Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-2891-z
Otology
The effect of total facial nerve decompression in preventing further recurrence of idiopathic recurrent facial palsy Yang Li · Zhi Li · Cheng Yan · Liu Hui
Received: 28 October 2013 / Accepted: 15 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The objective is to study the role of total facial nerve decompression in preventing further episodes and promoting facial nerve recovery of idiopathic recurrent facial palsy. 24 cases with idiopathic recurrent facial palsy were involved in the study, among which 16 undergoing total facial nerve decompression were classified into the surgery group, and 8 who refused surgery and received prednisolone were included in the control group. The recurrence rate and facial nerve function recovery of the two groups were compared. The mean follow-up of surgery and control group was 4.9 years (range 3–7 years) and 5.0 years (range 3–8 years), respectively. Further attacks of facial palsy affected 1 of 16 cases (6.2 %) among surgery group in comparison to 4 of 8 cases (50 %) among control group, with statistical difference (p 0.05). In conclusion, total facial nerve decompression is effective to prevent further episodes of facial palsy in idiopathic recurrent facial palsy, but ineffective to promote facial nerve recovery.
Keywords Recurrent facial palsy · Facial neve · Total facial nerve decompression
Y. Li Department of Otolaryngology‑Head and Neck Surgery, The Second Hospital of Medical School of Xi’an Jiao Tong University, Xi’an 710004, People’s Republic of China
Materials and methods
Y. Li · Z. Li (*) · L. Hui Department of Otorhinolaryngology, Shaanxi Provincial People’s Hospital, Xi’an 710061, People’s Republic of China e-mail: [email protected] C. Yan Department of Digestive Diseases, The Second Hospital of Medical School of Xi’an Jiao Tong University, Xi’an 710004, People’s Republic of China
Introduction Recurrent facial palsy is not uncommon in peripheral facial palsy, and it accounts for 8.2 % of patients with Bell’s palsy [1]. Most recurrent facial palsy is idiopathic, although it may be found in Melkersson Rosenthal syndrome, facial nerve neurinoma, and otitis media [2–4]. Recurrent facial palsy tends to recur [5], and facial nerve tends to deteriorate after repetitive recurrence [6]. The recovery after multiple episodes of facial palsy appears to be worse than that after a single palsy [1]. In order to prevent potential damage of facial nerve caused by repetitive recurrence, certain authors ever attempted either total or subtotal facial nerve decompression on small number of patients, and it seemed that both methods were effective to prevent recurrence of facial palsy [5–8]. Our study mainly aims to document the preventive role of surgical decompression in idiopathic recurrent facial nerve.
24 cases with idiopathic recurrent facial palsy (ipsilateral recurrent facial palsy) were involved in the study, among which 16 undergoing total facial nerve decompression were incorporated into the surgery group and the other 8 refusing surgery and accepting prednisolone treatment (oral administration of prednisolone, 1 mg/kg/day, for 7 days) classified into the control group. They were all excluded from diabetes, hypertension, sarcoidosis, Melkersson Rosenthal syndrome, facial nerve neurinoma, and otitis media. The
13
Eur Arch Otorhinolaryngol
Table 1 Summary of 16 cases undergoing total facial nerve decompression Patient no.
PreFPE
PosFPE
Side
Initial FNF
Final FNF
Age at the first onset
Frequency (times/year)
Follow-up (year)
Age
1 2 3 4
3 3 2 4
0 0 0 0
L R L L/R
V VI III IV
I II I I
20 35 10 16
29 41 17 23
3/9 3/6 2/7 4/7
5 5 6 6
5 6 7 8 9 10 11 12 13 14 15
2 6 3 2 5 4 2 5 3 2 2
0 0 0 0 1 0 0 0 0 0 0
L/R L/R R L R L R R L R L
III VI II V III IV II III IV III III
I III I I II II I II I I I
4 4 20 34 11 12 7 13 7 13 9
27 27 33 42 16 17 17 22 17 24 18
2/13 6/13 3/13 2/8 5/5 4/5 2/10 5/9 3/10 2/11 2/9
7 4 3 3 4 3 7 5 4 7 4
16
2
0
R
II
I
10
22
2/12
6
PreFPE preoperative facial palsy episode, PosFPE postoperative facial palsy episode, FNF facial nerve function, L left; R right Indications: Case 4 suffered right-sided facial palsy for four times and left-sided facial palsy for once, and underwent decompression of the right-sided facial nerve; Case 5 suffered left-sided facial palsy for two times and right-sided facial palsy for once, and underwent decompression of the left-sided facial nerve; Case 6 suffered left-sided facial palsy for six times and right-sided facial palsy twice, and underwent decompression of the left-sided facial nerve
Table 2 Summary of eight cases receiving prednisolone treatment Patient no.
