Real Examples of Results

RESULTS WITH ADEQUATE TREATMENT

A 24-year-old woman awoke one morning with a complete right facial palsy and right ear pressure. She had had a cold 1 week before for which she was taking tetracycline, 250 mg qid. She immediately consulted an otologist, who treated her with prednisone, 20 mg tid, and told her that recovery would be good. On the 9th day of palsy, another physician obtained an electromyelogram (EMG), which demonstrated facial nerve degeneration. At the direction of her uncle, a neurosurgeon, she was referred to the author. She was found to have a complete right facial palsy. Hilger nerve excitability test showed no activity on the right. The Schirmer tear test had 1.5-cm saturation of paper on the right. The electric taste test showed no reaction on the right. Audiogram for pure tones and speech discrimination was normal bilaterally.

Electronystagmography (ENG) showed a second-degree left-beating spontaneous nystagmus with normal caloric reactions. Impedance audiometry demonstrated absent stapedius reflexes on her right. Petrous pyramid imaging was within normal limits. The diagnosis of right Bell's palsy was made. On the 13th day postpalsy, a right facial nerve decompression from the stylomastoid foramen to the cochleariform process was performed. Edema 3+++ of the facial nerve was found extending from the tympanic segment near the midpoint of the footplate to the stylomastoid foramen. Facial motion began to return 7 weeks later. The face moved normally with no evidence of synkinesis when she was examined 14 weeks after surgery. Follow-up examination 9 months later indicated a perfect result, and she was very happy. This patient was very fortunate to have a good result despite delaying surgical decompression until nerve excitability had been lost.

The window of opportunity between the stage of neuro-praxia and the development of degeneration and scarring is fleeting and of uncertain length. The availability of a prognostic test to determine which patient will develop axon degeneration before it occurs would be ideal. As much as everyone would like to have such a test, unfortunately none exists. Surgical decompression performed when nerve excitability is normal will eliminate the risk of residual facial deformity. Decompression performed after loss of nerve excitability has occurred will minimize, but not always avoid, permanent poor results. The earlier surgery is done, the better the result, even in cases where the delay is months or years from the onset of complete palsy.

RESULTS WITHOUT EFFECTIVE TREATMENT

A significant number of patients (29% of Bell's palsy patients who develop complete palsy) who do not obtain surgical decompression of the nerve within 5 days of onset will have permanent disfigurement. The author has examined hundreds of patients with complaints of residual facial deformity years after their acute facial palsy. No surgery had been performed. For example, in one case, excessive closure of the eye was noted when she pursed her lips. When she attempted to close her eyes, the left side of her face simultaneously pulled strongly into an involuntary smile. Other patients have recovered good strength of all muscles but have significant synkinesis with excessive closure of the involved eye and distortion of the lower facial muscles. In some patients the eye fails to close.

Treatment for patients with these deformities involves the use of special training and facial exercises, as well as the judicial use of repeated Botox injections to paralyze unwanted facial muscle function. Most of these patients are unhappy with results of this type, but many physicians dismiss the problem as inconsequential and recommend neither thorough examination nor prompt surgical treatment at a time when surgery could prevent a bad result. It is human nature that patients wish to avoid or delay surgery until they are convinced that it is necessary. They are commonly advised to wait several weeks by a well-meaning relative, friend, or neighbor who made a good spontaneous recovery without treatment; 71% will. The problem is that 29% of all patients with untreated acute facial palsy will have not be so fortunate.1 Table 41-1 presents an algorithm for evaluating such cases of acute facial palsy.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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