Lehigh Valley Health Network-LVHN, Institute for Surgical Excellence, Otolaryngology Head & Neck Surgery, Allentown, Pennsylvania.
Cleveland Clinic Foundation, Department of Otolaryngology Head & Neck Surgery Cleveland, Ohio, USA.
Curr Opin Otolaryngol Head Neck Surg. 2024 Oct 1;32(5):294-300. doi: 10.1097/MOO.0000000000001007. Epub 2024 Aug 26.
This systematic review investigates the recent literature and aims to determine the approach, efficacy, and timing of facial nerve decompression with or without grafting in temporal bone fractures with facial palsy.
The surgical management of facial palsy is reserved for a small population of cases in which electrophysiologic tests indicate a poor likelihood of spontaneous recovery. The transmastoid (TM), middle cranial fossa (MCF), and translabyrinthine (TL) approaches to the facial nerve provide access to the entire intracranial and intratemporal segments of the facial nerve. In temporal bone (TB) related facial palsy, the peri-geniculate and labyrinthine portions of the facial nerve are most commonly affected by either direct trauma and/or subsequent edema. When hearing is still serviceable, the combined TM/MCF approach provides the best access to these regions. In the presence of severe sensorineural hearing loss (SNHL), the TL approach is the most appropriate for total facial nerve exploration (this can be done in conjunction with simultaneous cochlear implantation if the cochlear nerve has not been avulsed). Grade I to III House-Brackmann (HB) results can be anticipated in timely decompression of facial nerve injury caused by edema or intraneuronal hemorrhage. Grade III outcomes, with slight weakness and synkinesis, is the outcome to be expected from the use of interpositional grafts or primary neurorrhaphy. In addition to good eye care and the use of systemic steroids (if not contraindicated in the acute trauma setting), surgical decompression with or without grafting/neurorrhaphy may be offered to patients with appropriate electrophysiologic testing, physical examination findings, and radiologic localization of injury.
Surgery of the facial nerve remains an option for select patients. Here, we discuss the indications and results of treatment as well as the best surgical approach to facial nerve determined based on patient's hearing status and radiologic data. Controversy remains about whether timing of surgery (e.g., immediate vs. delayed intervention) impacts outcomes. However, no one with facial palsy due to a temporal bone fracture should be left with a complete facial paralysis.
本系统综述调查了近期文献，旨在确定伴有或不伴有移植的面神经减压术在颞骨骨折伴面瘫中的方法、疗效和时机。
面神经手术治疗仅保留用于一小部分电生理检查提示自发恢复可能性较小的病例。经乳突（TM）、中颅窝（MCF）和经迷路（TL）面神经入路可到达面神经的整个颅内和颞内段。在颞骨（TB）相关面瘫中，面神经的围神经节和迷路段最常受到直接创伤和/或随后的水肿的影响。当听力仍可用时，TM/MCF 联合入路提供了到达这些区域的最佳途径。在存在严重感音神经性听力损失（SNHL）的情况下，TL 入路最适合进行面神经总探查（如果耳蜗神经未撕裂，可与同期耳蜗植入同时进行）。由于水肿或神经元内出血引起的面神经损伤及时减压，可预期达到 I 至 III 级 House-Brackmann（HB）结果。使用间隔移植或直接神经吻合术，可预期达到 III 级结果，即仅有轻微无力和联带运动。除了良好的眼部护理和全身使用类固醇（如果在急性创伤情况下不被禁忌）外，如果患者的电生理检查、体格检查结果和损伤的影像学定位合适，可考虑进行手术减压伴或不伴移植/神经吻合术。
面神经手术仍然是一些患者的选择。在这里，我们讨论了基于患者的听力状况和影像学数据，手术治疗的适应证和结果以及面神经的最佳手术入路。手术时机（例如，立即干预与延迟干预）是否影响结果仍存在争议。然而，任何由于颞骨骨折而导致面瘫的患者都不应该完全面瘫。
