve decompression surgery, resulting in improved patient outcomes. Further research is required to validate the efficacy and safety of this method across various clinical contexts.

The use of basic fibroblast growth factor to treat intractable Bell's palsy administered via transcanal endoscopic ear surgery

PURPOSE

Facial nerve decompression surgery is an invasive procedure which has hitherto been the main option for patients with severe intractable Bell's palsy which is resistant to drug treatment. We have developed a new salvage treatment for such patients by using minimally invasive transcanal endoscopic ear surgery (TEES) to deliver the biological regenerative agent, basic fibroblast growth factor (bFGF), to the damaged facial nerve.

MATERIALS AND METHODS

An endoscopic salvage treatment group was studied prospectively and was made up of severe intractable Bell's palsy patients who did not respond to high dose steroid treatment and had an ENoG value of 5 % or less. This surgery group was retrospectively compared to a similar control group who had received high dose steroid only.

RESULTS

Complete recovery to House-Brackmann (HB) Grade I was achieved by 44.8 % of the endoscopic salvage treatment group which was significantly higher than the 21.2 % of the control group at one-year follow up. Patients with an ENoG value of 1 % to 5 % exhibited a significantly higher complete recovery rate of 71.4 % in the endoscopic salvage treatment group than the 28.6 % of the control group. In addition, no complications were observed including hearing loss.

CONCLUSIONS

bFGF delivered via TEES shows considerable promise as a new salvage treatment of severe intractable Bell's palsy that is resistant to high dose steroid treatment without the risks presented by facial nerve decompression surgery.

Frequency-dependent hearing outcomes with or without preservation of intact ossicular articulations

Objective

To determine the frequency-specific benefits of ossicular chain preservation compared to performing disarticulations and reconstructions in transmastoid facial nerve decompression surgery in patients with an intact ossicular chain.

Methods

A retrospective chart review (January 2007 and June 2018) of patients undergoing transmastoid facial nerve decompression on the intact middle ear for severe facial palsy at a tertiary referral center. Surgery was performed with ossicular chain disarticulation on an as-needed basis using either ossicular chain preservation (without ossicular disarticulation), incudostapedial separation, or incus disarticulation technique. Hearing outcomes were assessed.

Results

The 108 patients were included in this study. Among these, 89 patients underwent ossicular chain preservation, 5 underwent incudostapedial separation and 14 underwent incus repositioning. The proportion of patients with a change in the 4-frequency air conduction pure-tone average of less than 10 dB was 91%, 60%, and 50%, respectively, for the three surgical techniques; these were significantly different (Fisher's exact test, p < .001). Frequency-specific analysis showed that air conduction was significantly better following the ossicular chain preservation technique compared with the incus repositioning technique at stimulation frequencies lower than 250 Hz and higher than 2000 Hz, and compared with the incudostapedial separation technique at 4000 Hz. Analysis of biometric measures determined on CT images suggested that the feasibility of the ossicular chain preservation technique correlates with incus body thickness on coronal CT images.

Conclusions

Ossicular chain preservation is an effective approach for hearing preservation in transmastoid facial nerve decompression or similar surgical procedures.

Comparison of Medical and Surgical Treatment in Severe Bell's Palsy

(1) Background: The effectiveness of decompression surgery for Bell’s palsy is controversial. This study investigated the effects of facial nerve decompression in patients with severe Bell’s palsy who were expected to have a poor prognosis. (2) Methods: We retrospectively reviewed 1721 patients with Bell’s palsy who visited the Kyung Hee University Hospital between January 2005 and December 2021. Of these, 45 patients with severe Bell’s palsy were divided into two groups; 30 patients were treated conservatively with steroids and antiviral agents alone, while 15 patients underwent additional decompressive surgery after the conservative treatment. Outcomes were measured using House–Brackmann (H–B) grade for least 6 months after treatment was finished and conducted until full recovery was achieved. (3) Results: There was no significant difference in the rate of favorable recovery (H–B grade 1 or 2) between the surgery group and the conservative treatment group (75% vs. 70.0%, p > 0.05). Although H–B grade improvement occurred in both groups, the degree of improvement was not significantly different between groups. (4) Conclusions: Facial nerve decompression surgery in severe Bell’s palsy patients did not significantly improve prognosis beyond that offered by conservative treatment alone. Additional surgical decompression may not be necessary in patients with severe Bell’s palsy if they receive sufficient conservative treatment.

Endoscopic transcanal facial nerve decompression in Bell's palsy: A pilot study

PURPOSE

To explore the surgical effects of endoscopic facial nerve decompression in Bell's palsy.

MATERIALS AND METHODS

This retrospective study included 15 patients with Bell's palsy. All had grade VI (House-Brackmann grading system) complete unilateral facial paralysis before surgery and a >95% reduction in amplitude on electroneurography testing compared to the unaffected side. Their MRI results indicated perineural edema in the geniculate ganglion area. Endoscopic decompression surgery was performed soon after they presented at our hospital. The time between onset of facial paralysis and surgery ranged from 25 to 93 days. All patients had no relevant surgical history or ear diseases.

RESULTS

At 1-year follow-up, 13 of the 15 (87%) patients had recovered to normal or near-normal facial function (House-Brackmann grade I-II), and all patients had reached House-Brackmann grade III or lower facial function. No obvious air-bone gap or sensorineural hearing loss occurred after surgery, and there were no severe complications or synkinesis.

CONCLUSIONS

Endoscopic transcanal facial nerve decompression provides a less traumatic and improved exposure of the geniculate ganglion, and may also help prevent permanent severe facial sequela. Results of intraoperative facial nerve stimulation may be related to the length of time required for recovery. The optimal time of surgery after onset of paralysis needs to be investigated further, to identify a post-drug surgical therapy which may be more acceptable for patients. Patients' response to conservative treatments should be assessed as soon as possible so as not to delay surgery.

Peripheral facial nerve palsy in children: clinical manifestations, treatment and prognosis

Background

Sudden onset of unilateral weakness of the upper and lower muscles of one side of the face is defined as peripheral facial nerve palsy. Peripheral facial nerve palsy is often idiopathic and sometimes it could be due to infectious, traumatic, neoplastic, and immune causes. This study aimed to report the clinical manifestation, evaluation, and prognosis in children with peripheral facial nerve palsy.