FPE before T
FPE after T
Side
Initial FNF
Final FNF
Age at the first onset
Age
Frequency (times/year)
FU(year)
1 2 3 4 5 6 7
2 3 4 3 5 7 2
0 1 4 0 3 2 0
L R L R R L L
II VI V IV III VI II
I II III II I III I
19 30 8 16 18 7 34
30 40 20 25 30 22 42
2/11 3/10 4/12 3/8 5/12 7/15 2/8
4 4 6 3 6 5 8
8
3
0
L
V
I
25
37
3/12
4
FPE facial palsy episode, T treatment, FNF facial nerve function, FU follow-up, R right, L left
total facial nerve decompression was performed through middle cranial fossa combined with mastoid approach. There were 16 female and 8 male, and the median age was 26.6 ± 8.7 years (range 16–42 years). Left and right sides were almost equally affected by facial palsy. The average interval for one episode was calculated by the interval between the first and last facial palsy divided by the total number of episodes before treatment. Facial nerve function (FNF) was graded according to House-Brackmann grading system [9], and preoperative FNF of the cases ranged from Grade II to Grade VI. The recurrence rate and FNF recovery (return of FNF to Grade I or II) rate of the two groups were compared. We compared the recurrence rate and FNF
13
recovery rate of the double groups by Fisher’s exact test, with SPSS 16.0 software involved in statistics.
Results The summary of the patients in both groups is given in Tables 1 and 2. Patients in surgery group and control group were followed up for 4.9 ± 1.4 years (range 3–7 years) and 5.0 ± 1.6 years (range 3–8 years), respectively. The average interval for one episode of facial palsy before treatment was 2.9 years in surgery group compared to 3.0 years in control group. During the follow-up, further attacks of
Eur Arch Otorhinolaryngol
facial palsy affected 1 of 16 cases among surgery group with the recurrence rate of 6.2 % compared to 4 of 8 cases among control group with the recurrence rate of 50 % (p 0.05). No cases developed obvious complications due to the surgical procedures.
Discussion Recurrent facial palsy is not infrequent, and it tends to recur after conservative treatment or self-resolution. Subsequent attacks may be unilateral or contralateral. Outcomes of FNF tend to deteriorate progressively after repetitive episodes of facial palsy [8, 10, 11]. It is also documented by the electrophysiological study that there is loss of action potential amplitude in cases of recurrent facial palsy in contrast to those with only a single attack [12]. Moreover, the risk of facial palsy recurrence increases with every recurrence, from 15 % on the second episode to 50 % on the fourth attack [13], and the mean interval between the first and second recurrence was shortened dramatically in contrast to the interval between the first facial palsy and the first recurrence [14]. Considering those aspects, even prophylactic surgery is reasonable to protect facial nerve from potential damage for cases with recurrent facial palsy. Either total or subtotal facial nerve decompression seemed effective to prevent subsequent episodes of recurrent facial palsy [5–8]. Graham and Kartush [15] reported six patients with recurrent facial palsy, who underwent total facial nerve decompression and were then free from recurrence during the follow-up of 3–8 years. Similarly, Yetiser et al. [5] described three cases with recurrent facial palsy, who accepted subtotal facial nerve decompression and reported no further episodes within 4–9 years. However, Doshi and Irving [8] attempted facial nerve decompression of the mastoid segment alone on a young woman who had a left-sided facial palsy on an annual basis for 10 years, but failed to prevent recurrence of facial palsy. According to the facts above, it appeared that decompression of the mastoid segment only was not essential to prevent further recurrence of facial palsy, and total facial nerve decompression was more effective. In our study, the recurrence rate was 6.2 % in the surgery group, much lower than that of 50 % in the control group, with statistical difference (p 0.05), although FNF recovery rate of surgery group was 18.8 % higher than that of control group. Fisch and Esslen proposed that the most likely site for neural compression in Bell’s palsy was at the meatal foramen (the narrowest point) based on their finding that nerve conduction block region was