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Outcomes of pediatric delayed facial palsy after head trauma
G Model
ANL-2363; No. of Pages 4 Auris Nasus Larynx xxx (2017) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Outcomes of pediatric delayed facial palsy after head trauma Liping Li a, Peng Xu a, Aiyan Jin a, Wenna Zuo a, Xiaoming Su a, Hongqin Wang a, Yefeng Li b, Xue Jiang a,* a b
Department of Otolaryngology, Cangzhou Central Hospital, Cangzhou 061001, Hebei, PR China Department of Otolaryngology Head and Neck Surgery, Peking University Health Science Center, Beijing 100191, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 March 2017 Accepted 13 September 2017 Available online xxx
Objective: To analyze clinical outcomes of delayed facial palsy after head trauma in the pediatric population. Methods: A total of 45 pediatric cases with delayed facial palsy after head trauma were conservatively or surgically treated in our hospital between January 2009 and January 2015, and they were followed up for one year after the corresponding treatment. The clinical data were collected and the outcomes of facial nerve were analyzed. Results: During the one-year follow-up, 33 cases (82.5%) completely recovered, and 5 cases (12.5%) recovered to Grade II among the 40 cases accepting conservative treatment. For the 5 surgically treated cases, 4 cases (80.0%) recovered to Grade I or Grade II, and one case recovered to Grade III. Conclusion: The outcomes of pediatric delayed facial palsy after head trauma were generally satisfactory. © 2017 Published by Elsevier Ireland Ltd.
Keywords: Head trauma Delayed facial palsy Pediatric Clinical outcomes
1. Introduction Head trauma is common in children and the incidence of facial nerve injury after head trauma ranges from 7% to14.8% [1,2], with either immediate or delayed onset. Delayed facial palsy is defined as onset of facial palsy symptoms at least 48 h after the trauma [3]. There have been some reports about delayed facial palsy in adults after head trauma [3–5]. However, we did not find any reports focusing on pediatric delayed facial palsy after head trauma. Therefore, we retrospectively analyzed 45 children with delayed facial palsy after head trauma treated at our hospital from January 2009 to January 2015 and aimed to
* Corresponding author. E-mail address: [email protected] (X. Jiang).
present the outcomes of facial nerve among the pediatric population. 2. Materials and methods 2.1. Materials Forty five pediatric cases who developed delayed facial palsy among 2120 pediatric cases admitted due to head trauma from January 2009 to January 2015 at our hospital were reviewed retrospectively, and 225 pediatric cases with immediate facial palsy after head trauma were excluded in this study. Symptoms of facial nerve injury gradually appeared at least 48 h after trauma, including weakness of eyelid closure on the affected side, shallowing or disappearance of wrinkles on the forehead on the affected side, shallowing of the nasolabial groove, tilting of the mouth corner towards the affected side,
http://dx.doi.org/10.1016/j.anl.2017.09.012 0385-8146/© 2017 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
G Model
ANL-2363; No. of Pages 4 L. Li et al. / Auris Nasus Larynx xxx (2017) xxx–xxx
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and loss of taste sensation at the anterior 2/3 of the tongue on the affected side. 2.2. Auxiliary examinations All cases received high-resolution CT (HRCT) of the temporal bone and brain CT. They also underwent facial electroneurography (ENoG) within 2 weeks of facial palsy onset, pure tone audiometry, Schirmer’s test and taste test so as to determine the severity and position of facial nerve injury. Titers of virus were not examined in the present study, since the facial palsy in our study was thought to be related to trauma other than virus infection. 2.3. Treatment of delayed facial palsy All cases took oral prednisolone tablets within 3 days after facial palsy onset at the dosage of 1 mg/(kg d) (the maximum dosage was 80 mg), once per day, for one week. The dosage was then decreased by 10 mg every two days. Total facial nerve decompression (middle cranial fossa combined with transmastoid approach) was given to the cases who showed more than 90% degeneration of nerve fibers revealed by ENoG. 2.4. Facial nerve function evaluation House–Brackmann (HB) grading system was used for facial nerve function evaluation [6]. Before treatment, 4 cases were classified as Grade VI, 10 cases as Grade V, 26 cases as Grade IV, and 5 cases as Grade III. 3. Result Of the 45 children with delayed facial palsy after head trauma, 31 cases were males and 14 cases were females, aged 4– 14 years old (average, 6 5.6 years). Facial palsy appeared on day 3–7 in 30 cases, day 8–14 in 10 cases, and day 15–21 in 5 cases (Fig. 1). And the mean period of delay was 7.2 4.8 days (range, 3–21 days). 28 cases were caused by car accident and 17 by falling from the height. All of them reported an explicit history of head trauma and they were sent to hospital within 24 h after injury. 30 cases had different degrees of coma, and 13 cases lost consciousness. Ear and nose bleeding were noticed in 24 cases and 6 cases, respectively.
