|Year : 2009 | Volume
| Issue : 2 | Page : 78-81
Delayed facial palsy after mastoid and middle ear surgery
KSU Fellowship, Jordanian Board Assistant Professor/Consultant, ORL Department King Abdulaziz University Hospital, Riyadh, Saudi Arabia
|Date of Web Publication||7-Jan-2020|
M.D Abdulrahman Al-Essa
P.O. Box 245, Riyadh 11411
Source of Support: None, Conflict of Interest: None
Objectives: The purpose of this report is to provide data on delayed facial palsy (DFP) after mastoid and middle ear surgery, and to discuss the possible etiology.
Study Design and Setting: This is a retrospective report carried out at a university-based hospital
Patients: The records of 1980 patients with normal facial function before mastoid and middle ear surgery were reviewed.
Measures: Delayed facial palsy was defined as facial palsy occurring after the initial postoperative evaluation.
Results: During the 6-year period from 1998 to 2003 consecutive mastoid and middle ear operations were reviewed. A total of 7 delayed facial palsies (DFP) were identified. All were incomplete and recovered completely following conservative treatment. The mechanism of DFP was not known in two cases , chorda tympani stretching in one case , iatrogenic facial exposure in two patients and herpes viral reactivation in two patients.
Conclusion: DFP occurred in 0.35% after middle ear and mastoid operations. Several factors may contribute to DFP including chorda tympani injury,iatrogenic, infection, facial canal edema ,immune response and recently several reports suggesting strongly viral reactivation as one of the main causes of DFP.
Keywords: Delayed facial palsy, Causes of facial palsy
|How to cite this article:|
Al-Essa A. Delayed facial palsy after mastoid and middle ear surgery. Saudi J Otorhinolaryngol Head Neck Surg 2009;11:78-81
| Introduction|| |
Facial nerve palsies after middle ear and mastoid surgery are divided into immediate onset palsies and delayed onset palsies. Immediate onset palsies may be related to the local anesthesia or more often to direct trauma to the nerve. Once the possible effect of local anesthesia has worn off or excluded, immediate onset palsies should be considered for exploration, debridement and re-anastomosis or interposition of cable-grafts( 1) The “delayed onset” facial palsy which is the subject of this study is not clearly defined. Verbecdefined DFP as facial palsy occurring more than 72 hours after surgery. Fenton et aldefined it as any worsening of facial nerve function after the initial assessment of postoperative function. Of great importance, however, the postoperative initial evaluation must be thoroughly done and confirmed by unbiased, experienced observer. The personal attitude of the surgeon who is inclined to convince himself that the palsy is not immediate should be avoided. The incidence of DFP after middle ear and mastoid surgery seems to vary with the type of surgery. The reported incidences of post stapedectomy DFP in large series are between 0.1-0.51%,, The incidences for other procedures include 0.1% after mastoidectomy, 0.4% after tympanoplasties, 0 91% – 1.4% after tympanomas- toid operations,and 8% after radical mastoidectomy for cholesteatoma.
Without histological proof, the cause of DFP remains speculative. The possible suggested mechanism for DFP include edema secondary to surgical manipulation,, bony facial canal dehiscence with bare or bulging facial nerve herniation retrograde edema of the chorda tympani nerve into the facial canal, thermal injury and overheating of the nerve from drilling mechanical pressure by packing material coincidental Bell’s palsyan immune response bacterial infection sinusitis,granulomatous reaction to Gelfoamthermal energy generated from laser and virus reactivation,.
The aims of this paper were to provide data about DFP, post uneventful middle ear and mastoid operations in a unit performing a large amount of middle ear surgery and secondly to discuss the possible pathogenesis.
| Materials and Methods.|| |
Clinical and operative records of 1980 consecutive middle ear and mastoid surgery at King Abdulaziz University Hospital, Riyadh, Saudi Arabia were reviewed. Operations included all types of mastoid surgery (atticotomy, cortical, modified radical, radical and revision mastoidectomy), all types of stapes surgery, tympanoplasties and ossiculoplasties. Patients with preoperative facial nerve dysfunction were excluded. Delayed facial palsy is defined as dysfunction occurring after the initial immediate postoperative evaluation. The frequency and the time of onset, delayed facial nerve palsy were determined as well as the type of ear surgery following which these complication occurred. Any possible predisposing factors were identified and the facial palsies were analyzed to determine the outcome.
| Results.|| |
The types and numbers of operations are displayed in [Table 1]. A total of 7 patients developed DFP. The overall incidence of DFP was 0.35%. Three patients were males and four were females. The age ranged from 20 to42 years (mean 27 years). Patients’ data were summarized in [Table 2].
