Original Study

Surgical Reconsideration of Traumatic Facial Paralysis

Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH

*Jin Kim, †Jeon Mi Lee, ‡Sung-Il Nam, and §Moo Jin Baek
o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/19/2023

*Department of Otorhinolaryngology, Hallym University College of Medicine, Dong-tan Sacred Heart Hospital, Hwaseong-si; †Department
of Otorhinolaryngology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang-si; ‡Department of Otorhinolaryngology, Keimyung
University College of Medicine, Dong San Medical center, Deagu; and §Department of Otorhinolaryngology, Inje University College of
Medicine, Haeundae Paik Hospital, Busan, Korea

Introduction: Despite the different pathophysiological mechanisms
underlying Bell's palsy, in assessing severe traumatic facial paralysis,
many surgeons rely on electrophysiological criteria to determine
whether facial nerve exploration is warranted. To assess the value
of preoperative electroneurography (ENoG) and the time of sur-
gery, we analyzed data from three tertiary medical centers.
Materials and Methods: The records of 517 patients with a de-
generative ratio (DR) greater than 80% on ENoG were collected,
and two groups were defined: group A (90% DR ≤ ENoG) and
group B (80% DR ≤ ENoG < 90% DR). The difference in effec-
tiveness of surgery versus conservative treatment was analyzed based
on the postoperative outcome determined by the House-Brackmann
grading system. The independent-samples t test was used to compare
surgery with conservative treatment for each day of surgical exploration.
Result: In groups A and B, the average recovery time from facial
paralysis was better in patients who had undergone surgical explora-
tion than in those who had been treated conservatively. In group A,
the difference was significant only for patients who underwent sur-
gery within 8 days. In group B, a significant difference was found
for patients who underwent surgery within 16 days but also for sur-
gery performed 20 and 30 days after the onset of facial paralysis.
Discussion: In the surgical treatment of facial paralysis, the criteria
for trauma patients should be distinguished from those of patients
with Bell's palsy. In traumatic facial paralysis, some axons are more
vulnerable to external collapse, and the degree of Wallerian degen-
eration of the peripheral nervous system will vary depending on the
type of injury. The results of this study will help to identify those pa-
tients with traumatic facial paralysis who should be treated surgi-
cally and when they should be treated.
Key Words: Decompression—Electroneurography—Facial
paralysis—Trauma.
Otol Neurotol 43:968–972, 2022.

INTRODUCTION eration within 14 days is commonly accepted as an indica-

In the treatment of acute facial paralysis, the aim is to reduce
the occurrence of facial complications that result in potentially
devastating consequences, including ocular problems, impaired
speech, feeding difficulties, and an inability to convey emotions
through facial expression. A better understanding of the patho-
physiology of facial nerve injuries is important for improved de-
cision making regarding the optimal form of treatment for a pa-
tient with acute facial paralysis: surgical exploration or a conser-
vative approach based on medical observation.
For many patients with severe traumatic facial paralysis
(TFNP), the same electrophysiological criteria that are used
in Bell's palsy are applied to determine whether facial nerve
exploration is warranted. However, the two conditions dif-
fer in their pathophysiological mechanisms. Thus, although
an electroneurography (ENoG) cutoff value of 90% degen-
Address correspondence and reprint request to Jin Kim, M.D., Ph.D., De-
partment of Otorhinolaryngology, Hallym University College of Medicine,
Dong-tan Sacred Heart Hospital, 7 Keunjaebong-gil, Dongtan 1(il)-dong,
Hwaseong-si, Gyeonggi-do 445-907, Korea; E-mail: jinsound@gmail.com
Sources of support and disclosure of funding: None declared.
The authors disclose no conflicts of interest.
DOI: 10.1097/MAO.0000000000003633
tion for surgical intervention in TFNP, this value may not be
appropriate for these patients (1).
In TFNP, even if the facial nerve has not been severed, it
may be compressed by extrinsic factors, such as a bony frag-
ment, impingement, or a fibrotic change mixed with hema-
toma, all of which are absent in Bell's palsy, in which com-
pression is usually due to intrinsic factors, such as viral in-
flammation or ischemic neuropathy.
The final outcome of surgical exploration in TFNP is influ-
enced by many factors, the most important of which is the
preoperative ENoG value and the time of surgery after facial
paralysis. Other factors, including the type of temporal bone
fracture, the patient's medical state, the surgical approach,
and medical treatment, will also influence the outcome.
In this retrospective study, we used a large body of data on
TFNP patients, obtained over 25 years from three tertiary medi-
cal centers. Specifically, we used data on the preoperative ENoG
value and when surgery was performed to determine the optimal
timeframe for the surgical treatment of TFNP patients.
MATERIALS AND METHODS
Data from 520 patients with severe TFNP managed at Yonsei
University, Kyemyung University, and Inje University Medical

© 2022, Otology & Neurotology, Inc.

