Content uploaded by Hyung Chae Yang
Author content
All content in this area was uploaded by Hyung Chae Yang on Aug 05, 2015
Content may be subject to copyright.
A preview of the PDF is not available
Delayed Facial Nerve Paralysis after Tympanomastoid Surgery: The Potentiality of Fungal Infection and Treatment
Abstract and Figures
The purpose of this study was to assess the clinical courses and clinical outcomes of delayed facial nerve paralysis (DFNP) after middle ear and mastoid surgery.
Figures - uploaded by Hyung Chae Yang
Author content
All figure content in this area was uploaded by Hyung Chae Yang
Content may be subject to copyright.
ResearchGate has not been able to resolve any citations for this publication.
To investigate the clinical characteristics and outcome of fungal malignant external otitis (MEO).
The files of 60 patients treated for MEO in 1990-2008 at a tertiary medical center were reviewed for clinical characteristics and outcome, and findings were compared between patients with fungal and nonfungal infection.
Mean duration of follow-up was 4 years. Nine patients (15%) had fungal disease; the main pathogen was Candida spp. Compared with the nonfungal MEO group, patients with a fungal infection were younger at diagnosis (average 68 vs. 74 years, p = 0.01) and had more facial nerve palsies (55% vs. 14%, p = 0.01), fewer positive bacterial cultures at presentation (33% vs. 75%, p = 0.02), and higher rates of surgery (78% vs. 18%, p = 0.0008) and hyperbaric treatment (78% vs. 4%, p = 0.0001). Eighty-nine percent had persistent infection (>2 courses of systemic antibiotics before antifungal treatment) compared with 12% in the nonfungal group (p = 0.0001). Fungal disease was associated with more persistently positive imaging findings (87.5% vs. 25%, p = 0.0001). There was no significant between-group difference in survival.
Fungal MEO probably occurs secondary to prolonged antibiotic treatment for bacterial MEO. The fungal disease is more invasive than the bacterial disease, although survival is the same. Treatment should be aggressive and hyperbaric oxygen therapy should be considered.
The value of a preoperative swab for the treatment of postoperative infection after middle ear surgery was investigated. In a selected group of 80 patients with postoperative infection a preoperative swab was available, and the variability was analysed for each species. The well-known pathogens Pseudomonas aeruginosa, Staphylococcus aureus, Proteus and Escherichia coli showed good correlation between pre- and postoperative swabs. In contrast to this all other species found in preoperative swabs were of little value postoperatively. This observation is important for the treatment of infection after middle ear surgery, and should be considered if prophylactic antibiotics are planned.
This study aimed to review a single institution's experience with Clarion Multi-Strategy Cochlear Implant with respect to surgical technique, surgical complications, and rehabilitative outcome.
This study was a review of patients implanted with the Clarion Multi-Strategy Cochlear Implant.
The setting was a tertiary referral center with care delivered in the inpatient and outpatient environment.
The first 37 patients were implanted under an Investigational Device Exemption as part of the Food and Drug Administration (FDA) clinical trial of the Clarion implant. Subsequent patients were implanted after the device received FDA approval. Patients met the following criteria for implantation: 18 years of age or older, psychological and emotional stability, profound postlingual deafness without evidence of middle ear disease, one cochlea at least partially patent, and marginal or no benefit from conventional hearing aids.
Patients received implantation with the Clarion Multi-Strategy Cochlear Implant.
Measured were presence or absence of surgical complications and auditory performance with open- and closed-set word and sentence recognition testing.
A total of 47 patients have been implanted. Three patients have suffered complications: two cases of delayed-onset facial palsy both resolved with steroid therapy and one case of internal cochlear stimulator migration required refixation. Significant improvement in speech understanding has been seen in the majority of patients who were implanted within the first 6 months of device use. Specifically, at 6 months, scores on CID (Central Institute for the Deaf) sentences (implant alone) improved from a preoperative mean of 9% to a mean of 72%, and scores on the NU-6 (Northwestern University) monosyllabic word test increased from a preoperative mean of 3% (range, 0-20%) to a mean of 32% (range, 0-70%). More than two thirds (68%) of the adults were able to understand at least 50% of sentences over the telephone, and half were able to understand at least 75% of the sentence material.