Methods

57 children under 18 years of age diagnosed with peripheral facial nerve palsy at Çukurova University, Balcalı Hospital, between January 2018 and September 2021, were included in the study.

Results

The mean age of the children at the time of diagnosis was 9.6 ± 7, 4 years. Thirty-two (56.1%) of the patients were female and 25 (43.9%) were male. A total of 57 patients were diagnosed with peripheral facial nerve palsy and categorized into many groups by etiology: idiopathic Bell’s palsy in 27 (47.5%), infectious in 11 (19.2%), traumatic in 6 (10.5%), and others (due to congenital, immune, neoplastic, Melkersson–Rosenthal syndrome, drug toxicity, and iatrogenic causes) in 13 (22.8%). Forty-six of the children achieved full recovery under oral steroids within 1–7 months. Four patients with acute leukemia, myelodysplastic syndrome, Mobius syndrome and trauma did not recover and two patients (schwannoma, trauma) showed partial improvement. Five patients could not come to follow-up control.

Conclusion

Peripheral facial nerve palsy is a rare condition in children with different causes. It could be idiopathic, congenital, or due to infectious, traumatic, neoplastic, and immune reasons. So, when a child presents with facial palsy, a complete clinical history and a detailed clinical examination are recommended. Giving attention to the red flag is very important. Peripheral facial nerve palsy in children is considered to have a good prognosis.

Suprameatal-transzygomatic root endoscopic approach to the geniculate ganglion: an anatomical and radiological study

PURPOSE

To describe the suprameatal-transzygomatic root endoscopic approach (STEA) to the geniculate ganglion (GG), the labyrinthine facial nerve (FN) and epitympanum.

METHODS

The feasibility and limits of the STEA, maintaining the integrity of the ossicular chain, were analysed. Ten human cadaveric ears were dissected. Step-by-step description of the technique and relevant measurements were taken during the approach. The visualization and surgical working field on the anterior and posterior medial epitympanum, GG, greater superficial petrosal nerve, the labyrinthine FN and suprageniculate area were evaluated. The range of motion through the approach and the rate of the decompression of the GG and the labyrinthine portion of the FN were assessed as well. CT-scan measurements were compared with those obtained during the dissection.

RESULTS

A complete exploration of the epitympanum was possible in every specimen. Decompression of the GG and first portion of the FN was achieved without any trauma to the ossicular chain in nine ears. The endoscope movements were mainly limited by the distance between bony buttress-short process of the incus-tegmen. The working space, during GG and labyrinthine FN decompression, was limited by the distance between malleus head-medial epitympanic wall and malleus head-GG. Radiologic measurements were consistent with those obtained during the dissections.

CONCLUSION

The STEA is a promising minimally invasive approach for decompression of the GG and FN's labyrinthine portion. The applications of this corridor include the exploration and surgery of the medial epitympanum, preserving the ossicular chain.

Determining the Prognosis of Bell's Palsy Based on Severity at Presentation and Electroneuronography

OBJECTIVE

To examine the demographics of Bell's palsy and determine how House-Brackmann (HB) grade at nadir and electroneuronography (ENoG) results correlate with HB grade after recovery and development of synkinesis.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care military medical center.

METHODS

Patients with acute Bell's palsy and adequate follow-up, defined as 6 months or return to HB grade I function, were included. Demographic information, HB scores at nadir and recovery, and ENoG results were collected.

RESULTS

A total of 112 patient records were analyzed. Ages ranged from 8 to 87 years with peaks at 21 to 25 and 61 to 65 years. Among patients, 16.3% reached a nadir at HB II, 41.9% at HB III, 5.4% at HB IV, 16.3% at HB V, and 20.1% at HB VI. The overall recovery rate was 73.2% to HB I function, 17.0% to HB II, and 9.8% to HB III. The chance of recovery to HB I decreased as the severity of paralysis increased (r_s = -1.0, P < .0001). Mean time to recovery to HB I was 6 weeks. Greater degeneration on ENoG suggested worse recovery (r_s = 0.62, P = .01). Patients with HB V and VI were most likely to develop synkinesis.

CONCLUSION

More severe paralysis increased the chance of recovery to HB II or III function. The granularity of this study provides prognostic insights that may inform the counseling of patients with Bell's palsy with respect to prognosis and recovery timeline.

Surgical interventions for the early management of Bell's palsy

BACKGROUND

Bell's palsy is an acute unilateral facial paralysis of unknown aetiology and should only be used as a diagnosis in the absence of any other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option; this is ideally performed as soon as possible after onset. This is an update of a review first published in 2011, and last updated in 2013. This update includes evidence from one newly identified study.

OBJECTIVES

To assess the effects of surgery in the early management of Bell's palsy.

SEARCH METHODS

On 20 March 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. We handsearched selected conference abstracts for the original version of the review.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) or quasi-RCTs involving any surgical intervention for Bell's palsy. Trials compared surgical interventions to no treatment, later treatment (beyond three months), sham treatment, other surgical treatments or medical treatment.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. The primary outcome was complete recovery of facial palsy at 12 months. Secondary outcomes were complete recovery at three and six months, synkinesis and contracture at 12 months, psychosocial outcomes at 12 months, and side effects and complications of treatment.