Copyright © 2022 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
 TRAUMATIC FACIAL PARALYSIS
Centers between 1991 and 2018 were included in this study. The
mean age of the patients (432 men, 88 women) was 42.4 ± 10 years.
To reduce surgeon bias, data collection was restricted to one
surgeon's operative records per hospital, and only the patients of
surgeons who trained at the same medical center and had similar
surgical experience (L.W.S., N.S.I., and K.J.) were included.
The medical chart review focused on the preoperative status of
the patients, including the House-Brackmann (HB) facial nerve
Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH
grading system (2), ENoG, the date of surgery, and the postopera-
o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/19/2023
tive outcome after more than 1 year.
The records of surgically and nonsurgically treated patients whose
degenerative ratio (DR) was greater than 80% on ENoG performed
within 3 to 14 days after facial paralysis were collected. Based
on the ENoG value, the patients were divided into groups A
(90% DR ≤ ENoG) and B (80% DR ≤ ENoG < 90% DR).
ENoG (Viking Select; Nicolet, Madison, WI) was performed
by a single highly experienced examiner at each medical center.
After skin preparation, electrodes were placed using the optimized
lead placement technique (3,4). The results were interpreted accord-
ing to the peak-to-peak method and are reported as the percentage
(%) degeneration of the affected versus the unaffected side. The
mean value of one subsite (nasalis) was used in the analysis.
The date of surgery was calculated from the date of detection of
facial paralysis, not the day of trauma. If the onset of facial paral-
ysis could not be determined because of confounding factors, such
as neurological status or other life-threatening injuries, the patients
were classified as having facial paralysis of acute onset, as recom-
mended in the literature.
Cases of neural decompression or exploration performed via
transmastoid, translabyrinthine, and middle cranial fossa approaches
were included in this study, whereas patients who underwent
neurorrhaphy for transected nerve fibers were excluded.
Postoperative outcome was defined as the most severe HB grade
determined preoperatively minus the last HB grade measured more
than 1 year after surgery.
The difference in the effectiveness of surgery was analyzed using
the independent-samples t test (Microsoft Excel version 16.29;
Microsoft, Redmond, WA) to compare the postoperative outcomes
based on the HB grading system with the outcomes of conservative
treatment for each day of surgical exploration.
RESULTS
Patients
Among group A patients (90% DR ≤ ENoG) who un-
derwent surgical exploration (n = 211), the preoperative fa-
cial function was classified as HB grade IV in 23 patients,
HB grade V in 163 patients, and HB grade VI in 28 patients.
In the 76 conservatively treated group A patients, 12 were
classified as HB grade IV, 52 as HB grade V, and 12 as HB
TABLE 1. Distribution of the date of surgery and conservative treatment in group A and group B
8 10 12 14
Group A (n = 287; 90% DR ≤ ENoG) 23 31 33 40
Group B (n = 233; 80% DR ≤ ENoG < 90% DR) 12 10 13 18
HB indicates House-Brackmann grade; DR, degenerative ratio; ENoG, electroneurography; Tx, treatment.
Copyright © 2022 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
969
grade VI. The average HB grade and ENoG value were
5.0 ± 0.47 and 93.5 ± 7.4, respectively, in the surgical patients
and 5.0 ± 0.56 and 92.6 ± 8.4 in the conservatively treated pa-
tients. The average time from the onset of facial paralysis until
surgery was 15.1 ± 0.53 days. The surgical approach was
transmastoid in 162 patients, translabyrinthine in 15 patients,
via the middle cranial fossa in 18 patients, and via a combined
approach in 16 patients.
In group B (80% DR ≤ ENoG < 90% DR), the preoper-
ative facial function of the 199 surgically treated patients
was HB grade IV in 69, HB grade V in 126, and HB grade
VI in 4. Among the 34 conservatively treated patients, 8
were classified as HB grade IV, 24 as HB grade V, and 2
as HB grade VI. The average HB grade and ENoG value
were 4.7 ± 1.0 and 85.6 ± 6.6, respectively, in the surgical
patients and 4.8 ± 1.7 and 88.6 ± 8.4 in the conservatively
treated patients. The average time from the onset of facial
paralysis until surgery was 25.1 ± 0.93 days. The surgical
approach was transmastoid in 185 patients, translabyrinthine
in 2 patients, via the middle cranial fossa in 7 patients, and
via a combined approach in 5 patients. The number of patients
as a function of the time until surgery is shown in Table 1.
Difference Between Surgical Exploration and
Conservative Treatment
Group A and group B patients who underwent surgical
exploration had a better average recovery time from facial
paralysis than those who had been treated conservatively.
Preoperative facial function was not different between sur-
gical and conservatively treated patients (p = 0.696 and
0.176, respectively; independent-samples t test). After sur-
gery and conservative treatment, the difference was signif-
icant in both group A and group B patients (p = 0.0432 and
0.00003, respectively). However, a more detailed analysis
of the timing of surgery showed differences between the
211 patients who underwent surgery and the 76 who were
treated conservatively in group A. The facial changes in group
A patients as a function of the time of surgery after facial pa-
ralysis are shown in Table 2. Patients with early surgery had a
greater change in facial paralysis than those who had surgery
later. Moreover, the later the operation, the more similar the
outcome to that of the conservatively treated patients. The sig-
nificance of the date of surgery versus conservative treatment
with respect to outcome was determined; the results are shown
in Figure 1. In group A, the difference versus conservatively
treated patients was significant only for patients who
Surgical Exploration
Days From Facial Paralysis
16 18 20 22 24 26 28 30 40 60 Conservative Tx
22 17 10 12 8 7 8 N N N 76
(HB: IV, 23; V,163; VI, 28) (HB: IV, 12’ V, 52; VI, 12)
16 14 16 12 10 12 14 22 16 14 34
(HB: IV, 69; V, 126; VI, 4) (HB: IV, 8; V, 24; VI, 2)
Otology & Neurotology, Vol. 43, No. 8, 2022
 970 J. KIM ET AL.
TABLE 2. Facial changes of group A patients
Days of Facial Nerve Decmopression From Onset of Facial Palsy
Conservative
8d 10d 12d 14d 16d 18d 20d 22d 24d 26d 28d Treatment
No. patients 23 31 33 40 22 17 10 12 8 7 8 76
Facial changes(preop HB − postop HB) 4 4 3 3 3 3 2 2 2 2 3 2 2 1 2 1 2 0 2 3 0 2
3 5 3 3 4 2 2 3 2 2 2 1 2 3 3 2 1 2 3 2 3 3
4 5 2 3 3 3 3 2 2 3 3 2 3 2 1 2 3 1 2 1 2 3
Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH

