Magnetic Resonance Imaging Findings in Delayed Facial Palsy After Stapes Surgery

Effects of Age on Delayed Facial Palsy After Otologic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To report 4 cases of delayed facial palsy (DFP) after pediatric middle ear (ME) surgery and systematically review and analyze the associated literature to evaluate the effects of age on DFP etiology, management, and prognosis.

METHODS

Systematic review of PubMed, Cochrane Library, and Embase for articles related to DFP after cochlear implantation (CI) was performed. These articles were assessed for level of evidence, methodological limitations, and number of cases. Meta-analysis was performed to assess the effects of age on DFP incidence. Furthermore, a comprehensive list of all pediatric DFP cases after otologic surgery was assembled through a multi-institutional retrospective review and systematic review of the literature.

RESULTS

Twenty-nine articles fit the criteria for inclusion in the meta-analysis. The incidence of DFP after CI was 0.23% and 1.01% for pediatric and adult cases, respectively. This difference was statistically significant (P < .001, odds ratio 4.36). Twenty-three cases, adding to the 4 presented herein, were suitable for a comprehensive list. The mean age was 6.9 years. Average postoperative day of paresis onset was 5.4, with an average maximum House-Brackmann grade of 3.5. All patients obtained full facial recovery after an average of 23.5 days.

CONCLUSIONS

The systematic review demonstrates that DFP after pediatric CI is rare and occurs at a significantly lower rate than in adults, further supporting the viral reactivation hypothesis of DFP. The prognosis for pediatric DFP after otologic surgery is excellent, with a high rate of full recovery in a short time frame. However, steroid administration can be considered.

LEVEL OF EVIDENCE

IIa.

Common features in patients with superior canal dehiscence declining surgical treatment

Background

Superior canal dehiscence (SCD) is a benign condition in which a surgical treatment may be considered depending on the patients’ tolerance of their symptoms. In this study, we aim to identify driving factors behind the patients’ choice of a surgical management over watchful waiting.

Methods

Sixty-two patients with cochlear and/or vestibular symptoms and a temporal bone high-resolution CT (HRCT) scan showing SCD were included in the study. All patients have been offered either surgical management or watchful waiting.

Results

Of these, 28 elected surgery and 34 declined it. The operated group showed more cochlear (6.6 vs. 2.4) symptoms than the non-operated group (P < 0.001) except for hypoacousis, but no significant difference (P = 0.059) was found for the number of vestibular symptoms between both groups (3.4 vs. 1.1). Footstep and eating hyperacousis were both present in 57.1% of operated vs. 3% of non-operated patients (P < 0.001). Oscillopsia with effort and with walking was found in 50% and 35.7% of operated patients, respectively, but none in the non-operated group (P < 0.001). Hearing tuning fork at malleolus and Valsalva and pneumatic speculum induced vertigo showed a statistically significant difference between the two groups (P = 0.003, P < 0.001, P = 0.010 respectively). Cervical vestibular-evoked myogenic potential (cVEMP) thresholds, air and bone conduction thresholds, and mean air-bone gap (ABG) were similar in the two populations (P > 0.05). The average dehiscence size was 4.7 mm (2.0 - 8.0 mm) and 3.8 mm (1.3 - 7.7 mm) in the operated and non-operated patients, respectively (P = 0.421).

Conclusions

The natures of cochleovestibular signs and symptoms were shown to be key factors in patients’ choice of a surgical management whereas paraclinical tests seem to be less significant in the patients’ decision for a surgical treatment.

Delayed Facial Paralysis following Uneventful KTP Laser Stapedotomy: Two Case Reports and a Review of the Literature

Facial palsy that occurs immediately after middle ear surgery (stapedectomy, stapedotomy, and tympanoplasty) can be a consequence of the local anesthetics and it regresses completely within a few hours. In the case of delayed facial palsy, the alarming symptom occurs several days or even weeks after uneventful surgery. The mechanism of the neural dysfunction is not readily defined. Surgical stress, intraoperative trauma, or laceration of the chorda tympani nerve with a resultant retrograde facial nerve edema can all be provoking etiological factors. A dehiscent bony facial canal or a multiple microporotic fallopian canal (microtrauma or laser effect) can also contribute to the development of this rare phenomenon. The most popular theory related to the explanation of delayed facial palsy at present is the reactivation of dormant viruses. Both the thermal effect of the laser and the elevation of the tympanomeatal flap can reactivate viruses resting inside the ganglion geniculi, facial nerve, or facial nuclei. The authors report the case histories of a 55-year-old female, and a 45-year-old male who presented with a delayed facial palsy following laser stapedotomy. The clinical characteristics, the therapeutic options, and the possibility of prevention are discussed.

Clinical factors associated with prolonged recovery after superior canal dehiscence surgery

OBJECTIVE

To identify clinical factors associated with prolonged recovery after superior canal dehiscence surgery.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care academic medical center.

PATIENTS

Thirty-three patients that underwent surgery for SCDS were identified from a database of 140 patients diagnosed with SCD (2000-2010) at the Massachusetts Eye and Ear Infirmary (U.S.A.). The diagnosis of SCDS was based on clinical signs and symptoms, audiometric and vestibular testing and high-resolution temporal bone computed tomography.

INTERVENTION

For the primary repair, the superior canal was plugged in 31 patients through a middle fossa craniotomy approach and in 1 patient through a transmastoid approach. In 1 patient, the SCD was resurfaced through a middle fossa craniotomy approach.

MAIN OUTCOME MEASURES

Postoperative clinical signs and symptoms and factors that may influence duration of disequilibrium after surgery.

RESULTS

Thirty-three patients (15-71 yr; mean, 43 yr) underwent surgery for SCDS on 35 ears (2 bilateral). Mean follow-up was 28.7 months (range, 3 mo to 10 yr); 33 of 33 (100%) patients experienced initial improvement of the chief complaint. Three patients required revision surgery, improving symptoms in 2 patients. Six patients had dizziness lasting more than 4 months postoperatively, and all had bilateral SCD, migraines, and a dehiscence of 3 mm or greater.

CONCLUSION

Surgical plugging of SCD is an effective management option to provide long-term improvement of the chief complaint in SCDS patients. Patients with bilateral SCD, a history of migraines, and larger defects may be at risk of prolonged recovery and should be appropriately counseled.

Delayed facial nerve palsy after endolymphatic sac surgery

Data on delayed facial nerve palsy (DFNP) following endolymphatic sac enhancement surgery are limited. We conducted a retrospective chart review to determine the incidence, possible predisposing factors, treatment, and prognosis of DFNP in such cases. We reviewed the records of 779 patients who had undergone endolymphatic sac surgery for intractable Ménière disease from January 1997 through December 2007 at a tertiary care otologic referral center. We found 5 cases (0.64%) of postoperative DFNP. The length of time between surgery and the onset of DFNP ranged from 7 to 20 days (mean: 11). Paralysis was incomplete in all 5 patients. Four of these patients had an abnormal mastoid bone anatomy, as the sigmoid sinus was either anteriorly or anteromedially displaced. The 5 patients had been treated with a steroid, either with or without an antiviral, and all 5 experienced a complete recovery of facial nerve function within 8 weeks of the onset of their paralysis. It is difficult to delineate the exact etiology of DFNP following endolymphatic sac surgery, but we speculate that factors such as physical injury to the nerve and/or a viral reactivation might have played a role. Also, the unusual mastoid bone anatomy seen in 4 of these patients might have been responsible, as well.