MAIN RESULTS

Two trials with 65 participants met the inclusion criteria; one was newly identified at this update. The first study randomised 25 participants into surgical or non-surgical (no treatment) groups using statistical charts. One participant declined surgery, leaving 24 evaluable participants. The second study quasi-randomised 53 participants; however, only 41 were evaluable as 12 declined the intervention they were allocated. These 41 participants were then divided into early surgery, late surgery or non-surgical (no treatment) groups using alternation. There was no mention on how alternation was decided. Neither study mentioned if there was any attempt to conceal allocation. Neither participants nor outcome assessors were blinded to the interventions in either study. There were no losses to follow-up in the first study. The second study lost three participants to follow-up, and 17 did not contribute to the assessment of secondary outcomes. Both studies were at high risk of bias. Surgeons in both studies used a retro-auricular/transmastoid approach to decompress the facial nerve. For the outcome recovery of facial palsy at 12 months, the evidence was uncertain. The first study reported no differences between the surgical and no treatment groups. The second study fully reported numerical data, but included no statistical comparisons between groups for complete recovery. There was no evidence of a difference for the early surgery versus no treatment comparison (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.05 to 11.11; P = 0.84; 33 participants; very low-certainty evidence) and for the early surgery versus late surgery comparison (RR 0.47, 95% CI 0.03 to 6.60; P = 0.58; 26 participants; very low-certainty evidence). We considered the effects of surgery on facial nerve function at 12 months very uncertain (2 RCTs, 65 participants; very low-certainty evidence). Furthermore, the second study reported adverse effects with a statistically significant decrease in lacrimal control in the surgical group within two to three months of denervation. Four participants in the second study had 35 dB to 50 dB of sensorineural hearing loss at 4000 Hz, and three had tinnitus. Because of the small numbers and trial design we also considered the adverse effects evidence very uncertain (2 RCTs, 65 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very low-certainty evidence from RCTs or quasi-RCTs on surgery for the early management of Bell's palsy, and this is insufficient to decide whether surgical intervention is beneficial or harmful. Further research into the role of surgical intervention is unlikely to be performed because spontaneous or medically supported recovery occurs in most cases.

Facial and hearing outcomes in transmastoid nerve decompression for Bell's palsy, with preservation of the ossicular chain

Objectives

Facial nerve decompression is a salvage treatment for Bell's palsy patients for whom a poor prognosis is anticipated with standard medical treatment. The transmastoid approach is a frequently performed approach, but it remains unknown if this surgery is effective when the ossicular chain is preserved. This study aimed to determine the efficacy of facial nerve decompression using the transmastoid approach in Bell's palsy.

Design, setting and participants

This retrospective study included patients who had undergone transmastoid facial nerve decompression with ossicular chain preservation and patients who met the criteria for surgery, but received only medical treatment between January 2007 and May 2019, at a single centre.

Main outcome measures

Attainment of House‐Brackmann grade I at 12 months after onset of facial palsy.

Results

The recovery rate to House‐Brackmann grade I in the decompression group in the early phase (≤18 days after onset) was higher than that of the medical treatment group, although the difference was not significant (70% vs 47%, P = .160). However, within this early surgery group, a subgroup of cases with ≥95% facial nerve degeneration demonstrated a significant improvement in recovery rate (73% vs 30%, P = .018). Among surgeries performed in the late phase (≥19 days), only a subgroup with ≥95% facial nerve degeneration was available for analysis, and the difference in recovery rate was not significant compared with medical treatment alone (26% vs 30%, P = 1.00). Post‐surgical hearing evaluation demonstrated that average hearing deterioration was 1.3 dB which was non‐significant, suggesting this procedure does not cause hearing loss.

Conclusions

Transmastoid facial nerve decompression with ossicular chain preservation in the early phase after symptom‐onset is an effective salvage treatment for severe Bell's palsy with ≥95% facial nerve degeneration.

Non-recovery animal model of severe facial paralysis induced by freezing the facial canal

OBJECTIVE

Some cases of peripheral facial paralysis are resistant to treatment, thus, a non-recovery model of facial paralysis is needed to develop new treatment strategies for this condition. The purpose of the current study was to develop an animal model of which facial palsy was severe and prolonged.

METHODS

Ten 8-week-old female Hartley guinea pigs weighing between 400 and 500 g were used for the animal model. The vertical segment of the facial canal was accessed via the otic bulla, without removing the bony wall of the facial canal. The canal was then frozen for 5 s using freeze spray. Facial movements, electroneurography (ENoG), histology, and changes in temperature were evaluated.

RESULTS

All animals exhibited complete facial paralysis immediately after the procedure and recovered gradually, however, not all of them had recovered completely 15 weeks after freezing. The ENoG values one week after freezing for all animals (10/10) were 0%. Histological examination one week after freezing revealed that most of the vertically placed myelinated nerve fibers which had been frozen were remarkably affected and denatured. The number of vertically placed myelinated nerve fibers increased 15 weeks after freezing, but the nerve fibers were smaller than normal nerve fibers and were distorted in shape.

CONCLUSION

Complete facial paralysis was induced in Hartley guinea pigs by freezing the facial canal. The behavioral, ENoG, and histopathological data suggest that the facial paralysis was severe and prolonged. This model may assist in developing novel treatment for severe facial palsy and facilitate basic research on facial nerve regeneration.

Nerve Integrity Monitor Responses to Direct Facial Nerve Stimulation During Facial Nerve Decompression Surgery Can Predict Postoperative Outcomes

OBJECTIVE

To test whether the threshold of nerve integrity monitor (NIM) responses during facial nerve decompression surgery can predict the postoperative outcome.

STUDY DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

Twenty peripheral facial palsy patients who underwent transmastoid decompression surgery.

INTERVENTION

During decompression surgery, thresholds of NIM responses were measured via direct facial nerve stimulation at three sites: the geniculate ganglion (GG), the second genu (2 G), and the stylomastoid foramen.

MAIN OUTCOME MEASURES

Facial nerve function was evaluated before and 6 months after surgery using the Yanagihara grading score (maximum score = 40 points). Complete recovery was defined as an improvement of the grading score to ≥ 36 points without synkinesis. Variables including age, sex, disease (Bell's palsy or Ramsay Hunt syndrome), time after onset, Yanagihara grading score, and electroneurography before surgery, and the thresholds of NIM responses during surgery were compared in the complete and incomplete recovery groups. NIM responders were defined as those exhibiting a NIM response of < 1.5 mA at any site. Postoperative Yanagihara grading scores in NIM responders and NIM nonresponders were compared.

RESULTS

No variables differed significantly in the complete and incomplete recovery groups before surgery. NIM response thresholds in the complete recovery group at the GG and the 2nd G were significantly lower than the corresponding thresholds in the incomplete recovery group. The postoperative Yanagihara grading scores of NIM responders were significantly better than those of NIM nonresponders.

CONCLUSION

NIM responses to intraoperative direct facial nerve stimulation were useful for predicting outcomes after decompression surgery.