3 3 3 4 2 4 2 3 2 2 4 1 2 3 2 1 2 1 2 1 2 3
o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/19/2023

3 4 3 3 3 3 3 2 2 3 3 0 1 4 1 3 3 2 3 2 3 4
4 4 2 3 4 2 2 3 3 2 1 1 3 2 2 1 1 0 1 2 3
3 2 3 3 3 3 4 1 2 2 4 2 3 1 2 3 2 3 2
3 2 3 2 3 4 3 1 3 3 3 3 2 3 3 3 3 3
3 2 3 3 3 3 2 2 2 3 4 2 4 2 4
2 3 2 2 2 2 2 3 2 2 4 3 3 0 3
4 4 3 3 2 3 2 2 2 3 2 4 2 4
3 3 2 4 2 4 3 1 2 4 1 3 1 3
3 4 3 3 2 3 4 2 2 3 2 3 2
2 3 2 2 2 2 3 3 3 4 3 4 3
3 4 3 3 2 2 2 3 2 2 2 2
4 2 4 4 2 3 3 1 3 3 3 3
4 3 3 3 3 4 0 2 2 2 2
Average 3.48 2.84 2.85 2.6 2.41 1.71 2.1 3.17 2 2 1.88 2.36
Statistical Differences (Independent-Samples t Test) Compared With Conservative Treatment
p 0.00013a 0.0552 0.0527 0.1157 0.3001 0.2035 0.3412 0.3119 0.2492 0.312 0.3821

Shown here is the recovery from facial paralysis according to the time of surgical exploration for patients with severe facial palsy (degenerative ratio >90%)
due to head trauma. The 211 surgically treated patients were compared with the 76 conservatively treated patients. A greater change in facial paralysis was
determined in patients with early versus late surgery. The later the operation, the more similar was the outcome to that of the conservatively treated patients.
a
Statistical difference on independent-samples t test.
HB indicates House-Brackmann grade.

underwent surgery within 8 days. In all other group A sur-
gical patients, the difference was not significant.
The facial changes of 199 patients in group B who un-
derwent surgery were compared with those of the 36 group
B patients who were treated conservatively (Table 3). Pa-
tients with early surgery had a greater change in the degree
of facial paralysis than those who had late surgery. As in
group A, the later the operation, the more similar the out-
come to that of the patients treated conservatively. How-
ever, in group B, the differences between patients who

FIG. 1. A, Differences at each time point ( p < 0.05 indicated a significant difference; blue color). In group A, only patients who underwent sur-
gery within 8 days differed significantly from the conservatively treated patients. The difference for patients who underwent surgery after 8 days
was not significant (red color). B, Differences at each time point ( p < 0.05 indicated a significant difference; blue color). In group B, patients who
underwent surgery within 16 days and those treated 20 and 30 days from the onset of facial paralysis differed significantly from the conserva-
tively treated patients. The differences for all other patients were not significant (red color).

