Surgery for post-traumatic facial paralysis: are we overdoing it?

PURPOSE: Early facial nerve decompression is recommended for cases of post-traumatic facial palsy on the basis of ENoG with degeneration > 95%. There is still a dispute in the literature concerning the role and timing of surgery versus conservative treatment in such cases. This study has been planned to evaluate the outcome of conservative management in traumatic facial paralysis with regard to type of trauma, onset, and electrodiagnostic tests.

METHODS

A prospective cohort study included 39 patients with post-traumatic facial palsy. All patients underwent ENoG, nerve stimulation test, HRCT temporal bone and Schirmer's test. The patients received intravenous methylprednisolone 1 gm/day for 5 days or oral prednisolone 1 mg/kg in tapering doses for 3 weeks. Follow-up was done at 4, 12 and 24 weeks after the treatment. Surgical exploration was limited to patients showing no improvement after 12 weeks. Facial nerve function was evaluated by the HBFNS and FEMA grading systems.

RESULTS

Among the 39 patients in the study [5 women and 34 men; mean (SD) age, 33.5 (11.37) years], facial nerve recovery with conservative treatment alone was noted in 31 patients. The first signs of clinical recovery were noted in 27 patients by 4 weeks, in 31 patients by 12 weeks. Seven patients required surgical exploration. At 24 weeks, 31 patients recovered to House-Brackmann grade I/III and 1 patient to grade IV. 19 of 26 patients with longitudinal fractures had grade I/III recovery, whereas all 6 patients with transverse fracture recovered on conservative treatment.

CONCLUSIONS

Patients with incomplete facial palsy are candidates for conservative management. It is justified to try conservative management in patients with complete facial paralysis for up to 3 months even in cases where ENoG and NET suggest poor prognosis. The presence of sensorineural hearing loss or transverse fracture at presentation does not suggest a poor prognosis for improvement.