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1 Continuing Education Column Facial Nerve Paralysis and Surgical Management Won Sang Lee, MD Jin Kim, MD Department Otolaryngology, Yonsei University College of Medicine E - mail : wsleemd@yuhs.ac J Korean Med Assoc 2009; 52(8): Abstract The facial nerve coursing through the temporal bone provides a challenge to the otologic surgeon. Advances in surgical instrumentation and refinements of surgical strategies enable the otologist to uncover the entire course of the facial nerve safely from brainstem to its exit from temporal bone. The most common cause of facial nerve paralysis is Bell s palsy, followed by traumatic facial paralysis, herpes zoster oticus, and intratemporal tumous lesion. The surgical approaches to the injured facial nerve depend on its causes. Acute, severe facial nerve paralysis caused by viral infection or trauma can be managed by early use of transmastoid approach, middle cranial approach, or combined approach. In case of intratemporal benign tumor with favorable facial function, great care must be taken not to damage the facial nerve with nerve preservation technique. However, in malignant tumor with favorable facial function, the priority must be placed on the complete resection than to the facial nerve preservation. In consideration of selecting surgical technique of facial nerve paralysis reconstruction, clinician must find out the cause, degree and duration of paralysis for the appropriate technique. Keywords: Facial nerve paralysis; Decompression; Preservation; Facial nerve reconstruction 807

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3 Facial Nerve Paralysis and Surgical Management Table 1. Causes of facial nerve paralysis Infectious Trauma Neoplastic Neurologic Congenital Systemic Herpes simplex virus -1 (Bell s palsy) Varicellar-zoster virus (Ramsay-Hunt syndrome) Mumps virus Rubella virus Influenza virus Infectious mononeucleosis Lyme HIV Tuberculosis Otitis media Temporal bone fracture, skull base fracture Iatrogenic Penetrating wound of face or neck Birth trauma Cholesteatoma Vestibular schwannoma Facial schwannoma Carcinoma Glomus jugularae Histocytosis Rhabdomyosarcoma Osteopetrosis Hemangioblastoma Leukemia Guillain-Barre Multiple sclerosis Millard-Gubler syndrome Mobius syndrome Melkersson-Rosenthal syndrome Dystrophic myotonia Sarcoidosis Diabetes mellitus Hyperthyroidism Autoimmune disease 809

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Facial Nerve Paralysis and Surgical Management T = tympanic segment, GG = geniculate

View of intratemporal facial nerve during neural decompression.

Facial nerve decompression was done using middle cranial fossa approach.

5 Facial Nerve Paralysis and Surgical Management T = tympanic segment, GG = geniculate ganglion, L = labyrinthine segment, IC = intracanalicular segment Figure 1. View of intratemporal facial nerve during neural decompression. 56- year old male patient with herpes zoster oticus of right side. Facial nerve decompression was done using middle cranial fossa approach. Black arrow indicates the difference of swolen segment between geniculate ganglion and tympanic segment. Pinkish normal tympanic segment was visible on this approach. 811

The surgical intervention to decompress and remove bony impingement and granulation tissue employed a combined approach through the

(A) The right facial nerve was injured near the geniculate ganglion; some granulation tissue is visible on the CT scan (red arrow).

6 Lee WS Kim J B A C Figure 2. A 38- year-old man had complete facial palsy due to injury near the geniculate ganglion of the facial nerve. The surgical intervention to decompress and remove bony impingement and granulation tissue employed a combined approach through the middle cranial fossa and a transmastoid approach. (A) The right facial nerve was injured near the geniculate ganglion; some granulation tissue is visible on the CT scan (red arrow). (B) Swelling and hyperemic change in the geniculate ganglion, including the labyrinthine and tympanic segments of the facial nerve, were visible through the middle cranial fossa approach (blue arrows). (C) Bony impingement and granulation tissue were found near the tympanic segment of the facial nerve via the transmastoid approach (white arrow). 812

Facial Nerve Paralysis and Surgical Management A B C D Figure 3.

(A) After complete labyrinthectomy, it was shown that a thin bony wall covered the facial nerve

Using the electrical stimulator, we divided the facial nerve from the schwannoma.

7 Facial Nerve Paralysis and Surgical Management A B C D Figure 3. The fundus exposure technique for huge vestibular schwannomas with normal facial function. (A) After complete labyrinthectomy, it was shown that a thin bony wall covered the facial nerve and the mass at the fundus of internal auditory canal. Using the electrical stimulator, we divided the facial nerve from the schwannoma. (B) Widening the exposed window of fundus, we advanced the separating procedure from the schwannoma. (C) After the mass was debulked, the path of the facial nerve could be seen (it was not exposed due to the compressive effect of the huge mass). (D) Along the exposed path of the facial nerve, the mass was debulked and removed. The capsule of the mass was easily separated from the facial nerve. 813

Lee WS Kim J A B Figure 4. The stripping technique for facial nerve schwannoma with good facial function.