Otology & Neurotology, Vol. 43, No. 8, 2022

Copyright © 2022 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
 TRAUMATIC FACIAL PARALYSIS 971
TABLE 3. Facial changes of group B patients
Days of Facial Nerve Decmopression From Onset of Facial Palsy
Conservative
8d 10d 12d 14d 16d 18d 20d 22d 24d 26d 28d 30d 40d 60d Treatment
No. patients 12 10 13 18 16 14 16 12 10 12 14 22 16 14 34
Facial 3 3 3 3 2 1 2 2 1 2 1 2 3 1 3 2 2 1
changes 4 3 3 2 3 3 3 3 2 2 1 2 3 4 2 2 1
(preop 3 4 2 3 2 2 2 2 2 3 2 1 2 3 2 2 3
Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH

HB − 4 3 4 3 3 1 3 3 3 2 1 3 2 2 3 2 1
o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/19/2023

postop 3 3 2 2 3 2 1 4 3 3 3 2 3 3 1 3 2
HB) 3 2 4 3 2 3 2 3 2 2 2 3 2 3 2 1
3 3 4 3 4 4 3 2 3 3 4 3 3 2 3 2
3 4 4 3 3 5 3 3 3 2 3 3 2 2 3 3
3 3 4 3 2 4 3 3 3 3 4 2 1 2 2 2
3 3 3 3 3 3 3 2 2 3 2 3 2 2 3 0
4 4 3 2 2 2 3 2 3 3 1 2 2 2
3 3 2 3 1 3 2 2 2 3 2 1 2 3
2 3 3 2 3 3 2 1 2 2 3
4 4 3 3 0 3 2 4 3 1
5 3 4 3 3 2 2
4 3 2 3 2 3 2
3 2 2 3
Average 3.25 3.10 3.23 3.00 2.75 2.64 2.63 2.58 2.50 2.33 2.29 2.50 2.25 2.14 2.09
Statistical Differences (Independent-Samples t Test) compared With Conservative Treatment
p 0.0000004a 0.000199a 0.0003a 0.00023a 0.0081 0.1139 0.0213 0.0754 0.0643 0.3721 0.5578 0.0379 0.5239 0.8241

Shown here is the recovery from facial paralysis according to the time of surgical exploration for patients with severe facial palsy (degenerative ratios >80 and
<90%) due to head trauma. The 199 surgically treated patients were compared with the 34 conservatively treated patients. A greater change in facial paralysis was
determined in patients with early versus late surgery. The later the operation, the more similar was the outcome to that of the conservatively treated patients.
a
Statistical difference on independent-sample t test.

underwent surgery within 16, 20, or 30 days versus those
treated conservatively were significant (Fig. 1B).
DISCUSSION
The optimal treatment for patients with severe TFNP in-
duced by a temporal bone fracture remains unclear. Al-
though most studies have reported beneficial effects of early
facial nerve exploration in patients with severe TFNP (5,6),
patients with temporal bone fractures usually have other in-
juries that require urgent attention. Consequently, the assess-
ment and subsequent management of facial paralysis may be
delayed until the patient's condition has stabilized. Insights
into when surgery is likely to be most effective can be obtained
by considering Wallerian degeneration (WD) (7). Thus, surgi-
cal exploration of an injured peripheral nerve should be con-
ducted within the active period of WD, which differs depending
on the neural injury (7–9). The start and end of WD can be pre-
dicted by ENoG. In nerve fibers with a high proportion of
neurotmesis, the DR will be greater than 90%, and the start
and end of WD will occur within a short period. For nerve fi-
bers with a high proportion of axonotmesis, the DR will be
greater than 75% but less than 90%, and WD will develop
much later (7,10,11) (Fig. 2). This may explain the reports
of excellent facial nerve recovery even in cases in which sur-
gery was performed very late.
In this study, significant differences between surgically
treated and conservatively treated patients as a function of

FIG. 2. Wallerian degeneration in the peripheral nervous system varies depending on the type of injury.

