The case of an anatomically intact facial nerve, but with evidence of electrical degeneration, presents a therapeutic dilemma, regardless of whether trauma or Bell's palsy is the cause. Some degree of spontaneous recovery without any therapy would be expected in this setting, and so arises the controversy in treatment. Although treatment with steroids or antiviral agents, or both, depending on etiology, may improve outcomes in high-risk patients, the literature is still incomplete. In our opinion, the possible benefits of treatment despite potential side effects are worth the risk. Until further research is completed, however, we remain cautious in our recommendations of the possible benefits of facial nerve decompression.

Anatomic disruption of the facial nerve is an absolute indication for exploration and possible grafting. Determining the extent of injury preoperatively with CT scans and electrical testing can be difficult. Even with direct inspection during surgery, an accurate determination can be difficult because of disease, traumatic anatomic distortion, and surgeon bias.


Chen and Arriaga—CHAPTER 42

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