Facial nerve trauma

Maisa Alsmadi
Types of trauma
 temporal bone fracture (commonest cause)
 Penetrating Trauma
 Iatrogenic Trauma
Temporal bone fracture
 longitudinal fracture 20%
 transverse fracture 50%
 Injuries: compression from bone fragments, intraneural
hematomas, entrapment from compression, and loss of
continuity.
 The distal labyrinthine segment and geniculate ganglion are
the areas most susceptible to injury.
Penetrating Trauma
 Gun shot wounds cause both intratemporal
and extratemporal injuries.
 GS wounds to temporal bone result in FN
paralysis in 50% of cases
 Mixture of avulsion and blunt trauma to different portions of
the nerve
 Much worse outcome when comparing GS related paralysis
to TB fracture related paralysis.
 Iatrogenic Trauma
 Surgical
• Most common overall surgery with FN injury is parotidectomy.
• Most common otologic procedures with FN paralysis:
– Mastoidectomy – 55%
– Tympanoplasty – 14%
– Exostoses removal – 14%
 Mechanism - direct mechanical injury or heat generated from drilling.
 Most common area of injury - tympanic portion ( high incidence of
dehiscence )
• Unrecognized injury during surgery in nearly 80% of cases
 Birth trauma
• Forceps delivery with compression of the facial nerve against the spine.
Sunderland Nerve Injury
Classification
 Class I (Neuropraxia)
• Conduction block caused by cessation of axoplasmic flow
• Full recovery

 Class II (Axonotmesis)
• Axons are disrupted
• Wallerian degeneration occurs distal to the site of injury
• Endoneural tube still intact
• Full recovery expected

 Class III (Neurotmesis)

• Neural tube is disrupted
• Poor prognosis
• If regeneration occurs, high incidence of synkinesis(abnormal mass movement of
muscles which do not normally contract together)
Sunderland Nerve Injury
Classification (cont.)
 Class IV
- Epineurium remains intact
- Perineurium, endoneurium, and axon disrupted
- Poor functional outcome with higher risk for synkinesis
 Class V
- Complete disruption
- Little chance of regeneration
- Risk of neuroma formation
history

 Mechanism – recent surgery, facial/head trauma

 Timing – progressive loss of function or sudden loss
 Transected nerve  sudden loss
 Intraneural hematoma or impengiment  progressive loss
(better prognosis)
 Unknown status of facial nerve at the time of trauma e.g
intubation, is treated as immediate onset palsy.
 Associated symptoms – hearing loss or vertigo.
 Examination
House-Brackmann Grading System

(grade I – VI)
Facial Nerve Testing
 Nerve Excitability Test (NET)
 Maximal Stimulation Test (MST)
 Electroneurography (ENoG)

 Electromyography( EMG).
NET
 Compares amount of current required to illicit minimal
muscle contraction - normal side vs. paralyzed side.
 A difference of 3.5 mA or greater between the two sides is
considered significant.
 Subjective.
MST
 Similar to the NET, except it utilizes maximal stimulation
rather than minimal.
• Comparison rated as equal, slightly decreased, markedly
decreased, or absent.
 Subjective.
ENoG
 The most accurate of the electrodiagnostic tests.
 The two sides are compared as a percentage of
response(usually only 3% difference)
 90% degeneration – surgical decompression should be
performed
 Less than 90% degeneration within 3 weeks predicts 80 -
100% spontaneous recovery.
Electrical testing
 NET, MST, ENoG are helpful in early complete paralysis
until it begins to recover or show complete loss of
excitability.
 In applicable in cases of partial paralysis after the beginning
of clinical recovery.
 Electrical testing can differentiate between Sunderland class I
& classes (II-V).
EMG
 Give good prognostic indicator in the phase “after loss of
excitability”.
 Help to assess weather facial repair is unsuccessful.
investigation
 High-resolution CT of the temporal bone is the most
effective way to identify potential sites of injury of the facial
nerve.
 MRI or angiography is indicated if a major vascular injury is
suspected.
 Approach to Treatment and Treatment
Options - Iatrogenic Injury

If transected during surgery

Explore 5-10mm of the involved segment

(Stimulate both proximally and distally)

If only response distally = poor Response with 0.05mA = good

prognosis, and further exposure prognosis; further exploration
is warranted not required
if loss of function is noted following surgery, wait 2-3 hours and
then re-evaluate the patient.
Waited time and still paralysis
Unsure of nerve integrity Integrity of nerve known
to be intact
re-explore as soon as
possible High dose steroids – prednisone at
1mg/kg/day x 10 days and then taper

if worsening paralysis
occurs re-explore 72 hours –
ENoG
if no regeneration,
but no worsening, <90% degeneration –
timing of >90%
monitor degeneration – re-
exploration or
whether to is explore
controversial
Blunt Trauma with FN Paralysis

 Birth trauma and Extratemporal blunt trauma

– Recommend no surgical exploration
– >90% expected to regain normal/near normal recovery
 Complete paralysis following temporal bone fracture
– Likely nerve transection
– Surgical exploration
 Partial or delayed loss of function
– Approach similar to iatrogenic partial or delayed loss
– High dose steroids
– ENoG 72 hours
 >90% degeneration – explore
 < 90% degeneration – can monitor and explore at later
 date depending on worsening or failure to regenerate
Time of surgery
 Fisch stablished a criterion of >90% degeneration within 6
days of onset.
 The timing of surgery, however, does not have to be within 6
days; in fact, there may be some advantage to delaying
surgery up to 3 weeks after an immediate paralysis to allow
resolution of edema and hematoma and make the surgical
field more discernible.
Penetrating Trauma with FN paralysis

 High likelihood of transection.

 Do not explore if injury occurs distal (medial) to the lateral
canthus, Nerve endings are very small, Rich anastomotic
network from other branches in this area
 Exploration should occur within 3 days of injury.
 Delayed exploration with gunshot wounds is recommended
 GS results in extensive nerve damage
 Waiting a little longer to indentify the extent of injury can be
beneficial in forming a surgical plan
Thank you