Radiological examinations showed that there were 15 cases (33.3%) with temporal bone fractures, and 7 cases with cerebral contusion with dispersive hemorrhage. Fracture lines were not observed at the fallopian canal among the 30 cases with temporal bone fractures. According to ENoG of facial nerve, 40 cases had less than 90% degeneration of nerve fibers and 5 cases had greater than 90% degeneration. Pure tone audiometry showed that 25 cases had conductive hearing loss on the affected side, with hearing loss of 25–50 dB in speech frequencies (500 Hz, 1000 Hz and 2000 Hz), 4 cases had moderate to severe sensorineural hearing loss, and 24 cases had normal hearing. 21 cases had decreased secretion of tears on the affected side and 28 cases had taste loss on the affected side. All the cases were followed up for one year. Among the 40 cases receiving conservative treatment, 29 of 40 cases (72.5%) completely recovered within one month, 2 cases (5%) recovered to Grade I between one month and two months, and 1 case recovered to Grade I between two months and three months. One year later, 38 of 40 cases (95%) recovered to Grade I or Grade II (good recovery). Specifically, 33 cases (82.5%) completely recovered, and 5 cases (12.5%) recovered to Grade II (Table 1). Only 5 of 45 cases who showed more than 90% degeneration of nerve fibers revealed by ENoG underwent total facial nerve decompression. Among the 5 cases receiving surgical decompression, edema of facial nerve was found in all the 5 cases, and micro-bony spicules were found in 1 case (20.0%). For the 5 surgically treated cases, one case recovered to Grade I (Fig. 2), three cases recovered to Grade II, and one case recovered to Grade III, with a good recovery rate of 80.0% (Table 2). No cases developed obvious complications due to surgical procedures. Only one of the five cases developed synkinesis, and none of the five cases showed contracture. 4. Discussion Facial palsy following head trauma may be immediate or delayed. Sometimes, it is difficult to identify immediate or delayed facial palsy when the patient is in deep coma. Actually, we could not exclude the possibility that few immediate facial palsy cases might be contained in this study because of deep coma. The immediate onset of facial palsy after head trauma is mainly caused by temporal bone fractures which compress or transect facial nerve, while the reasons of delayed facial palsy are much more complicated. In our study, HRCT revealed temporal bone fractures in only 33% cases. Delayed facial palsy may be caused by fierce shock injury and subsequent edema of facial nerve or micro-bony spicules which are not revealed by high-resolution CT [5]. Sanus et al. [3] performed surgical exploration and decompression on 13 cases who had delayed facial palsy without gross temporal bone fractures on HRCT, Table 1 Facial nerve function of 40 pediatric cases before and after conservative treatment (one year later).
Fig. 1. Onset distribution of pediatric delayed facial palsy after head trauma. Facial palsy appeared on day 3–7 in 30 cases, day 8–14 in 10 cases, and day 15– 21 in 5 cases.