(B) Complete local exposure of the tumor and normal nerve appearance is needed to identify the junction between the intact nerve and

The surgical intervention of neural repair was employed via transmastoid approach. Closure without tension (white arrow).

8 Lee WS Kim J A B Figure 4. The stripping technique for facial nerve schwannoma with good facial function. (A) After complete mastoidectomy on right side, the tumor was found to originate from the geniculate ganglion of the facial nerve. (B) Complete local exposure of the tumor and normal nerve appearance is needed to identify the junction between the intact nerve and the capsule of the tumor. Dissecting with sharp microscissors at the junction, we can strip the tumor from the intact facial nerve. A B Figure 5. A 65-year -old woman had complete facial palsy on left side due to iatrogenic injury at the tympanic segment of the facial nerve. The surgical intervention of neural repair was employed via transmastoid approach. Closure without tension (white arrow). (A) After cutting greater superficial petrosal nerve, the approximated ends of the nerve repair site must match in terms of the endoneural surface (B) A 9~0 or 10~0 monofilament suture is placed through the epineurium. About 5 knots are tied in order to prevent the suture from unraveling. 814

Facial Nerve Paralysis and Surgical Management A B Figure 6. A 44- year- old woman had complete facial palsy on right side due to cholesteatoma at the tympanic segment of the facial nerve.

(A) To suture donor to recipient, the epineurium is peeled back to expose the protruding endoneural surface. (B) The ends of the donor and recipient nerves should be brought together without tension.

9 Facial Nerve Paralysis and Surgical Management A B Figure 6. A 44- year- old woman had complete facial palsy on right side due to cholesteatoma at the tympanic segment of the facial nerve. The surgical intervention of sural nerve graft was employed via transmastoid approach. Closure without tension (white arrow). (A) To suture donor to recipient, the epineurium is peeled back to expose the protruding endoneural surface. (B) The ends of the donor and recipient nerves should be brought together without tension. Nerve reversed so that the distal end of the graft is attached to the proximal end of the donor nerve. 11. Terzis JK. Microreconstruction of nerve injuries. Part 5: combating facial paralysis. Philadelphia: WB Saunders, Rubin LR. Reanimation of the paralyzed face: new approaches. St. Loius: C.V. Mosby,