Otology & Neurotology, Vol. 43, No. 8, 2022

Copyright © 2022 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
 972 J. KIM ET AL.
the timing of surgery were identified. This information also
indicates when surgical exploration in TFNP patients will be
most effective.
Unlike in other studies, we focused on two groups of pa-
tients: those with DR values on preoperative ENoG of
greater than 80% and less than 80%. Patients with a DR be-
tween 80% and 89% (group B in our study) are not usually
Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH
candidates for surgery, and their recovery is typically poor.
o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/19/2023
However, a large number of these patients were treated at the
three institutes that participated in this study, and the data
were sufficient to allow statistical analysis. Recent studies
of patients similar to those in our group B reported that
nonrecovery is likely in Bell's palsy patients with a DR greater
than 81.5% and in Ramsay-Hunt syndrome patients with a
DR less than 78% (12,13). Our study evaluated the surgical
treatment of TFNP patients and did not address the surgical
indications for those with Bell's palsy. This is because, based
on our clinical experience, even if the facial nerve has not
been severed but only compressed by a bony fragment, im-
pingement, or a fibrotic change mixed with hematoma, facial
function may well be aggravated and conservative treatment
will not guarantee full recovery. Another reason for lowering
the surgical threshold from greater than 90% to greater than
80% DR on ENoG is that some axons are more vulnerable
to external collapse, unlike in Bell's palsy.
The main issue in this study was the timing of surgery to
decompress the nerve under pressure. Therefore, we included
only cases in which decompression was performed in the part
that had been expected to be under pressure due to nerve in-
jury as determined via temporal bone computed tomography,
which could be either over a fracture line across a segment of
the nerve or along a clear bony impingement in temporal
bone. A majority of cases were treated using the transmastoid
approach. Most patients treated using the middle cranial fossa
approach and translabyrinthine approach were excluded from
the study because they included large numbers of cases
with nerve anastomosis or nerve graft.
The major limitation was that the data were from 25 years
ago, so most medical records rarely had video attached and
Otology & Neurotology, Vol. 43, No. 8, 2022
Copyright © 2022 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
only records of facial movements before and after surgery
using the HB grade system remained. However, we proceeded
with the study because these data are very important to deter-
mine the direction for treatment of traumatic facial palsy
patients. The results of our simple but convincing study will
facilitate both the selection of TFNP patients eligible for sur-
gery and the determination of the optimal timing of surgery.
REFERENCES
1. Remenschneider AK, Michalak S, Kozin ED, et al. Is serial
electroneuronography indicated following temporal bone trauma?
Otol Neurotol 2017;38:572–6.
2. House JW. Facial nerve grading systems. Laryngoscope. 1983;93:1056–69.
3. Esslen E. The acute facial palsies: Investigations on the localization and
pathogenesis of meato-labyrinthine facial palsies. Schriftenr Neurol 1977;
18:1–164.
4. Fisch U. Prognostic value of electrical tests in acute facial paralysis.
Am J Otol 1984;5:494–8.
5. May M. Total facial nerve exploration: Transmastoid, extralabyrinthine,
and subtemporal indications and results. Laryngoscope 1979;89:906–17.
6. Kim J, Moon IS, Shim DB, Lee WS. The effect of surgical timing on
functional outcomes of traumatic facial nerve paralysis. J Trauma
2010;68:924–9.
7. Dahlin LB. Nerve injury and repair: From molecule to man. In: Slutsky
DJ, Hentz VR, eds. Peripheral Nerve Surgery: Practical Applications in
the Upper Extremity. Philadelphia: Churchill Livingston, Elsevier; 2006:
1–22.
8. Lunn ER, Brown MC, Perry VH. The pattern of axonal degeneration
in the peripheral nervous system varies with different types of lesion.
Neuroscience 1990;35:157–65.
9. Raff MC, Whitmore AV, Finn JT. Axonal self-destruction and
neurodegeneration. Science 2002;296:868–71.
10. Seddon HJ. Three types of nerve injury. Brain 1943;66:237–88.
11. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management
of Bell's palsy. Laryngoscope 1999;109:1177–88.
12. Byun H, Cho YS, Jang JY, et al. Value of electroneurography as a
prognostic indicator for recovery in acute severe inflammatory facial
paralysis: A prospective study of Bell's palsy and Ramsay Hunt
syndrome. Laryngoscope 2013;123:2526–32.
13. Takemoto N, Horii A, Sakata Y, Inohara H. Prognostic factors of
peripheral facial palsy: Multivariate analysis followed by receiver
operating characteristic and Kaplan-Meier analyses. Otol Neurotol
2011;32:1031–6.