HB grade
I
II
III
IV
V
VI
Before treatment After treatment
0 33
0 5
5 1
26 0
8 0
1 0
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
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Fig. 2. Recovery of one child with delayed facial palsy after head trauma. This case was found to have delayed facial palsy at the fourth day after head trauma (falling from the height with the occipital portion touching the earth), with the worst facial nerve function of Grade V before treatment (A). She recovered completely at 1 year after total facial nerve decompression (B).
and found edema in all patients and noticed micro-bony spicules in 4 cases (30.8%). In our study, among the 5 cases receiving surgical decompression, edema of facial nerve was found in all the 5 cases, and micro-bony spicles were found in 1 case (20.0%), similar to Sanus’s findings [3]. High-resolution CT of the temporal bone can clearly show the exact course of fracture lines of the temporal bone, although it is not reliable in revealing fractures at pyramid segment and mastoid segment [7–13]. MRI is better than HRCT in showing edema and hematoma of the facial nerve [14], although it was not performed on each case in our study. ENoG is quite significant for determining conservative treatment or surgical decompression, because it is widely accepted that surgical intervention is necessary for delayed traumatic facial palsy with more than 90% degeneration of nerve fibers revealed by ENoG [15–17]. In our study, surgical decompression was performed only on the 5 cases with over 90% degeneration of nerve fibers revealed by ENoG. Regarding to the extent of facial nerve decompression, we recommend total facial nerve decompression although some authors may choose small area decompression for traumatic facial palsy. Since micro-bony spicules may be found in some delayed facial palsy cases [3], it may well ignore the micro-bony spicules if only small area decompression is adopted. Moreover, surgery revealed that edema affected the geniculate ganglion, labyrinthine segment, horizontal segment and mastoid segment of facial nerve. Thus, we think small area decompression may be insufficient. Of course, our opinion remains to be validated by well-designed comparative studies. For the vast majority cases with delayed facial palsy, surgical decompression is not required, and conservative treatment is enough. Prednisolone is still the standard therapy for delayed facial palsy, although neuroprotective effects of other agents, such as TJ-23 (tokishakuyakusan) and vitamin E, have been reported in peripheral facial nerve injury of animal models [18]. The outcomes of pediatric delayed facial palsy after head trauma by conservative treatment were excellent in Table 2 Facial nerve function of 5 pediatric cases before and after surgical treatment (one year later). Before treatment After treatment HB grade
0 1 I
0 3 II
0 1 III
0 0 IV
2 0 V
3 0 VI
our study. 72.5% of the cases completely recovered within one month after conservative treatment. After one-year follow-up, up to 82.5% cases completely recovered, and 12.5% cases recovered to Grade II. According to Li et al.’s study [5], 81.8% adult cases with who accepted conservative treatment for delayed facial palsy after head trauma fully recovered, and 9.1% recovered to Grade II during the one-year follow-up. It seemed that outcomes of pediatric delayed facial palsy after head trauma were not different from those of adult delayed facial palsy after head trauma, both of which were generally good. For the cases with pediatric delayed facial palsy who met the surgical indication, the outcomes following surgery were acceptable. In our study, 80.0% of the cases recovered to Grade I or II one year after surgical decompression. It appeared that outcomes of delayed facial palsy related to various diseases were generally satisfactory after conservative or surgical treatment. As mentioned above, outcomes of both pediatric and adult cases with delayed facial palsy after head trauma were satisfactory. Xu et al. reported that all cases with delayed facial palsy after tympanomastoid surgery recovered completely within two months [19]. Similarly, outcomes of delayed facial palsy after microvascular decompression for hemifacial spasm were fairly good [20]. Moreover, outcomes of delayed facial palsy after cochlear implantation were also excellent, with a recovery rate of 90.5% [21]. Therefore, pediatric delayed facial palsy after head trauma has good prognosis after corresponding treatment. References [1] Ort S, Beus K, Isaacson J. Pediatric temporal bone fractures in a rural population. Otolaryngol Head Neck Surg 2004;131(4):433–7. [2] Holsti M, Kadish HA, Sill BL, Firth SD, Nelson DS. Pediatric closed head injuries treated in an observation unit. Pediatr Emerg Care 2005;21 (10):639–44. [3] Sanus GZ, Tanriverdi T, Tanriover N, Ulu MO, Uzan M. Hearing preserved traumatic delayed facial nerve paralysis without temporal bone fracture: neurosurgical perspective and experience in the management of 25 cases. Surg Neurol 2009;71(3):304–10. [4] Puvanendran K, Vitharana M, Wong PK. Delayed facial palsy after head injury. J Neurol Neurosurg Psychiatry 1977;40(4):342–50. [5] Li Q, Jia Y, Feng Q, Tang B, Wei N, Zhang Y, et al. Clinical features and outcomes of delayed facial palsy after head trauma. Auris Nasus Larynx 2016;43(5):514–7. [6] House JW, Brackmann DF. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93(2):146–7.