proximal to the geniculate ganglion using intraoperative electrical stimulation [16]. Hence, we opted for total facial nerve decompression. However, subtotal facial nerve decompression from stylomastoid foramen to geniculate ganglion or that from meatal foramen to geniculate ganglion also seemed effective to prevent further episodes of facial palsy in a small number of cases [5, 8], although there have been no study to document the exact efficacy. Surgical decompression is infrequently reported for recurrent facial palsy, and there was no convincing study to determine the efficacy of surgical decompression for recurrent facial palsy in the past. However, our study reveals that total facial nerve decompression is effective to prevent further episodes of facial palsy, and thereby valuable to prevent potential facial nerve damage in idiopathic recurrent facial palsy.
References 1. van Amstel AD, Devriese PP (1988) Clinical experiences with recurrences of Bell’s palsy. Arch Otorhinolaryngol 245(5):302–306 2. Greene RM, Rogers RS III (1989) Melkersson-Rosenthal syndrome: a review of 36 patients. J Am Acad Dermatol 21:1263–1270 3. Scholz E, Langer J, Begall K (2007) Recurrent facial paresis with facial neurinoma. Laryngorhinootologie 86(6):443–447 4. Kim J, Jung GH, Park SY, Lee WS (2012) Facial nerve paralysis due to chronic otitis media: prognosis in restoration of facial function after surgical intervention. Yonsei Med J 53(3):642–648 5. Yetiser S, Satar B, Kazkayasi M (2002) Immunologic abnormalities and surgical experiences in recurrent facial nerve paralysis. Otol Neurotol 23(5):772–778 6. Canale TJ, Cox RH (1974) Compression of the facial nerve in Melkersson syndrome. Arch Otolaryngol 100(5):373–374 7. Dutt SN, Mirza S, Irving RM, Donaldson I (2000) Total decompression of facial nerve for Melkersson Rosental syndrome. J Laryngol Otol 114(11):870–873 8. Doshi J, Irving R (2010) Recurrent facial nerve palsy: the role of surgery. J Laryngol Otol 124(11):1202–1204 9. Hous JW, Brackmann DE (1985) Facial nerve grading system. Otolaryngol Head Neck Surg 93(2):146–147 10. Boddie HG (1972) Recurrent Bell’s palsy. J Laryngol Otol 86:117–120 11. Ralli G, Magliulo G (1988) Bell’s palsy and its recurrences. Arch Otorhinolaryngol 244:387–390
13
12. Mamoli B, Neumann H, Ehrmann L (1977) Recurrent Bell’s palsy. Etiology, frequency, prognosis. J Neurol 216(2):119–125 13. Pitts DB, Adour KK, Hilsinger RL Jr (1988) Recurrent Bell’s palsy: analysis of 140 patients. Laryngoscope 98(5):535–540 14. Crego F, Galindo J, Quesada P, Naches S, Piñas J, Vila J et al (1998) Recurrent peripheral facial paralysis. Our case load from 1995. Acta Otorrinolaringol Esp 49(4):280–282
13
Eur Arch Otorhinolaryngol 15. Graham MD, Kartush JM (1989) Total facial nerve decompression for recurrent facial paralysis: an update. Otolaryngol Head Neck Surg 101(4):442–444 16. Fisch U, Esslen E (1972) Total intratemporal exposure of the facial nerve. Pathologic findings in Bell’s palsy. Arch Otolaryngol 95(4):335–341
Otology
The effect of total facial nerve decompression in preventing further recurrence of idiopathic recurrent facial palsy Yang Li · Zhi Li · Cheng Yan · Liu Hui
Received: 28 October 2013 / Accepted: 15 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The objective is to study the role of total facial nerve decompression in preventing further episodes and promoting facial nerve recovery of idiopathic recurrent facial palsy. 24 cases with idiopathic recurrent facial palsy were involved in the study, among which 16 undergoing total facial nerve decompression were classified into the surgery group, and 8 who refused surgery and received prednisolone were included in the control group. The recurrence rate and facial nerve function recovery of the two groups were compared. The mean follow-up of surgery and control group was 4.9 years (range 3–7 years) and 5.0 years (range 3–8 years), respectively. Further attacks of facial palsy affected 1 of 16 cases (6.2 %) among surgery group in comparison to 4 of 8 cases (50 %) among control group, with statistical difference (p 0.05). In conclusion, total facial nerve decompression is effective to prevent further episodes of facial palsy in idiopathic recurrent facial palsy, but ineffective to promote facial nerve recovery.
