Department of Otolaryngology-Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India.
Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
JAMA Otolaryngol Head Neck Surg. 2018 Apr 1;144(4):315-321. doi: 10.1001/jamaoto.2017.3147.
Current recommendations envisage early surgical exploration for complete facial nerve paralysis associated with temporal bone fracture and unfavorable electrophysiologic features (response to electroneuronography, <5%). However, the evidence base for such a practice is weak, with the potential for spontaneous improvement being unknown, and the expected results from alternative nonsurgical treatment also undefined.
To document the results of nonsurgical treatment for posttraumatic complete facial paralysis with undisplaced temporal bone fracture and unfavorable electrophysiologic features.
DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study recruiting from April 2010 to April 2013 at a tertiary care university hospital. Follow-up continued until 9 months or until complete recovery if earlier. Study group included 28 patients with head injury-associated complete unilateral facial nerve paralysis with unfavorable results of electroneuronography (<5% response) with or without undisplaced temporal bone fracture. Undisplaced temporal bone fractures were documented in 26 patients (24 longitudinal fractures and 2 transverse fractures).
Patients received prednisolone, 1 mg/kg, for 3 weeks combined with clinical monitoring every 2 weeks and electromyography monitoring every 4 weeks. As per study protocol, surgical exploration was limited to patients demonstrating motor end plate degeneration on results of electromyography, or having no improvement until 18 weeks.
Facial nerve function was evaluated by the House-Brackmann grading system; Forehead, Eye, Mouth, and Associated defect grading system; and the modified Adour system. Observations were completed at 40 weeks.
Among the 28 patients in the study (3 women and 25 men; mean [SD] age, 32.2 [8.7] years), facial nerve recovery with conservative treatment alone was noted in all patients. No recovery was seen in any patient at the initial 4-week review. The first signs of clinical recovery were noted in 4 patients by 8 weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks. No patient required surgical exploration. At 40 weeks, 27 patients recovered to House-Brackmann grade I/II and 1 patient to grade III. All 24 patients with longitudinal fractures had grade I/II recovery.
For undisplaced temporal bone fractures, nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results. Recovery is delayed and usually first manifests at 8 to 12 weeks after the fracture. In the current era of high-resolution computed tomography, surgical exploration should not be first-line treatment for undisplaced longitudingal temporal bone fractures associated with complete facial nerve paralysis and unfavorable electrophysiologic features.
目前的建议设想对伴有颞骨骨折和不利电生理特征（电神经图反应，<5%）的完全面神经麻痹进行早期手术探查。然而，这种做法的证据基础薄弱，不知道是否存在自发改善的可能性，也不清楚替代非手术治疗的预期结果。
记录无移位颞骨骨折和不利电生理特征的外伤性完全性面瘫的非手术治疗结果。
设计、地点和参与者：前瞻性队列研究，于 2010 年 4 月至 2013 年 4 月在一家三级护理大学医院进行。随访持续到 9 个月或更早出现完全恢复。研究组包括 28 例因头部外伤导致的单侧完全性面神经麻痹，电神经图结果（<5%反应）不佳，伴有或不伴有无移位的颞骨骨折。26 例患者（24 例纵向骨折和 2 例横向骨折）有未移位的颞骨骨折。
患者接受泼尼松龙，1mg/kg，治疗 3 周，同时每 2 周进行临床监测，每 4 周进行肌电图监测。根据研究方案，仅对肌电图结果显示运动终板退化的患者或在 18 周内无改善的患者进行手术探查。
采用 House-Brackmann 分级系统、额、眼、口和相关缺陷分级系统和改良 Adour 系统评估面神经功能。观察在 40 周时完成。
在研究的 28 例患者（3 名女性和 25 名男性；平均[SD]年龄，32.2[8.7]岁）中，单独采用保守治疗即可恢复面神经功能，所有患者均如此。在最初的 4 周复查中，没有患者出现恢复。4 例患者在 8 周时首次出现临床恢复迹象，27 例患者在 12 周时出现恢复迹象，所有患者在 20 周时出现恢复迹象。没有患者需要手术探查。在 40 周时，27 例患者恢复至 House-Brackmann 分级 I/II 级，1 例患者恢复至 III 级。所有 24 例纵向骨折患者均恢复至 I/II 级。
对于无移位的颞骨骨折，非手术治疗可导致接近普遍恢复至 House-Brackmann I/II 级，优于报道的手术结果。恢复是延迟的，通常在骨折后 8 至 12 周首次出现。在高分辨率计算机断层扫描时代，手术探查不应该是伴有不利电生理特征的完全性面神经麻痹和无移位纵向颞骨骨折的一线治疗方法。