Clinical Implication of Facial Nerve Decompression in Complete Bell's Palsy: A Systematic Review and Meta-Analysis

We compared the therapeutic efficacy of facial nerve decompression (FND) and conservative treatment in patients with Bell’s palsy through a systematic review and meta-analysis. Primary database search was performed in PubMed, Medline, and Embase. After screening, 13 studies were assessed for their eligibility. Among them, seven studies employing either the House-Brackmann grading system (HBGS) or May’s classification (modified HBGS) were selected for quantitative and qualitative analysis. Based on May’s classification, the degree of recovery was classified into complete (HBGS I), fair (HBGS II–III), or failed (HBGS IV–VI) recovery. The outcomes were assessed between 6 and 12 months after surgery. The estimated pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using random effects model. Cohorts were comprised of patients who underwent FND (n=202, 53.0%) and conservative treatments (n=179, 47.0%). In pooled analysis, the rate of complete recovery was significantly higher in the FND group than in the control group (OR, 2.06; 95% CI, 1.22 to 3.48; P=0.007) showing neither heterogeneity nor publication bias. Meanwhile, the rates of fair recovery (OR, 0.71; 95% CI, 0.42 to 1.21; P=0.208) and failed recovery (OR, 0.60; 95% CI, 0.22 to 1.67; P=0.327) in the FND group were similar to that in the control group. In subgroup analyses, there was no significant difference in the OR according to the operation timing and surgical approach. FND can be a possible treatment option for patients with complete Bell’s palsy, especially for complete recovery, which provide insights on decision-making and outcome prediction. However, FND should be determined carefully given the risk of small study effects and possible complications.

Delayed transmastoid facial nerve decompression surgery in patients with Ramsay-Hunt syndrome presenting with neurophysiologically complete paralysis

OBJECTIVES

To determine the efficacy of delayed transmastoid facial nerve decompression in patients with Ramsay Hunt Syndrome (RHS) presenting with complete facial paralysis.

METHODS

Twenty-five RHS patients with complete facial nerve paralysis presenting electroneuronographic (ENoG) degeneration ≥90% underwent transmastoid facial nerve decompression more than 3 weeks after the onset of paralysis. The principal features measured were 12 months pre- and post-operative House-Brackmann (HB) grades and the presence of a direct intraoperative neural response (INR) prior to decompression procedure. Correlations between these parameters, and the time between symptom onset and surgery (within or later than 30 and 50 d) were statistically analyzed.

RESULTS

Of the 25 patients 13 (52%) exhibited good recovery (HB grade I or II) at 12 months-post-operatively. The timing of decompression generally did not significantly influence outcome but patients treated within 50 d of symptom onset enjoyed better outcomes than those treated later (p = .047). The presence of an INR significantly influenced outcomes (p = .0003).

CONCLUSIONS

The success of delayed transmastoid facial nerve decompression in RHS patients was not affected between 25-30 and 30-40 d from symptom onset but was compromised when the delay was >50 d. The presence or absence of an INR was a good predictor of post-operative prognosis.

Surgical Management of Acute Facial Palsy

Bell palsy and traumatic facial nerve injury are two common causes of acute facial palsy. Most patients with Bell palsy recover favorably with medical therapy alone. However, those with complete paralysis (House-Brackmann 6/6), greater than 90% degeneration on electroneurography, and absent electromyography activity may benefit from surgical decompression via a middle cranial fossa (MCF) approach. Patients with acute facial palsy from traumatic temporal bone fracture who meet these same criteria may be candidates for decompression via an MCF or translabyrinthine approach based on hearing status.

Patients Over 60 Years of Age Have Poor Prognosis in Facial Nerve Decompression Surgery with Preserved Ossicular Chain

OBJECTIVE

We report our retrospective study of the recovery rate of auditory ossicles preserved facial nerve decompression surgery via the transmastoid approach in cases of both an electroneurography score of < 10% and a Yanagihara score of ≤8 in Bell's palsy and Ramsay Hunt syndrome.

MATERIALS AND METHODS

We retrospectively reviewed 47 patients who we were able to follow-up for more than 6 months following the onset of palsy. The recovery rate was defined by the Japan Society for Facial Nerve Research or the Yanagihara score.

RESULTS

Twelve months after palsy onset, the recovery rate was 48.8% (20/41) for all patients, 65.2% (15/23) for patients with Bell's palsy, and 27.8% (5/18) for patients with Ramsay Hunt syndrome. Comparing the clinical efficacy of surgical treatment at 12 months after palsy onset, we observed a statistically significant effect of age. Comparing the Yanagihara scores of patients aged < 60 years with those of patients aged ≥60 years revealed that patients aged ≥60 years had significant poor prognosis, particularly in patients with Ramsay Hunt syndrome, which showed a very low recovery rate (14.3%). We also analyzed six other factors, but none showed statistical significance.

CONCLUSION

The clinical efficacy of surgical treatment of Ramsay Hunt syndrome was inferior to that of Bell's palsy, which is consistent with previous reports. There was a statistically significant difference in the Yanagihara score between patients aged < 60 years and those aged ≥60 years. Particularly, patients with Ramsay Hunt syndrome aged ≥60 years have a very low recovery rate.

Delayed facial nerve decompression for severe refractory cases of Bell's palsy: a 25-year experience

Background

This study aims to assess the effectiveness of delayed facial nerve decompression for Bell’s palsy (BP).

Methods

We performed a retrospective case review of all patients having undergone facial nerve decompression for severe refractory BP between 1984 and 2009 at our tertiary referral center. Demographics, timing between onset of symptoms and surgical decompression, degree of facial nerve dysfunction pre- and post-operatively, follow-up length after surgery and postoperative complications were recorded. Facial nerve dysfunction was assessed using the House-Brackmann (HB) scale. Electroneuronography, electromyography and imaging results were assessed when available.

Results

Eighteen patients had surgery between 21 and 60 days after onset of BP (group I), and 18 patients had surgery more than 60 days after onset of symptoms (group II). In group II, 11 patients had surgery between 61 and 89 days and 7 patients after 90 days. Groups I and II showed similar functional gain and rates of improvement to HB 3 or better (11/18 vs. 11/18, p > 0.05). In group II, patients operated 60 to 89 days after onset of BP showed a significantly higher rate of improvement to HB 3 or better (9/11 vs. 2/6, p = 0.049) with higher functional gain compared to those operated after 90 days (p = 0.0293).

