Permanent facial disfigurement is often the source of great misery and suffering to the patient. Most physicians treat patients with facial palsy in a cavalier manner, not appreciating the seriousness of the problem from the patient's point of view. Unfortunately for most patients, thorough examination is not performed and adequate treatment is delayed or not provided at all. Prompt medical and surgical treatment as well as thorough evaluation including audiometric, vestibular, topognostic tests and imaging by MRI with gadolinium and CT scan of the temporal bone needs to be done. Neoplasms and tumors are the cause of paralysis in 15%. To avoid the risk of lasting facial deformity, surgical decompression of the entrapped edematous portion of the facial nerve must be performed before loss of nerve excitability occurs. This means that, for the best results, surgical facial nerve decompression must be performed within the first 5 days of onset of facial palsy.


Pulec—CHAPTER 41

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2. Yanagihara N, Mehle B. New Horizons in Facial Nerve Research and Facial Expression. Krueger.

3. Pulec J. Early decompression of the facial nerve in Bell's palsy. Ann OtolRinolLaryngol 1981;90:570-577

4. Kettle K. Peripheral Facial Palsy: Pathology and Surgery. Copenhagen: Munksgaard; 1959

5. Pulec JL. Bell's palsy: diagnosis, management and results of treatment. Laryngoscope 1975;84:483-492

6. Pulec JL. Total decomprsesion of the facial nerve. Laryngoscope 1966;76:1015-1028

7. Pulec JL. Total facial nerve decompression: technique to avoid complications. ENT J 1996;7:410-415

8. Pulec JL. Facial nerve: how to find it. ENT J 1993;10:677-682

9. Pulec JL. Facial nerve neuroma. ENT J 1994;10:1-20

10. Pulec JL. Facial nerve angioma. ENT J 1996;75:225-238

11. Pulec JL. Aggressive fibromatosis (fibrosarcoma) of the facial nerve. ENT J 1993;72:460-467, 470-472

12. Neely JG, Jekel JF, Chueng JY. Variations in maximum amplitude of facial expressions between and within normal subjects. Otolaryngol Head Neck Surg 1994;110:60-63

13. Helling TD, Neely JG. Validation of objective measures for facial paralysis. Laryngoscope 1997;107:1345-1349

14. Adour KK. Combination treatment with Acyclovir and prednisone for Bell palsy. Arch Otolaryngol Head Neck Surg 1988;124:824

15. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell's palsy. Laryngoscope 1999;109: 1177-1188

Acute Facial Paralysis

Douglas A. Chen and Moisés A. Arriaga


The most common causes of acute unilateral facial paralysis include Bell's palsy and trauma to the temporal bone. The physical as well as emotional liability it produces can be devastating. Accurate evaluation and proper management can reduce the sequelae the patient may sustain. Because most facial palsies are associated with some spontaneous resolution, the evaluation of various treatment modalities has been problematic.

Important prognostic and management implications can be determined by means of accurate observation at the time of initial physical examination, with documentation of any degree of facial function that subsequently deteriorates. The House-Brackmann classification grading facial paralysis has been widely accepted and is recommended by the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS).1

By definition, patients with Bell's palsy have idiopathic facial paralysis with no other identifiable cause. Fortunately, most patients with Bell's palsy have a satisfactory recovery, but 15 to 20% will have significant sequelae. Facial paralysis associated with the unilateral auditory or vestibular symptoms should be evaluated to rule out retrocochlear pathology. In addition, recurrent ipsilateral Bell's palsy, or one that has a poor outcome after 6 months, should be imaged. Whether all patients with Bell's palsy require an imaging procedure is debatable.

Patients with facial paralysis secondary to temporal bone trauma frequently have other life-threatening injuries, making facial nerve evaluation a low priority, and simply not possible in other cases. Frequently, the otolaryngologist is consulted several days after the initial trauma, confounding the important assessment of whether the facial paralysis was complete, of immediate onset, or a partial delayed progressive paralysis. The timing of this assessment is critical, especially in extratemporal facial nerve injuries, because surgical exploration is facilitated substantially by intraoperative electrical stimulation, which can only be done up to approximately 3 days after injury.

Temporal bone imaging after traumatic facial paralysis, especially for intratemporal injuries, provides important information required for subsequent decision making. Although axial computed tomography (CT) scan of the head has usually already been performed, it is usually inadequate for evaluation of the temporal bone. CT scan of the temporal bone should be done in 1-mm-thin cuts in axial and coronal planes. The full course of the nerve should be evaluated. Cervical spine injury may prevent coronal CT scanning of the temporal bone. Magnetic resonance imaging (MRI) for evaluation of facial nerve trauma has not been helpful in our experience.

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