10 Lee WS Kim J 13. Evans AK, Licameli G, Brietzke S, Whittemore K, Kenna M. Pediatric facial nerve paralysis: patients, management and outcomes. Int J Pediatr Otorhinolaryngol 2005; 69: Epub 2005 Jun Holland NJ, Weiner GM. Recent developments in Bell s palsy. BMJ 2004; 329: Chan EH, Tan HM, Tan TY. Facial palsy from temporal bone lesions. Ann Acad Med Singapore 2005; 34: Marson AG, Salinas R. Bell s palsy. West J Med 2000; 173: Peitersen E. Bell s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of diverent etiologies. Acta Otolaryngol Suppl 2002; 549: Prescott CA. Idiopathic facial nerve palsy (the evect of treatment with steroids). J Laryngol Otol 1988; 102: Adour KK, Wingerd J, Doty HE. Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis. Diabetes 1975; 24: Pitts DB, Adour KK, Hilsinger RL. Recurrent Bell s palsy: Analysis of 140 patients. Laryngoscope 1988; 98: Adour KK, Wingerd J. Idiopathic facial paralysis (Bell s palsy): factor affecting severity and outcome in 446 patients. Neurology 1974; 24: Sullivan FM, Swan IR, Donnan PT. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med 2007; 357: Selesnick SH, Patwardhan A. Acute facial paralysis: Evaluation and early management. Am J Otolaryngol 1994; 15: Hato N, Matsumoto S, Kisaki H. Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone. Otol Neurotol 2003; 24: Adour KK, Ruboyiances JM, Von Doersten PG. Bell s palsy treatment with acyclovir and prednisolone compared with prednisolone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol 1996; 105: Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K, Fukuda S, Furuta Y, Ohtani F, Aizawa H, Aoyagi M, Inamura H, Nakashima T, Nakata S, Murakami S, Kiguchi J, Yamano K, Takeda T, Hamada M, Yamakawa K. Valacyclovir and prednisolone treatment for Bell s palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol 2007; 28: Alberton DL, Zed PJ. Bell s palsy: a review of treatment using antiviral agents. Ann Pharmacother 2006; 40: De Diego JI, Prim MP, De Sarria MJ, Madero R, Gavilan J. Idiopathic facial paralysis: A randomised, prospective and controlled study using single-dose prednisone versus aciclovir three times daily. Laryngoscope 1998; 108: Antunes ML, Fukuda Y, Testa JRG. Clinical treatment of Bell s palsy: comparative study among valaciclovir plus deflazacort, deflazacort and placebo. Acta AWHO 2000; 19: Zhou P. Aciclovir in treating Bell's palsy. Chinese Journal of New Drugs and Clinical Remedies 1999; 18: Hunt JR. On herpetic inflammations of the geniculate ganglion. A new syndrome and its complications. J Nerv Ment Dis 1907; 34: Hunt JR. Geniculate neuralgia (neuralgia of the nervus facialis). A further contribution to the sensory system of the seventh nerve and its neuralgic conditions. Arch Neurol Psychiat 1937; 37: Meier JL, Straus SE. Comparative biology of latent varicellazoster virus and herpes simplex virus infections. J Infect Dis 1992; 166: Byl FM, Adour KK. Auditory symptoms associated with herpes zoster or idiopathic facial paralysis. Laryngoscope 1977; 87: Kim J, Jung JS, Moon IS, Lee HK, Lee WS. Statistical analysis of pure tone audiometry and caloric test in herpes zoster oticus. CEO 2008; 1: Furuta Y, Ohtani F, Sawa H, Fukuda S, Inuyama Y. Quantitation of varicella-zoster virus DNA in patients with Ramsay Hunt syndrome and zoster sine herpete. J Clin Microbiol 2001; 39: Furuta Y, Aizawa H, Ohtani F, Sawa H, Fukuda S. Varicellazoster virus DNA level and facial paralysis in Ramsay Hunt syndrome. Ann Otol Rhinol Laryngol 2004; 113: Aizawa H, Ohtani F, Furuta Y, Sawa H, Fukuda S. Variable patterns of varicella-zoster virus reactivation in Ramsay Hunt syndrome. J Med Virol 2004; 74: Wackym PA, Popper P, Kerner MM, Grody WW. Varicellazoster DNA in temporal bones of patients with Ramsay Hunt syndrome. Lancet 1993; 342: McKennan KX, Chole RA. Facial paralysis in temporal bone trauma. Am J Otol 1992; 13: Mchugh HZ. The surgical treatment of facial paralysis and traumatic conductive deafness in fracture of the temporal bone. Ann Otol Rhinol Laryngol 1959; 68: Canon CR, Jahrsdoefer RA. Temporal bone fracture: Review of 10 cases. Arch Otolaryngol 1989; 109: Kelly KE, Tamz TA. Temporal bone and skull base trauma. In: Jacker RK. Brackmann DZ, eds. Neurotology, 1st ed. St. Louis: Mosby -Year Books Inc, 1994: Khan AA, Maria M, Hinojosa R. Temporal bone fractures: A histopathologic study. Otolaryngol Head Neck Surg 1985; 93: Travis LW, Stalnaker RL, Melvin JW. Impact trauma of human temporal bone. J Trauma 1977; 17: Lambert PR, Brackmann DZ. Facial paralysis in longitudinal temporal bone fracture: A review of 26 cases. Laryngoscope 1984; 94: May M, Shambaugh GE. Facial nerve paralysis. In: Paparella MM, Shumrick DA, Gluckman JL, eds. Otolaryngology, 3rd 816

