Nonsurgical Treatment for Posttraumatic Complete Facial Nerve Paralysis

JAMA Otolaryngol Head Neck Surg. 2018 Apr 1;144(4):315-321. doi: 10.1001/jamaoto.2017.3147.

Abstract

Importance: Current recommendations envisage early surgical exploration for complete facial nerve paralysis associated with temporal bone fracture and unfavorable electrophysiologic features (response to electroneuronography, <5%). However, the evidence base for such a practice is weak, with the potential for spontaneous improvement being unknown, and the expected results from alternative nonsurgical treatment also undefined.

Objective: To document the results of nonsurgical treatment for posttraumatic complete facial paralysis with undisplaced temporal bone fracture and unfavorable electrophysiologic features.

Design, setting, and participants: Prospective cohort study recruiting from April 2010 to April 2013 at a tertiary care university hospital. Follow-up continued until 9 months or until complete recovery if earlier. Study group included 28 patients with head injury-associated complete unilateral facial nerve paralysis with unfavorable results of electroneuronography (<5% response) with or without undisplaced temporal bone fracture. Undisplaced temporal bone fractures were documented in 26 patients (24 longitudinal fractures and 2 transverse fractures).

Interventions: Patients received prednisolone, 1 mg/kg, for 3 weeks combined with clinical monitoring every 2 weeks and electromyography monitoring every 4 weeks. As per study protocol, surgical exploration was limited to patients demonstrating motor end plate degeneration on results of electromyography, or having no improvement until 18 weeks.

Main outcomes and measures: Facial nerve function was evaluated by the House-Brackmann grading system; Forehead, Eye, Mouth, and Associated defect grading system; and the modified Adour system. Observations were completed at 40 weeks.

Results: Among the 28 patients in the study (3 women and 25 men; mean [SD] age, 32.2 [8.7] years), facial nerve recovery with conservative treatment alone was noted in all patients. No recovery was seen in any patient at the initial 4-week review. The first signs of clinical recovery were noted in 4 patients by 8 weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks. No patient required surgical exploration. At 40 weeks, 27 patients recovered to House-Brackmann grade I/II and 1 patient to grade III. All 24 patients with longitudinal fractures had grade I/II recovery.

Conclusions and relevance: For undisplaced temporal bone fractures, nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results. Recovery is delayed and usually first manifests at 8 to 12 weeks after the fracture. In the current era of high-resolution computed tomography, surgical exploration should not be first-line treatment for undisplaced longitudingal temporal bone fractures associated with complete facial nerve paralysis and unfavorable electrophysiologic features.

Publication types

  • Observational Study

MeSH terms

  • Adult
  • Conservative Treatment
  • Craniocerebral Trauma / complications*
  • Craniocerebral Trauma / physiopathology
  • Craniocerebral Trauma / rehabilitation
  • Electrodiagnosis / methods
  • Facial Paralysis / etiology
  • Facial Paralysis / rehabilitation
  • Facial Paralysis / surgery*
  • Female
  • Glucocorticoids / administration & dosage
  • Humans
  • Male
  • Middle Aged
  • Neurosurgical Procedures / methods*
  • Prednisolone / administration & dosage
  • Prospective Studies
  • Recovery of Function
  • Skull Fractures / physiopathology
  • Skull Fractures / surgery
  • Temporal Bone / injuries
  • Treatment Outcome
  • Young Adult

Substances

  • Glucocorticoids
  • Prednisolone