Keywords Recurrent facial palsy · Facial neve · Total facial nerve decompression
Y. Li Department of Otolaryngology‑Head and Neck Surgery, The Second Hospital of Medical School of Xi’an Jiao Tong University, Xi’an 710004, People’s Republic of China
Materials and methods
Y. Li · Z. Li (*) · L. Hui Department of Otorhinolaryngology, Shaanxi Provincial People’s Hospital, Xi’an 710061, People’s Republic of China e-mail: [email protected] C. Yan Department of Digestive Diseases, The Second Hospital of Medical School of Xi’an Jiao Tong University, Xi’an 710004, People’s Republic of China
Introduction Recurrent facial palsy is not uncommon in peripheral facial palsy, and it accounts for 8.2 % of patients with Bell’s palsy [1]. Most recurrent facial palsy is idiopathic, although it may be found in Melkersson Rosenthal syndrome, facial nerve neurinoma, and otitis media [2–4]. Recurrent facial palsy tends to recur [5], and facial nerve tends to deteriorate after repetitive recurrence [6]. The recovery after multiple episodes of facial palsy appears to be worse than that after a single palsy [1]. In order to prevent potential damage of facial nerve caused by repetitive recurrence, certain authors ever attempted either total or subtotal facial nerve decompression on small number of patients, and it seemed that both methods were effective to prevent recurrence of facial palsy [5–8]. Our study mainly aims to document the preventive role of surgical decompression in idiopathic recurrent facial nerve.
24 cases with idiopathic recurrent facial palsy (ipsilateral recurrent facial palsy) were involved in the study, among which 16 undergoing total facial nerve decompression were incorporated into the surgery group and the other 8 refusing surgery and accepting prednisolone treatment (oral administration of prednisolone, 1 mg/kg/day, for 7 days) classified into the control group. They were all excluded from diabetes, hypertension, sarcoidosis, Melkersson Rosenthal syndrome, facial nerve neurinoma, and otitis media. The
13
Eur Arch Otorhinolaryngol
Table 1 Summary of 16 cases undergoing total facial nerve decompression Patient no.
PreFPE
PosFPE
Side
Initial FNF
Final FNF
Age at the first onset
Frequency (times/year)
Follow-up (year)
Age
1 2 3 4
3 3 2 4
0 0 0 0
L R L L/R
V VI III IV
I II I I
20 35 10 16
29 41 17 23
3/9 3/6 2/7 4/7
5 5 6 6
5 6 7 8 9 10 11 12 13 14 15
2 6 3 2 5 4 2 5 3 2 2
0 0 0 0 1 0 0 0 0 0 0
L/R L/R R L R L R R L R L
III VI II V III IV II III IV III III
I III I I II II I II I I I
4 4 20 34 11 12 7 13 7 13 9
27 27 33 42 16 17 17 22 17 24 18
2/13 6/13 3/13 2/8 5/5 4/5 2/10 5/9 3/10 2/11 2/9
7 4 3 3 4 3 7 5 4 7 4
16
2
0
R
II
I
10
22
2/12
6
PreFPE preoperative facial palsy episode, PosFPE postoperative facial palsy episode, FNF facial nerve function, L left; R right Indications: Case 4 suffered right-sided facial palsy for four times and left-sided facial palsy for once, and underwent decompression of the right-sided facial nerve; Case 5 suffered left-sided facial palsy for two times and right-sided facial palsy for once, and underwent decompression of the left-sided facial nerve; Case 6 suffered left-sided facial palsy for six times and right-sided facial palsy twice, and underwent decompression of the left-sided facial nerve
Table 2 Summary of eight cases receiving prednisolone treatment Patient no.