11 Facial Nerve Paralysis and Surgical Management ed. Philadelphia: WB Saunders, 1991: Fisch U. Facial paralysis in fractures of the petrous bone. Laryngoscope 1974; 84: Adour KK, Boyajian JA, Kahn ZM, Schneider GS. Surgical and nonsurgical management of facial paralysis following closed head injury. Laryngoscope 1977; 87: Fisch U. Lacrimation in facial nerve surgery. Birmingham: Aesculapius Publishing, 1977: Yanagihara N. Transmastoid decompression of the facial nerve in temporal bone fracture. Otolaryngol. Head Neck Surg 1982; 90: Shambaugh GE, Clemis JD. Facial nerve paralysis, in otolaryngology, vol.2, Paparella and Shumrick, eds. Philadelphia: WB Saunders, 1973: Pulec JL. Symposium on ear surgery II. Facial nerve neuroma. Laryngoscope 1972; 82: Conley J, Janecka I. Neurolemmoma of the facial nerve. Plast Reconstr Surg 1973; 52: Neely JG. Neoplastic involvement of the facial nerve. Otolaryngol Clin North Am 1974; 7; Alford BR, Gifford FR. A comprehensive study of the tumor of the glomus jugulare. Laryngoscope 1962; 72: Schuknect H. Neoplastic growth. In: pathology of the ear. Harvard university press, Cambridge, MA and London, Eng., 1974: Arena S. Tumor surgery of the temporal bone, Laryngoscope 1974; 84: Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell's palsy. Laryngoscope 1999; 109: Canter ARJ, Naedzelski JM, McLeasn JA. Evoked electromyography in Bell s palsy: a clinically useful test? J Otolaryngol 1986; 15: Coker NJ, Fordice JO, Moore S. Correlation of the nerve excitability test and electroneuronography in acute facial nerve paralysis. Am J Otol 1992; 13: Fisch U. Prognostic value of electrical tests in acute facial paralysis. Am J Otol 1984; 5: Canter ARJ, Naedzelski JM, McLeasn JA. Evoked electromyography in Bell s palsy: a clinically useful test? J Otolaryngol 1986; 15: Fisch U. Surgery for Bell s palsy. Arch Otolaryngol 1981; 107: Sanuş GZ, Tanriöver N, Tanriverdi T, Uzan M, Akar Z. Late decompression in patients with acute facial nerve paralysis after temporal bone fracture. Turk Neurosurg 2007; 17: Quaranta A, Campobasso G, Piazza F, Quaranta N, Salonna I. Facial nerve paralysis in temporal bone fractures: outcomes after late decompression surgery. Acta Otolaryngol 2001; 121: Kim J, Moon IS, Lee WS. Effect of delayed decompression after early steroid treatment on facial function of patients with facial paralysis. Acta Otolaryngol 2009 May 13: Eicher SA, Coker NJ, Alford BR, Igarashi M, Smith RJ. A comparative study of the fallopian canal at the meatal foramen and labyrinthine segment in young children and adults. Arch Otolaryngol Head and Neck Surg 1990; 116: Nakashima S, Sando I, Takahashi H, Fujita S. Computer-aided 3-D reconstruction and measurement of the facial canal and facial nerve. I. Cross-sectional area and diameter: preliminary report. Laryngoscope 1993; 103: Ogawa A, Sando I, Spatial occupancy of vessels and facial nerve in the facial canal. Ann Otol Rhinol Laryngol 1982; 91: Kim J, Chung SM, Moon IS, Lee HK, Lee WS. Correlation between enhanced MRI and surgical findings in herpes zoster oticus Acta Otolaryngol 2008; 3: Song MH, Kim J, Jeon JH, Cho CI, Yoo EH, Lee WS, Lee HK. Clinical significance of quantitative analysis of facial nerve enhancement on MRI in Bell's palsy. Acta Otolaryngol 2008; 128: Sunderland S. Nerves and nerve injuries. 2nd ed. New York: Churchill Livingstone, Felix H, Eby TL, Fisch U. New aspects of facial nerve pathology in temporal bone fractures. Acta Otolaryngol 1991; 111: Chang CYJ, Cass SP. Management of facial nerve injury due to temporal bone trauma. Am J Otol 1999; 20: W.B. Gormley, L.N. Sekhar, D.C. Wright, D. Kamerer, D. Schessel. Acoustic neuromas: results of current surgical management. Neurosurgery 1997; 41: M. Samii, C. Matthies. Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them. Neurosurgery 1997; 40: M. Samii, V. Gerganov, A. Samii. Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients. J Neurosurg 2006; 105: Wiggins RH 3rd, Harnsberger HR, Salzman KL, Shelton C, Kertesz TR, Glastonbury CM. The many faces of facial nerve schwannoma. AJNR Am J Neuroradiol 2006; 27: 1804; author reply Lipkin AF, Coker NJ, Jenkins HA, Alford BR. Intracranial and intratemporal facial neuroma. Otolaryngol Head Neck Surg 1987; 96: Lee JD, Kim SH, Song MH, Lee HK, Lee WS. Management of facial nerve schwannoma in patients with favorable facial function. Laryngoscope 2007; 117: Fisch U, Rouleau N. Facial nerve reconstruction. J Otolaryngol 1980; 9:

12 Lee WS Kim J 73. Luxford WM, Brackmann DE. Facial nerve substitution: a review of 66 cases. Am J Otol 1985; 6: Conley J. Hypoglossal crossover-122 cases. Tran Amer Acad Ophthalmol Otolaryngol 1977; 84: Atlas MD, Lowinger DSG. A new technique for hypoglossalfacial nerve repair. Laryngoscope 1997; 107: Baker DC, Conley J. Regional muscle transposition for rehabilitation of paralyzed face. Clin Plast Surg 1979; 6: May M, Ducker C. Temporalis muscle for facial reanimation. A 13-year experience with 224 procedures. Arch Otolaryngol Head Neck Surg 1993; 119: May M. Muscle transposition for facial reanimation-indications and results. Arch Otolarymgol 1984; 110: Peer Reviewers Commentary 818

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