Conclusions

When indicated, facial nerve decompression for BP is usually recommended within the first 2 weeks of onset of facial paralysis. Nonetheless, our results suggest that patients with severe BP could benefit from decompression surgery within 90 days after onset of symptoms in the absence of an opportunity to proceed earlier to surgery. Further investigation is still required to confirm our findings.

Trial registration

Retrospective registered. IRB# 2016–6154, CE 15.154 – CA

Bilateral Facial Paralysis: A 13-Year Experience

BACKGROUND

Bilateral facial palsy is a rare clinical entity caused by myriad disparate conditions requiring different treatment paradigms. Lyme disease, Guillain-Barré syndrome, and leukemia are several examples. In this article, the authors describe the cause, the initial diagnostic approach, and the management of long-term sequelae of bilateral paralysis that has evolved in the authors' center over the past 13 years.

METHODS

A chart review was performed to identify all patients diagnosed with bilateral paralysis at the authors' center between January of 2002 and January of 2015. Demographics, signs and symptoms, diagnosis, initial medical treatment, interventions for facial reanimation, and outcomes were reviewed.

RESULTS

Of the 2471 patients seen at the authors' center, 68 patients (3 percent) with bilateral facial paralysis were identified. Ten patients (15 percent) presented with bilateral facial paralysis caused by Lyme disease, nine (13 percent) with Möbius syndrome, nine (13 percent) with neurofibromatosis type 2, five (7 percent) with bilateral facial palsy caused by brain tumor, four (6 percent) with Melkersson-Rosenthal syndrome, three (4 percent) with bilateral temporal bone fractures, two (3 percent) with Guillain-Barré syndrome, one (2 percent) with central nervous system lymphoma, one (2 percent) with human immunodeficiency virus infection, and 24 (35 percent) with presumed Bell palsy. Treatment included pharmacologic therapy, physical therapy, chemodenervation, and surgical interventions.

CONCLUSIONS

Bilateral facial palsy is a rare medical condition, and treatment often requires a multidisciplinary approach. The authors outline diagnostic and therapeutic algorithms of a tertiary care center to provide clinicians with a systematic approach to managing these complicated patients.

Temporal Lobe Retraction Provides Better Surgical Exposure of the Peri-Geniculate Ganglion for Facial Nerve Decompression via Transmastoid Approach

PURPOSE

For the exposure of the labyrinthine segment of the facial nerve, transmastoid approach is not usually considered due to being situated behind the superior semicircular canal. To obtain a better view and bigger field for manipulation in the peri-geniculate area during facial nerve decompression, retraction of temporal lobe after bony removal of tegmen mastoideum was designed via transmastoid approach.

MATERIALS AND METHODS

Fifteen patients with traumatic facial paralysis [House-Brackmann (HB) grade IV-VI], 3 patients with Bell's palsy (HB grade V-VI), and 2 patients with herpes zoster oticus (HB grade V-VI) underwent facial nerve decompression surgery between January 2008 and July 2014. In all patients, we performed temporal lobe retraction for facial nerve decompression via the transmastoid approach. Patients were examined using pre operative tests including high-resolution computed tomography, temporal magnetic resonance imaging, audiometry, and electroneurography (degenerative ratio >90%). Facial function was evaluated by HB grading scale before and 6 months after the surgery.

RESULTS

After the surgery, facial function recovered to HB grade I in 9 patients and to grade II in 11 patients. No problems due to surgical retraction of the temporal lobe were noted. Compared to the standard transmastoid approach, our method helped achieve a wider surgical view for improved manipulation in the peri-geniculate ganglion in all cases.

CONCLUSION

Facial nerve decompression via the transmastoid approach with temporal lobe retraction provides better exposure to the key areas around the geniculate ganglion without complications.

Bell's Palsy

Bell's palsy is unilateral, acute onset facial paralysis that is a common condition. One in every 65 people experiences Bell's palsy in the course of their lifetime. The majority of patients afflicted with this idiopathic disorder recover facial function. Initial treatment involves oral corticosteroids, possible antiviral drugs, and protection of the eye from desiccation. A small subset of patients may be left with incomplete recovery, synkinesis, facial contracture, or hemifacial spasm. A combination of medical and surgical treatment options exist to treat the long-term sequelae of Bell's palsy.

Antiviral agents convey added benefit over steroids alone in Bell's palsy; decompression should be considered in patients who are not recovering

BACKGROUND

The management of Bell's palsy has been the subject of much debate, with corticosteroids being the preferred medication. However, evidence also supports the use of antiviral drugs for severe cases and even decompression surgery in patients who, despite medical treatment, are not recovering.

METHOD

A literature review was conducted on the management of Bell's palsy.

RESULTS

This paper describes the background, statistical evidence, study results and pathophysiological theories that support more aggressive treatment for patients with severe palsy and those who have inadequate recovery.

CONCLUSION

Combination therapy including antiviral medication significantly improves outcomes in patients with severe Bell's palsy. Decompression should be considered in patients who have not recovered with drug treatment.

Delayed facial nerve decompression for Bell's palsy

Incomplete recovery of facial motor function continues to be long-term sequelae in some patients with Bell's palsy. The purpose of this study was to investigate the efficacy of transmastoid facial nerve decompression after steroid and antiviral treatment in patients with late stage Bell's palsy. Twelve patients underwent surgical decompression for Bell's palsy 21-70 days after onset, whereas 22 patients were followed up after steroid and antiviral therapy without decompression. Surgical criteria included greater than 90 % degeneration on electroneuronography and no voluntary electromyography potentials. This study was a retrospective study of electrodiagnostic data and medical chart review between 2006 and 2013. Recovery from facial palsy was assessed using the House-Brackmann grading system. Final recovery rate did not differ significantly in the two groups; however, all patients in the decompression group recovered to at least House-Brackmann grade III at final follow-up. Although postoperative hearing threshold was increased in both groups, there was no significant between group difference in hearing threshold. Transmastoid decompression of the facial nerve in patients with severe late stage Bell's palsy at risk for a poor facial nerve outcome reduced severe complications of facial palsy with minimal morbidity.

