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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
(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 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