FPE before T
FPE after T
Side
Initial FNF
Final FNF
Age at the first onset
Age
Frequency (times/year)
FU(year)
1 2 3 4 5 6 7
2 3 4 3 5 7 2
0 1 4 0 3 2 0
L R L R R L L
II VI V IV III VI II
I II III II I III I
19 30 8 16 18 7 34
30 40 20 25 30 22 42
2/11 3/10 4/12 3/8 5/12 7/15 2/8
4 4 6 3 6 5 8
8
3
0
L
V
I
25
37
3/12
4
FPE facial palsy episode, T treatment, FNF facial nerve function, FU follow-up, R right, L left
total facial nerve decompression was performed through middle cranial fossa combined with mastoid approach. There were 16 female and 8 male, and the median age was 26.6 ± 8.7 years (range 16–42 years). Left and right sides were almost equally affected by facial palsy. The average interval for one episode was calculated by the interval between the first and last facial palsy divided by the total number of episodes before treatment. Facial nerve function (FNF) was graded according to House-Brackmann grading system [9], and preoperative FNF of the cases ranged from Grade II to Grade VI. The recurrence rate and FNF recovery (return of FNF to Grade I or II) rate of the two groups were compared. We compared the recurrence rate and FNF
13
recovery rate of the double groups by Fisher’s exact test, with SPSS 16.0 software involved in statistics.
Results The summary of the patients in both groups is given in Tables 1 and 2. Patients in surgery group and control group were followed up for 4.9 ± 1.4 years (range 3–7 years) and 5.0 ± 1.6 years (range 3–8 years), respectively. The average interval for one episode of facial palsy before treatment was 2.9 years in surgery group compared to 3.0 years in control group. During the follow-up, further attacks of
Eur Arch Otorhinolaryngol
facial palsy affected 1 of 16 cases among surgery group with the recurrence rate of 6.2 % compared to 4 of 8 cases among control group with the recurrence rate of 50 % (p 0.05). No cases developed obvious complications due to the surgical procedures.
Discussion Recurrent facial palsy is not infrequent, and it tends to recur after conservative treatment or self-resolution. Subsequent attacks may be unilateral or contralateral. Outcomes of FNF tend to deteriorate progressively after repetitive episodes of facial palsy [8, 10, 11]. It is also documented by the electrophysiological study that there is loss of action potential amplitude in cases of recurrent facial palsy in contrast to those with only a single attack [12]. Moreover, the risk of facial palsy recurrence increases with every recurrence, from 15 % on the second episode to 50 % on the fourth attack [13], and the mean interval between the first and second recurrence was shortened dramatically in contrast to the interval between the first facial palsy and the first recurrence [14]. Considering those aspects, even prophylactic surgery is reasonable to protect facial nerve from potential damage for cases with recurrent facial palsy. Either total or subtotal facial nerve decompression seemed effective to prevent subsequent episodes of recurrent facial palsy [5–8]. Graham and Kartush [15] reported six patients with recurrent facial palsy, who underwent total facial nerve decompression and were then free from recurrence during the follow-up of 3–8 years. Similarly, Yetiser et al. [5] described three cases with recurrent facial palsy, who accepted subtotal facial nerve decompression and reported no further episodes within 4–9 years. However, Doshi and Irving [8] attempted facial nerve decompression of the mastoid segment alone on a young woman who had a left-sided facial palsy on an annual basis for 10 years, but failed to prevent recurrence of facial palsy. According to the