The authors' institutional experience with the Clarion Multi-Strategy Cochlear Implant shows minimal surgical morbidity and significant improvement on all open-set test measures of sentence and word recognition.
The purpose of this report is to provide data on the incidence of delayed facial palsy (DFP) after tympanomastoid surgery, compare incidence among various otologic and neurotologic procedures, and discuss the possible etiology.
The study design was a retrospective case review.
The study was conducted at a tertiary referral center.
The records of 486 patients with normal facial function before tympanomastoid surgery were reviewed.
Patients underwent tympanomastoid surgery.
Delayed facial palsy was defined as facial palsy occurring more than 72 hours after surgery.
Seven of 486 (1.4%) patients had DFP after tympanomastoid surgery. In two patients, the DFP was caused by a postoperative wound infection. Facial palsy in the other five patients likely was caused by viral reactivation.
Published data for otologic surgery suggest a rising incidence of DFP with increased manipulation of the sensory branches of the facial nerve. Viral reactivation is postulated to be an important contributing mechanism in the development of DFP. A number of viruses could potentially cause this phenomenon, but observations in this study implicate the varicella zoster virus. Patients with a history of viral reactivation may be at greater risk for development of this complication.
Delayed facial paralysis after stapes surgery is uncommon and has been reported after traditional, nonlaser techniques for stapedotomy. The purpose of this paper is to inform the reader of the potential risk of delayed facial nerve paralysis associated with the use of the potassium titanyl phosphate (KTP) laser for stapedotomy. Etiologic mechanisms are discussed.
The study was a descriptive study-case report.
The study was conducted at a university-based otologic practice.
Two patients with otosclerosis and delayed onset facial palsy 5 to 7 days after uncomplicated stapedotomy using the KTP laser were included in the study.
Potassium titanyl phosphate laser stapedotomy was performed. Patients received treatment of facial palsy with a tapering course of oral steroids.
House-Brackmann facial nerve grade scores were used.
Improvement of House-Brackmann facial nerve scores from Grade VI to Grade I-II in one patient, and improvement from Grade IV to Grade I-II in the other was seen.
The probable etiology of delayed facial palsy is viral neuritis from reactivation of dormant virus within the facial nerve, initiated by thermal stress of the KTP laser. Presentation and resolution of the facial palsy is similar to other types of delayed facial palsy resulting from nonlaser techniques of stapes surgery and other types of middle ear and neurotologic surgeries previously reported.
To study the incidence, pathogenesis, and prevention of delayed facial palsy after stapedectomy.
Retrospective case review.
Otology/neurotology referral center.
A series of 2152 stapedectomy procedures in 2106 patients over 12 years.
Delayed facial palsy after stapedectomy was studied.
House-Brackmann facial nerve grading system and serum antibody titer tests for herpes simplex virus type I and type II, and varicella zoster virus.
Delayed facial palsy occurred in 11 of 2152 procedures. Delayed facial palsy occurred from 5 to 16 days (mean 8) after stapedectomy. Predisposing factors were bony facial canal dehiscence with bare or bulging facial nerve herniation in 5 patients; chorda tympani nerve stretched, manipulated, or cut in 2 patients; granulomatous reaction to Gelfoam in 1 patient; fever blisters on the upper lip in 1 patient; and sinusitis in 2 patients. Elevated anti-varicella antibody titers were found in all 6 patients studied. Anti-herpes simplex type I and II antibody titers were elevated in 5 of 6 patients. Acyclovir was effective in preventing delayed facial palsy in 1 patient who had undergone revision stapedectomy and experienced delayed facial palsy after previous stapedectomy in the same ear with elevated anti-herpes antibody titer.