Recurrent facial palsy in Melkersson Rosenthal syndrome: total facial nerve decompression is effective to prevent further recurrence

OBJECTIVE

To study the role of total facial nerve decompression in preventing further recurrence of facial palsy in Melkersson Rosenthal syndrome (MRS).

METHODS

Total facial nerve decompression was performed on nine patients with recurrent facial palsy in MRS, and prednisolone treatment was given to 6 cases who declined surgery. They were incorporated into surgery group and control group, respectively. Patients in surgery group and control group were followed up for 5.4 ± 1.4 years (range, 4 to 8 years) and 6.0 ± 1.4 years (range, 4 to 8 years), respectively.

RESULTS

Further episodes of facial palsy affected none of 9 cases (0.0%) in surgery group, while they affected 3 of 6 cases (50.0%) in control group, with significant difference (p<0.05).

CONCLUSIONS

Total facial nerve decompression was effective to prevent further episodes of facial palsy in MRS.

Surgical outcomes of facial nerve hemangiomas in temporal bones

OBJECTIVE

To report surgical outcomes of 15 cases who had facial nerve hemangiomas.

METHODS

All cases underwent complete removal of hemangiomas, and preservation of nerve integrity was attempted. The postoperative outcomes of facial nerve was assessed.

RESULTS

Nerve integrity was successfully preserved in 10 cases, all of which maintained or recovered to Grade I or Grade II, and facial nerve was sacrificed in 5 cases, who recovered to Grade III or Grade IV.

CONCLUSIONS

When possible, facial nerve preservation should be attempted, which was critical to yield better outcomes of facial nerve.

The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends

Background

Recent advances in Bell’s palsy (BP) were reviewed to assess the current trends in its management and prognosis.

Material/Methods

We retrieved the literature on BP using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Key words and phrases used during the search included ‘Bell’s palsy’, ‘Bell’s phenomenon’, ‘facial palsy’, and ‘idiopathic facial paralysis’. Emphasis was placed on articles and randomized controlled trails (RCTs) published within the last 5 years.

Results

BP is currently considered the leading disorder affecting the facial nerve. The literature is replete with theories of its etiology, but the reactivation of herpes simplex virus isoform 1 (HSV-1) and/or herpes zoster virus (HZV) from the geniculate ganglia is now the most strongly suspected cause. Despite the advancements in neuroimaging techniques, the diagnosis of BP remains one of exclusion. In addition, most patients with BP recover spontaneously within 3 weeks.

Conclusions

Corticosteroids are currently the drug of choice when medical therapy is needed. Antivirals, in contrast, are not superior to placebo according to most reliable studies. At the time of publication, there is no consensus as to the benefit of acupuncture or surgical decompression of the facial nerve. Long-term therapeutic agents and adjuvant medications for BP are necessary due to recurrence and intractable cases. In the future, large RCTs will be required to determine whether BP is associated with an increased risk of stroke.

Clinical practice guideline: Bell's palsy

OBJECTIVE

Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

PURPOSE

The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

Surgical interventions for the early management of Bell's palsy

BACKGROUND

Bell's palsy is an acute paralysis of one side of the face of unknown aetiology. Bell's palsy should only be used as a diagnosis in the absence of all other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option. This is an update of a review first published in 2011.

OBJECTIVES

To assess the effects of surgery in the management of Bell's palsy.

SEARCH METHODS

On 29 October 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2012, Issue 10), MEDLINE (January 1966 to October 2012) and EMBASE (January 1980 to October 2012). We also handsearched selected conference abstracts for the original version of the review.

SELECTION CRITERIA

We included all randomised or quasi-randomised controlled trials involving any surgical intervention for Bell's palsy. We compared surgical interventions to no treatment, sham treatment, other surgical treatments or medical treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether trials identified from the searches were eligible for inclusion. Two review authors independently assessed the risk of bias and extracted data.

MAIN RESULTS

Two trials with a total of 69 participants met the inclusion criteria. The first study considered the treatment of 403 people but only included 44 participants in the surgical trial, who were randomised into surgical and non-surgical groups. However, the report did not provide information on the method of randomisation. The second study randomly allocated 25 participants into surgical or control groups using statistical charts. There was no attempt in either study to conceal allocation. Neither participants nor outcome assessors were blind to the interventions, in either study. The first study lost seven participants to follow-up and there were no losses to follow-up in the second study.Surgeons in both studies decompressed the nerves of all the surgical group participants using a retroauricular approach. The primary outcome was recovery of facial palsy at 12 months. The first study showed that the operated group and the non-operated group (who received oral prednisolone) had comparable facial nerve recovery at nine months. This study did not statistically compare the groups but the scores and size of the groups suggested that statistically significant differences are unlikely. The second study reported no statistically significant differences between the operated and control (no treatment) groups. One operated participant in the first study had 20 dB sensorineural hearing loss and persistent vertigo. We identified no new studies when we updated the searches in October 2012.

AUTHORS' CONCLUSIONS

There is only very low quality evidence from randomised controlled trials and this is insufficient to decide whether surgical intervention is beneficial or harmful in the management of Bell's palsy.Further research into the role of surgical intervention is unlikely to be performed because spontaneous recovery occurs in most cases.

Surgical experience of nine cases with intratemporal facial hemangiomas and a brief literature review

CONCLUSIONS

It was practicable to remove hemangiomas at the labyrinth region and distal internal auditory canal with complete or serviceable hearing preservation by the transmastoid approach. The majority of cases where the nerve integrity was preserved achieved acceptable recovery of facial nerve function during the first few years according to our study. Long-term outcomes of nerve graft were acceptable, while short-term outcomes were unsatisfactory based on the literature.

OBJECTIVE

This study aimed to present our surgical experience of nine intratemporal facial nerve hemangiomas and provide a brief literature review.

METHODS

Clinical data for the cases were retrospectively analyzed. They were followed up for 5-59 months and related literature was reviewed.

RESULTS

All of the hemangiomas were removed by the transmastoid approach, and only three cases developed mild conductive hearing loss. Nerve integrity was preserved for all cases. In all, 66.7% of patients maintained or recovered to grade III or better, and one patient with grade VI recovered to grade V during the average follow-up period of 2 years. In the literature the majority of grafted patients recovered to an acceptable level 5 years later, although recovery was usually poor during the first year.