facts above, it appeared that decompression of the mastoid segment only was not essential to prevent further recurrence of facial palsy, and total facial nerve decompression was more effective. In our study, the recurrence rate was 6.2 % in the surgery group, much lower than that of 50 % in the control group, with statistical difference (p 0.05), although FNF recovery rate of surgery group was 18.8 % higher than that of control group. Fisch and Esslen proposed that the most likely site for neural compression in Bell’s palsy was at the meatal foramen (the narrowest point) based on their finding that nerve conduction block region was proximal to the geniculate ganglion using intraoperative electrical stimulation [16]. Hence, we opted for total facial nerve decompression. However, subtotal facial nerve decompression from stylomastoid foramen to geniculate ganglion or that from meatal foramen to geniculate ganglion also seemed effective to prevent further episodes of facial palsy in a small number of cases [5, 8], although there have been no study to document the exact efficacy. Surgical decompression is infrequently reported for recurrent facial palsy, and there was no convincing study to determine the efficacy of surgical decompression for recurrent facial palsy in the past. However, our study reveals that total facial nerve decompression is effective to prevent further episodes of facial palsy, and thereby valuable to prevent potential facial nerve damage in idiopathic recurrent facial palsy.
References 1. van Amstel AD, Devriese PP (1988) Clinical experiences with recurrences of Bell’s palsy. Arch Otorhinolaryngol 245(5):302–306 2. Greene RM, Rogers RS III (1989) Melkersson-Rosenthal syndrome: a review of 36 patients. J Am Acad Dermatol 21:1263–1270 3. Scholz E, Langer J, Begall K (2007) Recurrent facial paresis with facial neurinoma. Laryngorhinootologie 86(6):443–447 4. Kim J, Jung GH, Park SY, Lee WS (2012) Facial nerve paralysis due to chronic otitis media: prognosis in restoration of facial function after surgical intervention. Yonsei Med J 53(3):642–648 5. Yetiser S, Satar B, Kazkayasi M (2002) Immunologic abnormalities and surgical experiences in recurrent facial nerve paralysis. Otol Neurotol 23(5):772–778 6. Canale TJ, Cox RH (1974) Compression of the facial nerve in Melkersson syndrome. Arch Otolaryngol 100(5):373–374 7. Dutt SN, Mirza S, Irving RM, Donaldson I (2000) Total decompression of facial nerve for Melkersson Rosental syndrome. J Laryngol Otol 114(11):870–873 8. Doshi J, Irving R (2010) Recurrent facial nerve palsy: the role of surgery. J Laryngol Otol 124(11):1202–1204 9. Hous JW, Brackmann DE (1985) Facial nerve grading system. Otolaryngol Head Neck Surg 93(2):146–147 10. Boddie HG (1972) Recurrent Bell’s palsy. J Laryngol Otol 86:117–120 11. Ralli G, Magliulo G (1988) Bell’s palsy and its recurrences. Arch Otorhinolaryngol 244:387–390
13
12. Mamoli B, Neumann H, Ehrmann L (1977) Recurrent Bell’s palsy. Etiology, frequency, prognosis. J Neurol 216(2):119–125 13. Pitts DB, Adour KK, Hilsinger RL Jr (1988) Recurrent Bell’s palsy: analysis of 140 patients. Laryngoscope 98(5):535–540 14. Crego F, Galindo J, Quesada P, Naches S, Piñas J, Vila J et al (1998) Recurrent peripheral facial paralysis. Our case load from 1995. Acta Otorrinolaringol Esp 49(4):280–282
13
Eur Arch Otorhinolaryngol 15. Graham MD, Kartush JM (1989) Total facial nerve decompression for recurrent facial paralysis: an update. Otolaryngol Head Neck Surg 101(4):442–444 16. Fisch U, Esslen E (1972) Total intratemporal exposure of the facial nerve. Pathologic findings in Bell’s palsy. Arch Otolaryngol 95(4):335–341