All operations were performed under general anesthesia. Local infiltration of 1% lignocaine and 1:200,000 adrenaline were injected in all patients except in two patients (no. 1 and 4). The onset of DFP was between 24 hours and 10 days postoperatively (mean 3 days). All cases of DFP were incomplete at the initial diagnosis. All patients attended for a weekly postoperative review. Complete return of function was recorded in all cases. However, in one patient the palsy has progressed from House-Brackmann grade II to grade IV before gradual recovery occurred subsequently. None of the patients had facial nerve anomalies. The facial nerve was reported in the operative notes as dehiscent in two of the cases. Two patients had the nerve iatrogenically exposed; one in the tympanic segment and one in the mastoid portion. Chorda tympani was reported as excessively manipulated in one patient. All those five cases developed ipsilateral facial palsy graded as House-Brackman Grade 11and treated with removal of the mastoid packs and steroids ( Prednisone ) . The first case who developed DFP with susppicion of viral reactivation was a female patient who underwent an uneventful, revision right canal wall down radical mastoidectomy for a recurrent cholesteatoma , and the facial nerve sheath was not exposed either by disease or by surgery. Twenty-four hours postoperatively she developed ipsilateral facial palsy which was graded as House-Brackmann Grade II paralysis. The facial palsy was considered to be due to facial nerve edema possibly due to heat generated by drilling along the facial canal.
The mastoid pack was removed and steroid therapy initiated. Two days later, the patient developed herpetic eruption in the buccal mucosa of the ipsilateral side. Therefore, the assumed cause of the facial palsy was modified and considered to be a result of reactivation of herpes virus and Acyclover was administered. However, the palsy deteriorated from House-Brackmann II to grade IV in the following week before gradual improvement occurred with complete recovery recorded 8 weeks later.
The second case was a young lady who underwent an uneventful right radical mastoidectomy without any trauma to the facial nerve. She developed facial palsy in the third postoperative day. She was treated with Acyclover, Steroids and antibiotic. A complete recovery occurred within three months.
She gave a history of idiopathic left facial palsy five year ago and treated as Bell,s palsy. Two years later she developed left facial palsy post an uneventful left tympanomastoidectomy in another medical centre.
| Discussion|| |
The frequency of delayed facial nerve palsy following uneventful middle ear and mastoid surgery in this study was 0.35%. This is lower than the 1% incidence reported by Nilssen and Wormaldwho reported 10 patients with DFP in a 1024 mastoidectomy series., Also, it is much lower than the 8% reported by Deka in 235 patients after tympanomastoid surgery for cholesteatoma. The reported incidence in the literature of DFP after stapes surgery is between 0.1 and 0.51%,,. Delayed onset facial palsy has been also associated with other otological surgery. Verbecreviewed three large series of surgery for acoustic neuroma and found an incidence ranging from 14.5 to 29.5%.
The onset of DFP is variable. In this study the onset of the DFP ranged between 24 hours and 10 days after the surgery. Shea( 13)called the DFP after stapes surgery “five and half days facial palsy” because this is the latent period after which the palsy appeared in all of his cases. In another report, Shea)noticed in a large series of stapedectomies, DFP occurred from 5 to 16 days (mean 8) after surgery. Likewise, all the five cases reported by Althaus and House occurred 5 days after surgery. The shortest latent period was reported by Paulsen who documented a case that occurred one day post stapes surgery. One of the long delayed onset is the case report by Gyo and Honda( 15) when the palsy was noticed on the 14th postoperative day. In this report, all cases have recovered completely by conservative treatment. The management protocol included immediate removal of any ear or mastoid packs, antibiotics , steroids and weekly follow-up. In two patients, Acyclovir was administered because it was thought that DFP has occurred due to virus reactivation. The reports of surgical exploration are scanty since most cases of DFP after surgery recover satisfactorily by conservative treatment. In one report, a 25% transection of the nerve was noted. In another study( 18) operative findings included an intact Fallopian canal More Details and neural edema in the tympanic and mastoid segments. Paulsen( 17) explored a patient’s ear with DFP that developed one day after stapes surgery to find the nerve to be so edematous that it displaced the stapes prosthesis. The nerve was found to be dehiscent in the tympanic segment at the initial procedure. Gyo and Honda ,1999 reported the finding of an ear that was explored on the 22nd day after the palsy. They noted extensive bulging of the facial nerve through the bony defect on the medial side of the horizontal segment that had not been seen during the primary revision tympanoplasty operation.