Surgical experience of intratemporal facial nerve neurofibromas

CONCLUSIONS

The first presentation of intratemporal facial neurofibromas was variable, with facial palsy most common. The tumors often involve two or more segments of facial nerve. Outcomes of the tumors were closely related to nerve integrity, preoperative facial nerve function level, and follow-up period.

OBJECTIVE

The aim of this study was to present surgical experience of 11 cases with intratemporal facial neurofibroma.

METHODS

Clinical data of the 11 cases with the tumors was retrospectively collected and analyzed. They were followed up for 37.9 ± 1.7 months, range 13-59 months, except for one case that was only followed up for 5 months and was excluded from the analysis of outcomes.

RESULTS

Facial palsy was the first presentation in 10 cases, with repetitive facial palsy and vertigo in 1 case; 6 cases (54.5%) were insidious and 5 (45.5%) were sudden in terms of onset. Ear pain around the onset of facial palsy was found in four cases (36.4%). The tumor involved more than one segment in six cases. Among the non-grafted cases one patient with grade V facial nerve function recovered to grade III and another patient with grade VI facial nerve function recovered to grade IV, whereas only one case with grade VI recovered to grade IV among the grafted cases.

Use of computed tomography to predict the possibility of exposure of the first genu of the facial nerve via the transmastoid approach

HYPOTHESIS

The purpose of this study was to investigate whether computed tomography (CT) could predict the possibility of first genu exposure of the facial nerve via the transmastoid approach in patients with acute facial paralysis.

BACKGROUND

Temporal bone CT is the best method for visualizing the intratemporal segment of the facial nerve canal, which is known to have diverse anatomic variations.

METHODS

A prospective study was conducted on 11 patients who underwent facial nerve decompression via the transmastoid approach. Two groups of patients underwent surgery to expose the perigeniculate area via the transmastoid approach. One group included patients who had anatomic parameters of the temporal bone that met the CT criteria, including length of the labyrinthine segment, level of the geniculate ganglion, bony thickness of the lateral semicircular canal, and height interval between the tympanic and labyrinthine segments. The other group included patients with facial paralysis who required facial nerve exploration, especially distal to the geniculate ganglion. Facial nerve decompression was performed in all patients as far proximal in the transmastoid view as was possible without causing damage to the semicircular canals.

RESULTS

We correlated the temporal bone CT images and surgical findings in 11 patients who underwent facial nerve decompression via the transmastoid approach. The facial nerves of 6 patients who had anatomic structures that met the CT criteria were successfully exposed to the proximal labyrinthine segment without labyrinthine damage. The facial nerves of another 4 patients who did not have anatomic structures that met the CT criteria could be decompressed only to the geniculate ganglion.

CONCLUSION

CT scan can predict the possibility of first genu exposure of the facial nerve via the transmastoid approach based on the CT parameters suggested in this study.

Facial nerve decompression surgery using bFGF-impregnated biodegradable gelatin hydrogel in patients with Bell palsy

OBJECTIVE

Basic fibroblast growth factor (bFGF) promotes the regeneration of denervated nerves. The aim of this study was to evaluate the regeneration-facilitating effects of novel facial nerve decompression surgery using bFGF in a gelatin hydrogel in patients with severe Bell palsy.

STUDY DESIGN

Prospective clinical study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Twenty patients with Bell palsy after more than 2 weeks following the onset of severe paralysis were treated with the new procedure. The facial nerve was decompressed between tympanic and mastoid segments via the mastoid. A bFGF-impregnated biodegradable gelatin hydrogel was placed around the exposed nerve. Regeneration of the facial nerve was evaluated by the House-Brackmann (H-B) grading system. The outcomes were compared with the authors' previous study, which reported outcomes of the patients who underwent conventional decompression surgery (n = 58) or conservative treatment (n = 43).

RESULTS

The complete recovery (H-B grade 1) rate of the novel surgery (75.0%) was significantly better than the rate of conventional surgery (44.8%) and conservative treatment (23.3%). Every patient in the novel decompression surgery group improved to H-B grade 2 or better even when undergone between 31 and 99 days after onset.

CONCLUSION

Advantages of this decompression surgery are low risk of complications and long effective period after onset of the paralysis. To the authors' knowledge, this is the first clinical report of the efficacy of bFGF using a new drug delivery system in patients with severe Bell palsy.

Surgical interventions for the early management of Bell's palsy

BACKGROUND

Bell's palsy is an acute paralysis of one side of the face of unknown aetiology. Bell's palsy should only be used as a diagnosis in the absence of all other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option.

OBJECTIVES

The objective of this review was to assess the effectiveness of surgery in the management of Bell's palsy and to compare this to outcomes of medical management.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (23 November 2010). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (23 November in The Cochrane Library, Issue 4 2010). We adapted this strategy to search MEDLINE (January 1966 to November 2010) and EMBASE (January 1980 to November 2010).

SELECTION CRITERIA

We included all randomised or quasi-randomised controlled trials involving any surgical intervention for Bell's palsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether trials identified from the search strategy were eligible for inclusion. Two review authors assessed trial quality and extracted data independently.

MAIN RESULTS

Two trials with a total of 69 participants met the inclusion criteria. The first study considered the treatment of 403 patients but only included 44 in their surgical study. These were randomised into a surgical and non surgical group. The second study had 25 participants which they randomly allocated into surgical or control groups.The nerves of all the surgical group participants in both studies were decompressed using a retroauricular approach. The primary outcome was recovery of facial palsy at 12 months. The first study showed that both the operated and non operated groups had comparable facial nerve recovery at nine months. This study did not statistically compare the groups but the scores and size of the groups suggested that statistically significant differences are unlikely. The second study reported no statistically significant differences between their operated and control groups. One operated patient in the first study had 20 dB sensorineural hearing loss and persistent vertigo.

AUTHORS' CONCLUSIONS

There is only very low quality evidence from randomised controlled trials and this is insufficient to decide whether surgical intervention is beneficial or harmful in the management of Bell's palsy.Further research into the role of surgical intervention is unlikely to be performed because spontaneous recovery occurs in most cases.

