Facial paralysis can result from a wide variety of etiologies including infectious, neurologic, congenital, neoplastic, traumatic, systemic, and iatrogenic causes. Regardless of cause, the management of facial paralysis is complex and often requires multidisciplinary intervention. The evaluation and treatment of facial paralysis is especially intricate because of the wide variation in the potential for regeneration and lack of reliable prognostic indicators for spontaneous recovery. Current management of facial paralysis consists of a combination of pharmacologic therapy, physical therapy for facial neuromuscular retraining, and surgical intervention via dynamic and static techniques for facial reanimation. This chapter will focus on the wide variety of surgical therapies available to the reconstructive surgeon for successful facial reanimation.
Surgical Management of Acute Facial Paralysis (< 3 weeks)
Any surgical intervention for facial paralysis must carefully take into account the patient’s age, medical history, residual hearing, segment of nerve injured, and the patient’s expectations and risk tolerance. Management of acute facial paralysis may involve facial nerve decompression surgery in cases of virally induced facial paralysis (eg, Bell palsy, Ramsay Hunt syndrome) or traumatic facial paralysis. Primary facial nerve repair/grafting is undertaken in cases of resection or transection of the facial nerve.
A. Facial Nerve Decompression
The transmastoid approach for facial nerve decompression (Figure 74–1) can be utilized when the trauma is clearly localized to the tympanic or mastoid segments of the facial nerve. The nerve should be decompressed for 180° of its circumference. Important landmarks for this approach include the lateral semicircular canal, fossa incudis, and digastric ridge. The incus can be removed and then replaced as an interposition graft to achieve decompression of the tympanic segment of the facial nerve all the way to the geniculate ganglion.
Transmastoid decompression of the facial nerve, left ear, with decompression of the geniculate ganglion. (With permission Sofferman RA. Facial nerve injury and decompression. In: Surgery of the Ear and Temporal Bone. Lippincott Williams and Wilkins; 2005.)
The middle fossa approach allows decompression of the facial nerve when the injury extends to the labyrinthine segment. It is sometimes used in combination with the transmastoid approach in cases of temporal bone trauma. Critical landmarks for this approach include the superior semicircular canal, the greater superficial petrosal nerve, and “Bill’s bar” or the vertical crest separating the facial nerve from the superior vestibular nerve.
3. Translabyrinthine approach