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Facial Nerve Paralysis Due to Chronic Otitis Media: Prognosis in Restoration of Facial Function After Surgical Intervention

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Facial Nerve Paralysis Due to Chronic Otitis Media: Prognosis in Restoration of Facial Function After Surgical Intervention http://dx.doi.org/10.3349/ymj.2012.53.3.642 Original Article pISSN: 0513-5796, eISSN: 1976-2437 Yonsei Med J 53(3):642-648, 2012 Facial Nerve Paralysis due to Chronic Otitis Media: Prognosis in Restoration of Facial Function after Surgical Intervention Jin Kim,1* Gu-Hyun Jung,1* See-Young Park,1 and Won Sang Lee2 1Department of Otorhinolaryngology, Inje University College of Medicine, Goyang; 2Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea. Received: December 21, 2010 Purpose: Facial paralysis is an uncommon but significant complication of chronic Revised: June 16, 2011 otitis media (COM). Surgical eradication of the disease is the most viable way to Accepted: July 6, 2011 overcome facial paralysis therefrom. In an effort to guide treatment of this rare Corresponding author: Dr. Won-Sang Lee, complication, we analyzed the prognosis of facial function after surgical treatment. Department of Otorhinolaryngology, Materials and Methods: A total of 3435 patients with COM, who underwent Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, various otologic surgeries throughout a period of 20 years, were analyzed retro- Seoul 120-752, Korea. spectively. Forty six patients (1.33%) had facial nerve paralysis caused by COM. Tel: 82-2-2228-3606, Fax: 82-2-393-0580 We analyzed prognostic factors including delay of surgery, the extent of disease, E-mail: [email protected] presence or absence of cholesteatoma and the type of surgery affecting surgical outcomes. Results: Surgical intervention had a good effect on the restoration of *Jin Kim and Gu-Hyun Jung contributed equally to this work. facial function in cases of shorter duration of onset of facial paralysis to surgery and cases of sudden onset, without cholesteatoma. No previous ear surgery and ∙ The authors have no financial conflicts of healthy bony labyrinth indicated a good postoperative prognosis. Conclusion: interest. COM causing facial paralysis is most frequently due to cholesteatoma and the presence of cholesteatoma decreased the effectiveness of surgical treatment and in- dicated a poor prognosis after surgery. In our experience, early surgical interven- tion can be crucial to recovery of facial function. To prevent recurrent cholesteato- ma, which leads to local destruction of the facial nerve, complete eradication of the disease in one procedure cannot be overemphasized for the treatment of pa- tients with COM. Key Words: Facial nerve paralysis, chronic otitis media INTRODUCTION Facial nerve paralysis is an uncommon but significant complication of chronic oti- tis media (COM). Although the incidence of facial nerve paralysis has decreased © Copyright: with the use of antibiotics, prevention thereof remains a challenging problem. It Yonsei University College of Medicine 2012 has been reported that the frequency of facial nerve paralysis in COM ranges from This is an Open Access article distributed under the 0.16 to 5.1%.1-3 terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/ Although the mechanism of facial nerve paralysis, as a result of COM, is not licenses/by-nc/3.0) which permits unrestricted non- commercial use, distribution, and reproduction in any fully understood, treatment recommendations have focused on both antibiotic medium, provided the original work is properly cited. treatment as well as surgery, including myringotomy, mastoidectomy and nerve 642 Yonsei Med J http://www.eymj.org Volume 53 Number 3 May 2012 Facial Palsy in Chronic Otitis Media decompression, in order to reestablish the physiological sible, the injured segment by cholesteatoma was resected state of the facial nerve.4-6 and facial nerve endings were revived. Also, fibrous seg- Surgical eradication of the disease is the most viable way ments were excised followed by facial nerve repair accord- to overcome facial nerve paralysis; however, there is a lack ing to the size of the defect. of data from which to draw significant conclusions on the All patients were informed of possible surgical complica- surgical management thereof. The variance in application tions and the limited reversibility of good facial nerve func- of surgical treatment for these patients stems from the lack tion. Recovery of facial nerve function was assessed no ear- of predictors for facial nerve paralysis remission.7-10 lier than 1 year after surgical intervention. The present study describes our experience with diverse clinical features of facial nerve paralysis, in an effort to Surgical strategies guide treatment of this rare complication. Also, we analyzed prognostic factors, including delay of surgery, extent of dis- Surgical timing ease, presence or absence of cholesteatoma and type of sur- Patients who had facial paralysis due to COM were operat- gery, affecting surgical outcomes. ed on as early as possible in order to remove the pathologic tissue. The severity of facial function, the presence of cho- lesteatoma, type of