Delayed facial palsy occurred in 0.51% of patients after stapedectomy. Serologic investigation suggests activation of latent herpesvirus. Mechanical irritation of the facial or chorda nerve during operation may trigger the activation. The anti-herpesvirus agent acyclovir may prevent delayed facial palsy after stapedectomy in patients suspected of having this complication.
The objectives of this study were to study the role of herpes virus reactivation in the onset of delayed facial paralysis (DFP) occurring more than 72 hours after vestibular schwannoma (VS) surgery and to advocate specific medical management.
We conducted a retrospective case review.
University-based, tertiary care center.
Eight patients managed for DFP in a series of 348 patients operated for a VS.
Patients were evaluated and graded according to the House and Brackmann grading system and followed up for 1 year. A serologic search for specific antiherpes simplex viruses type 1 and 2 (HSV-2) and varicella zoster virus (VZV) antibodies at the onset of DFP and 2 weeks later was possible in three cases. Seven of the eight patients were given intravenous acyclovir (30 mg/kg/ for 5 days) and methylprednisolone (2 mg.kg/ for 7 days).
Mean delay of DFP onset was 8.75 days. All treated patients had a House and Brackmann Grade 1 recovery: mean time to recovery was 40.4 days. The last one had only a Grade 3 recovery because he could not be treated because of postoperative transient psychiatric problems. Serologic testing in those patients in whom it could be done revealed either a high level of anti HSV or VZV antibodies at the time of onset or a dramatic increase in anti-HSV or anti-VZV antibodies between the two samples, strongly suggesting an HSV or VZV reactivation.
HSV or VZV reactivation might be responsible for most cases of DFPs, thus suggesting the usefulness of immediate steroid and acyclovir administration to obtain total recovery. The viral reactivation mechanism is comparable to that already suspected in DFP occurring with the same delay in middle ear surgical procedures.
To establish the frequency of occurrence of delayed facial nerve paralysis following tympano-mastoid surgery in our department and to determine the aetiological factors and long term prognosis.
Tertiary care academic centre.
A retrospective review of all patients who had undergone tympano-mastoid surgery in our department over the previous five years was carried out. A total of 219 patients were included in the study. Only two patients were identified as having delayed onset facial nerve palsy over this period of time. The patients' medical records were reviewed and the patients clinically assessed.
The frequency of delayed onset facial nerve palsy following tympano-mastoid surgery in our series was 0.91 per cent. Facial weakness set in on day eight and day 14 in the two patients. Serological investigations in both patients revealed raised titres of immunoglobulin (Ig) M and IgG to varicella-zoster virus, confirming the presence of varicella-zoster infection. In our experience, the combined use of prednisone and acyclovir was an effective form of treatment for both patients, whose facial nerve function fully recovered within six months of onset.
The incidence of delayed facial nerve palsy following tympano-mastoid surgery is low. It can occur up to two weeks after the surgery. Our two cases confirm viral reactivation to be an important aetiological factor in the development of delayed onset facial nerve palsy. The overall prognosis for delayed facial nerve palsy following tympano-mastoid surgery appears to be good.
To describe the level of neurologic impairment in a case of delayed facial palsy occurring after cochlear implantation surgery.
A 58-year-old man undergoing cochlear implantation who was found intraoperatively to have congenital bifurcation of the facial nerve just distal to the second genu.
Cochlear implantation was performed through a facial recess approach.
The lateral branch of the nerve impinged on the posterior tympanotomy slot and was uncovered during the procedure, rendering it vulnerable to direct thermal or mechanical injury or to the effects of local tissue injury products. The patient developed facial palsy 9 days later, affecting all facial muscle groups equally.
Theories regarding the cause of delayed facial palsy after cochlear implantation include direct thermal or mechanical injury to the nerve, local effects of blood breakdown products or other mediators causing vasospasm, and reactivation of latent herpes virus, leading to neural inflammation and neuropathy of the geniculate and labyrinthine segments of the nerve. The fact that the patient developed weakness that affected all facial muscle groups equally suggests that the level of neurologic impairment was proximal to the nerve bifurcation, so distant to the actual site of surgery. This finding lends support for the viral hypothesis of delayed nerve palsy.