Surgical management of Bell's palsy.
OBJECTIVE
Incomplete return of facial motor function and synkinesis continue to be long-term sequelae in some patients with Bell's palsy. The aim of this report is to describe a prospective study in which a well-defined surgical decompression of the facial nerve was performed in a population of patients with Bell's palsy who exhibit the electrophysiologic features associated with poor outcomes. In addition, management issues related to Bell's palsy including herpes simplex virus typel etiology, the natural history, electrodiagnostic testing, and efficacy of surgical strategies are reviewed.


METHODS
A multicenter prospective clinical trial was designed utilizing electroneurography (ENOG) and voluntary electromyography (EMG) to identify patients with Bell's palsy who would most likely develop poor return of facial function, as suggested by Fisch and Esslen. Patients who displayed electrodiagnostic features of poor outcome, >90% degeneration on ENOG testing and no voluntary motor unit EMG potentials within 14 days of onset of total paralysis, were offered a surgical decompression of the facial nerve through a middle cranial fossa surgical exposure, including the tympanic segment, geniculate ganglion, labyrinthine segment, and meatal foramen. Control subjects were those who displayed similar electrodiagnostic features and time course.


RESULTS
Subjects who did not reach 90% degeneration on ENOG within 14 days of paralysis all returned to House-Brackmann grade I (n = 48) or II (n = 6) at 7 months after onset of the paralysis. Control subjects self-selecting not to undergo surgical decompression when >90% degeneration on ENOG and no motor unit potentials on EMG were identified had a 58% chance of developing a poor outcome at 7 months after onset of paralysis (House-Brackmann grade III or IV [n = 19]). A group with similar ENOG and EMG findings undergoing middle fossa facial nerve decompression exhibited House-Brackmann grade I (n = 14) or II (n = 17) in 91% of the cases. An exact permutation test confirmed that the surgical group had a significantly higher proportion of patients with a good outcome (House-Brackmann grade I or II) (P = .0002).


CONCLUSIONS
Electroneurography in combination with voluntary EMG successfully identified patients who will most likely return to normal from those who had a greater chance of long-term sequelae from Bell's palsy. Surgical decompression medial to the geniculate ganglion significantly improves the chances of normal or near-normal return of facial function in the group that has a high probability of a poor result. Surgical decompression must be performed within 2 weeks of onset of total paralysis for it to be effective.
Gantz
B J
BJ
Department of Otolaryngology-Head and Neck Surgery, University of Iowa College of Medicine, Iowa City, USA.
Rubinstein
J T
JT
Gidley
P
P
Woodworth
G G
GG
D000328:Adult; D000368:Aged; D000465:Algorithms; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D019299:Decompression, Surgical / Q000379:methods; D018450:Disease Progression; D004558:Electric Stimulation / Q000379:methods; D004576:Electromyography / Q000379:methods; D005154:Facial Nerve / Q000503:physiopathology / Q000601:surgery; D005158:Facial Paralysis / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009410:Nerve Degeneration / Q000175:diagnosis; D009474:Neurons / Q000502:physiology; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D013256:Steroids; D013997:Time Factors
D000893:Anti-Inflammatory Agents; D013256:Steroids