Effect of delayed decompression after early steroid treatment on facial function of patients with facial paralysis

CONCLUSION

The earlier decompression is carried out, the better the result. However, decompression delayed a few days beyond 2 weeks after onset of facial paralysis can benefit the recovery of facial function in patients when combined with early use of steroids with or without antiviral agents.

OBJECTIVES

To demonstrate the correlation between the time of decompression after the onset of facial paralysis and the facial function after surgery and elucidate the beneficial effect of decompression delayed a few days beyond the 2 week period on recovery of facial function in patients who had received early steroid treatment.

PATIENTS AND METHODS

Between April 1994 and December 2007, 91 patients with complete facial paralysis who had received early treatment with steroid with or without antiviral agents were included in the study. An independent sample t test was used to analyze the recovery of facial function in patients receiving surgical decompression at different times after onset of paralysis and medical treatment only.

RESULTS

Functional gain according to the House-Brackman (HB) grade was 4.05+/-0.96 for early decompression, 3.63+/-0.58 for delayed decompression, 2.90+/-0.76 for late decompression, and 2.51+/-0.85 for medical treatment only. Delayed decompression significantly improved the functional outcome of patients compared with late decompression and medical treatment only (p<0.05).

Facial nerve decompression for idiopathic Bell's palsy: report of 13 cases and literature review

INTRODUCTION

The prognosis for cases of idiopathic facial palsy is usually good. However, some cases develop disabling sequelae, such as synkinesis or severe facial hemispasm, despite targeted medical treatment.

OBJECTIVES

The authors try to achieve that electromyography is useful to identify patients with severe palsy and an unfavourable prognosis. These patients would probably benefit from facial nerve decompression.

SETTING

The otolaryngology-head and neck surgery department of Pitié-Salpêtrière Hospital, Paris, a tertiary referral centre.

PARTICIPANTS

Thirteen cases undergoing surgery between January 1997 and March 2007.

MAIN OUTCOME MEASURES

We describe the electromyographic findings that led to surgery. All patients underwent surgery via a subpetrous approach, within four months of the onset of palsy. Decompression involved the first and second portions of the nerve and the geniculate ganglion.

RESULTS

Recovery to House-Brackmann grade III was obtained in all cases at one year follow up.

CONCLUSION

These results compared favourably with previous reports. A new therapeutic procedure may allow improved results.

Zygomatic root approach

CONCLUSIONS

The zygomatic root (ZR) approach provides improved intraoperative exposure of the key areas around the geniculate ganglion without a craniotomy, combining the advantages of middle cranial fossa (MCF) and transmastoid extralabyrinthine (TMEL) approaches. The ZR approach may be useful in cases of traumatic facial palsy, Bell's palsy, iatrogenic facial palsy, superior semicircular canal dehiscence and primary cholesteatoma.

OBJECTIVES

To describe and evaluate the new ZR approach technique in the treatment of traumatic intratemporal facial nerve injuries.

PATIENTS AND METHODS

This is a prospective clinical study of three consecutive procedures performed between July 2007 and January 2008, and a detailed discription of the surgical technique. The setting is a tertiary referral center. The patients' age range was 3-7 years. Interventions were based on drilling the ZR area extensively, so that the perigeniculate area was exposed through the space created between the middle cranial fossa basal dura and skeletonized external auditory canal. The ZR approach can be performed as an isolated technique or can be combined with an inferior mastoidectomy protecting the bony bridge between.

RESULTS

Two patients had a mixed-type fracture and one patient had a transverse fracture. All three patients received a ZR combined approach. There was no cerebrospinal fluid leak, hearing loss, tympanic membrane perforation or meatal stenosis.

Cutaneous electrical stimulation treatment in unresolved facial nerve paralysis: an exploratory study

OBJECTIVE

The purpose of this study was to assess clinical and neurophysiological changes after 6 mos of transcutaneous electrical stimulation in patients with unresolved facial nerve paralysis.

DESIGN

A pilot case series of 10 consecutive patients with chronic facial nerve paralysis either of idiopathic origin or because of herpes zoster oticus participated in this open study. All patients received below sensory threshold transcutaneous electrical stimulation for 6 mos for their facial nerve paralysis. The intervention consisted of gradually increasing the duration of electrical stimulation of three sites on the affected area for up to 6 hrs/day. Assessments of the facial nerve function were performed using the House-Brackmann clinical scale and neurophysiological measurements of compound motor action potential distal latencies on the affected and nonaffected sides. Patients were tested before and after the intervention.

RESULTS

A significant improvement was observed in the facial nerve upper branch compound motor action potential distal latency on the affected side in all patients. An improvement of one grade in House-Brackmann scale was observed and some patients also reported subjective improvement.

CONCLUSIONS

Transcutaneous electrical stimulation treatment may have a positive effect on unresolved facial nerve paralysis. This study illustrates a possibly effective treatment option for patients with the chronic facial paresis with no other expectations of recovery.

Outcome measures in facial plastic surgery: patient-reported and clinical efficacy measures

OBJECTIVE

To survey the existing literature to identify, summarize, and evaluate procedure- and condition-specific outcome measures for use in facial plastic and reconstructive surgery.

METHODS

A review of the English-language literature was performed to identify outcomes instruments specific for targeted facial plastic surgery interventions and conditions. A search was performed using MEDLINE (1950 to September 2007), CINAHL (Cumulative Index to Nursing & Allied Health) (1982 to September 2007), and PsychINFO (1806 to September 2007). Outcomes instruments were categorized as patient-reported or clinical efficacy measures (observer-reported or objective measures). Instruments were then categorized to include relevant details on the intervention, degree of validation, and subsequent use.

RESULTS

Sixty-eight distinct instruments were identified (23 patient-reported, 35 observer-reported, and 10 objective measures), with some overlap among categories. Most patient-reported measures (76%) and half observer-reported instruments (51%) were developed in the past 10 years. The rigor of validation varied widely among measures, with formal validation being most common among the patient-reported outcome measures.

CONCLUSIONS

Validated outcomes measures are present for many common facial plastic surgery conditions and have become more prevalent during the past decade, especially for patient-reported outcomes. Challenges remain in harmonizing patient-reported, observer-based, and other objective measures to produce standardized clinically meaningful outcome measures.