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
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[7] Rotondo M, D’Avanzo R, Natale M, Conforti R, Pascale M, Scuotto A. Post-traumatic peripheral facial nerve palsy: surgical and neuroradiological consideration in five cases of delayed onset. Acta Neurochir (Wien) 2010;152(10):1705–9. [8] Swartz JD, Daniels DL, Harnsberger HR, Shaffer KA, Mark L. The temporal bone. Am J Neuroradiol 1996;17(1):201–4. [9] Yamaki T, Yoshino E, Higuchi T, Horikawa Y, Hirakawa K. Value of high-resolution computed tomography in diagnosis of petrous bone fracture. Surg Neurol 1986;26(6):551–6. [10] Schubiger O, Valavanis A, Stuckmann G, Antonucci F. Temporal bone fractures and their complications. Examination with high resolution CT. Neuroradiology 1986;28(2):93–9. [11] Chen SS, Lao CB, Chiang JH, Chang CY, Lirng F, Guo WY, et al. High resolution computed tomography of temporal bone fracture. Zhonghua Yi Xue Za Zhi (Taipei) 1998;61(3):127–33. [12] Rajati M, Pezeshki Rad M, Irani S, Khorsandi MT, Motasaddi Zarandy M. Accuracy of high-resolution computed tomography in locating facial nerve injury sites in temporal bone trauma. Eur Arch Otorhinolaryngol 2014;271(8):2185–9. [13] Guo A, Li S, Qin Z, Lu W, Jiang L. The diagnostic value of high resolution CT in assessment of temporal bone traumatic facial nerve paralysis. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2009;23 (22):1011–3.
[14] Sartoretti-Schefer S, Scherler M, Wichmann W, Valavanis A. Contrastenhanced MR of the facial nerve in patients with posttraumatic peripheral facial nerve palsy. Am J Neuroradiol 1997;18(6):1115–25. [15] Fisch U. Possibilities of microsurgery of the petrous bone and the base of the skull. Ther Umsch 1987;44(2):102–8. [16] Quaranta A, Campobasso G, Piazza F, Quaranta N, Salonna I. Facial nerve paralysis in temporal bone fractures: outcomes after late decompression surgery. Acta Otolaryngol 2001;121(5):652–5. [17] Ulug T, Arif Ulubil S. Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures. Am J Otolaryngol 2005;26(4):230–8. [18] Ito M, Ohbayashi M, Furukawa M, Okoyama S. Neuroprotective effects of TJ-23 (Tokishakuyakusan) on adult rat motoneurons following peripheral facial nerve axotomy. Otolaryngol Head Neck Surg 2007;136(2):225–30. [19] Xu P, Liu W, Zuo W, Wang D, Wang H. Delayed facial palsy after tympanomastoid surgery: a report of 15 cases. Am J Otolaryngol 2015;36(6):805–7. [20] Hua Z, Da TY, Hui WX, Tingting Y, Jin Z, Yan Y, et al. Delayed facial palsy after microvascular decompression for hemifacial spasm. J Craniofac Surg 2016;27(3):781–3. [21] Alzhrani F, Lenarz T, Teschner M. Facial palsy following cochlear implantation. Eur Arch Otorhinolaryngol 2016;273(12):4199–207.