A number of mechanisms for the deterioration in facial nerve function are postulated. A diagnosis of coincidental Bell’s palsy was made by Zohar and Laurian. They reasoned this because their patient had concurrent sensory deficits of the trigeminal nerve on the same side as the paralysis. However, the incidence of Bell’s palsy is 1 in 8000 which is much lower than DFP after surgery.
Bacterial infection has been incriminated as a possible cause supported by clinical and experimental observations. Clinically, Verbecreported two patients with DFP in conjunction with drainage from the postauricu- lar wound and he assumed that bacterial infection with inflammation around the nerve was the suspected mechanism for facial dysfunction. In an animal model, bacterial infection reported to produce facial paralysis few days following the development of otorrhea. Edema of the facial nerve in the Fallopian canal has been suggested to be the cause of DFP after stapes surgery,. The edema is either secondary to surgical trauma to a dehiscent facial nerve or to the chorda tympani with retrograde extension to the facial nerve. Yamamato and Fischreported that experimental compression of the facial nerve in cats usually produce an immediate complete paralysis, while surgical manipulation of the nerve produced DFP. They noticed considerable variation in recovery of facial function ranging from complete to none at all. This suggests either that the amount of compression was not uniform or that dissection inflicted varying degrees of nerve injury.
Sheaspeculated that the cause of DFP after stapes surgery may be an immune response in the nerve. He noticed that none of the operations has been a complicated operation with drilling near the facial nerve, but all have been in tense, nervous patients. In this study, two patients developed DFP after uneventful mastoid surgery with the possibility of viral reactivation. The possible association between DFP and virul reactivation has been figured in the literature recently. One of the earliest report that drawn the attention to the relationship of virus reactivation to DFP after middle ear surgery was by Vrabecwhich was published as recent as 1999.
| References|| |
Green JD Jr, Shelton C, Brackmann DE. Surgical management of iatrogenic nerve injuries. Otolaryngol Head Neck Surg
Verbec JT. Delayed facial palsy after tympanomastoid surgery. Am J Otol
Fenton JE, Chin RY, et al. Delayed facial palsy after vestibular schwannoma surgery. Auris Nasus Larynx
Althaus SR, House HP. Delayed post-stapedectomy facial paralysis: a report of five cases. Laryngoscope
Smith MC, Simon P, Ramalingham KK. Delayed facial palsy following uncomplicated stapedectomy. J Laryngol Otol
Shea JJ Jr , Ge X.Delayed facial palsy after stapedectomy.Otol Neurotol
.2001 Jul ;22(4):465-70.
Nilssen ELK, Wormald PJ. Facial nerve palsy in mastoid surgery. J Laryngol Otol
Bonkowsky V, Kochanowski B, Strutz J, Pere P, Hosemann W, Arnold W. Delayed facial palsy following uneventful middle ear surgery: a herpes simplex virus type 1 reactivation? Ann Otol Rhinol Laryngol
Safdar A,Gendy S,Hilal A,Waishe P,Burns H.Delayed facial nerve palsy following tympano- mastoid surgery:incidence,aetiology and prognosis. Laryngol Otol.2006 Sep
Deka RC. Facial palsy and mastoid surgery. Ear Nose Throat
Althaus SR. Postoperative facial paralysis: the otologist’s dilemma. Laryngoscope
Zohar Y, Laurian N. Facial palsy following stapedectomy: a case report. J Laryngol
Shea JJ. Thirty years of stapes surgery. J Laryngol Otol 1988
Ng M, Maceri DR. Delayed facial paralyis after stapedotomy using KTP laser. Am J Otol
Gyo K, Honda N. Delayed facial palsy after middle ear surgery due to reactivation of varicella-zoster virus. J Laryngol Otol
Shea JJ Jr, Ge X. Delayed facial palsy after stapedectomy. Otol Neurotol
Paulsen K. Facialisparese nack stapesplastic. HNO
Coker NJ, Kendall KA, Jenkins HA, et al. Traumatic intratemporal facial nerve injury: management rationale for preservation of function. Otolaryngol Head Neck Surg
Furuta Y, Ohtani F, Fukuda S, Inuyama Y, Nagashima K. Reactivation of varicalle-zoster virus in delayed facial palsy after dental treatment and oro-facial surgery. J Med Virol
Yamamato E, Fisch U. Experimentally induced facial nerve compression in cats. Acta Otolaryngol (Stockl)
[Table 1], [Table 2]