onset, age, any previous otologic surgi- MATERIALS AND METHODS cal history and duration from onset had no effect on decid- ing surgical timing. A total of 3435 patients with COM, with or without choles- teatoma, who underwent canal down mastoidectomy, intact Revision surgery canal wall mastoidectomy or excision via a translabyrin- For patients who had previously undergone a mastoidecto- thine approach, throughout a period of 20 years (between my procedure to remove cholesteatoma, the complete re- January 1988 and December 2008), were analyzed retro- moval of cholesteatoma was thought to be as equally as im- spectively. Forty six patients (1.33%) had facial nerve pa- portant as the preservation of facial function. Exploration of ralysis caused by COM with or without cholesteatoma. Data the facial nerve was often difficult due to distorted surgical were collected concerning the patients’ age upon presenta- landmarks and adhesive or fibrotic change caused by previ- tion, sex, clinical presentation, cholesteatoma location, pre- ous surgery. Intraoperative facial nerve monitoring can be operative and postoperative facial nerve function and fol- used to confirm the location of the facial nerve, and the un- low-up. Computed tomography was obtained in all cases. changed location of surgical landmarks, including the stylo- Magnetic resonance imaging was available in several cases. mastoid foramen and the fundus of the internal auditory ca- The severity of facial nerve paralysis was graded using the nal, were used to find the facial nerve. House-Brackmann (HB) grading system.11 Surgery was performed as early as possible in 46 patients Cholesteatoma using the transmastoid and translabyrinthine approach. To- In cholesteatoma surgery, dissection of the cholesteatoma- tal removal of the cholesteatoma lesion and management of tous matrix from soft tissues, such as the dura, sigmoid si- the facial nerve were performed using various surgical nus, jugular bulb, internal carotid artery including the facial techniques depending on location and severity. nerve, was conducted carefully with wide bony removal. If Facial nerve decompression was performed in 42 patients complete removal was not possible, resection of the injured with opening of the epineural sheath, if there was facial segment by cholesteatoma was thought to be the only sure nerve edema or redness. Medical therapy in combination alternative for complete removal of the pathology. with surgery included antibiotic and steroid treatment (60 mg/d initial dose with tapering) in patients with abrupt on- Destruction of bony labyrinth set of edema. As the dissection and removal of the cholesteatomas ap- Four patients had aggressive cholesteatomas with com- proached the semicircular canals and cochlear, we expected plete facial nerve paralysis, and facial nerve interruption or that a labyrinthine fistula may be present. Dissection over replacement with fibrous tissue was found in the operative these areas was performed cautiously and delicately to avoid field. If complete removal of the cholesteatoma was impos- damage to the inner ear. When a fistula was encountered, re- Yonsei Med J http://www.eymj.org Volume 53 Number 3 May 2012 643 Jin Kim, et al. moval of the basement membrane from the endosteal lining operative facial function (less the HB Grade II), but had of the inner ear was conducted, if the removal met no resis- good post-operative facial function. All patients in Group B tance. However, in cases where the basement membrane of had much improved facial function. squamous epithelium was not easily detached from the end- 3. Group C (n=4) included patients who had a gain in fa- osteal membrane or when it was clear that the fistula was cial function of more than two grades on the HB scale after very large, an island of the basement membrane was surgery, but had poor post-operative facial function. All pa- trimmed away from that which had already been dissected tients in Group C had improved but slightly defective facial free and left over the fistula until the cholesteatoma could be function. totally removed from the mastoid and fallopian canal. 4. Group D (n=8) included patients who had a gain of fa- cial function less than two grades on the HB scale after sur- Facial nerve surgery gery and had poor post-operative facial function. All pa- Accurate assessment of facial nerve status was obtained in- tients in Group D had improved but severely defective facial traoperatively. Four different conditions of the facial nerves function. were observed among the patients, including a compressed but normal segment, a reddish edematous segment, a fi- Statistical methods brosed segment and an interrupted nerve. The differences among groups were evaluated statistically Edematous and compressed nerves were managed by de- using t-tests for continuous data (e.g. age, duration) and compression and removal of the overlying cholesteatoma equivalence tests for variables (e.g. previous ear surgery, matrix or infected granulation tissue. type of onset, cholesteatoma, destruction of bony labyrinth). If the facial nerve was found to be interrupted or fibrosed during surgery, the segments involved and adequate mar- gins were cut away.
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