The patient who has iatrogenic facial paralysis is usually noted to have facial paralysis in the recovery room immediately after surgery. The temporal relationship between the surgery and the onset of paralysis obviously suggests that the surgical procedure is the cause of paralysis.
The first step in the management of these patients is to consider each step of the procedure and the possible involvement of the facial nerve. Reasonable time should be given for the effects of local anesthesia to dissipate. In addition, if the ear or mastoid cavity was packed with firm material, this should be loosened to provide an opportunity for any direct pressure on the nerve to dissipate as well. After a few hours to allow these maneuvers to take effect, if the paralysis persists, consideration should be given to exploration of the facial nerve. Volitional EMG potentials may be helpful at this time. Evidence of volitional motor action potential corroborates an intact nerve that will recover with time.
Immediate postoperative facial paralysis is an emotionally charged situation for the patient as well as the surgeon. The surgeon should readily seek consultation in this situation and should preferably perform the facial nerve exploration in conjunction with another surgeon who has particular expertise in the facial nerve surgery. This provides the additional objectivity of another observer, as well as a surgeon who is less emotionally involved in the decision-making process. The presence of another surgeon acting as a co-observer to record findings and decision making in a more objective fashion also has potential medicolegal ramifications. In addition, although prompt exploration is indicated, waiting until the next morning for a complete fresh surgical team is preferable to subjecting the patient to a same-day operation with a team that is either tired or incomplete.
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