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
ANL-2363; No. of Pages 4 Auris Nasus Larynx xxx (2017) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Outcomes of pediatric delayed facial palsy after head trauma Liping Li a, Peng Xu a, Aiyan Jin a, Wenna Zuo a, Xiaoming Su a, Hongqin Wang a, Yefeng Li b, Xue Jiang a,* a b
Department of Otolaryngology, Cangzhou Central Hospital, Cangzhou 061001, Hebei, PR China Department of Otolaryngology Head and Neck Surgery, Peking University Health Science Center, Beijing 100191, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 March 2017 Accepted 13 September 2017 Available online xxx
Objective: To analyze clinical outcomes of delayed facial palsy after head trauma in the pediatric population. Methods: A total of 45 pediatric cases with delayed facial palsy after head trauma were conservatively or surgically treated in our hospital between January 2009 and January 2015, and they were followed up for one year after the corresponding treatment. The clinical data were collected and the outcomes of facial nerve were analyzed. Results: During the one-year follow-up, 33 cases (82.5%) completely recovered, and 5 cases (12.5%) recovered to Grade II among the 40 cases accepting conservative treatment. For the 5 surgically treated cases, 4 cases (80.0%) recovered to Grade I or Grade II, and one case recovered to Grade III. Conclusion: The outcomes of pediatric delayed facial palsy after head trauma were generally satisfactory. © 2017 Published by Elsevier Ireland Ltd.
Keywords: Head trauma Delayed facial palsy Pediatric Clinical outcomes
1. Introduction Head trauma is common in children and the incidence of facial nerve injury after head trauma ranges from 7% to14.8% [1,2], with either immediate or delayed onset. Delayed facial palsy is defined as onset of facial palsy symptoms at least 48 h after the trauma [3]. There have been some reports about delayed facial palsy in adults after head trauma [3–5]. However, we did not find any reports focusing on pediatric delayed facial palsy after head trauma. Therefore, we retrospectively analyzed 45 children with delayed facial palsy after head trauma treated at our hospital from January 2009 to January 2015 and aimed to
* Corresponding author. E-mail address: [email protected] (X. Jiang).
present the outcomes of facial nerve among the pediatric population. 2. Materials and methods 2.1. Materials Forty five pediatric cases who developed delayed facial palsy among 2120 pediatric cases admitted due to head trauma from January 2009 to January 2015 at our hospital were reviewed retrospectively, and 225 pediatric cases with immediate facial palsy after head trauma were excluded in this study. Symptoms of facial nerve injury gradually appeared at least 48 h after trauma, including weakness of eyelid closure on the affected side, shallowing or disappearance of wrinkles on the forehead on the affected side, shallowing of the nasolabial groove, tilting of the mouth corner towards the affected side,
http://dx.doi.org/10.1016/j.anl.2017.09.012 0385-8146/© 2017 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
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ANL-2363; No. of Pages 4 L. Li et al. / Auris Nasus Larynx xxx (2017) xxx–xxx
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and loss of taste sensation at the anterior 2/3 of the tongue on the affected side. 2.2. Auxiliary examinations All cases received high-resolution CT (HRCT) of the temporal bone and brain CT. They also underwent facial electroneurography (ENoG) within 2 weeks of facial palsy onset, pure tone audiometry, Schirmer’s test and taste test so as to determine the severity and position of facial nerve injury. Titers of virus were not examined in the present study, since the facial palsy in our study was thought to be related to trauma other than virus infection. 2.3. Treatment of delayed facial palsy All cases took oral prednisolone tablets within 3 days after facial palsy onset at the dosage of 1 mg/(kg d) (the maximum dosage was 80 mg), once per day, for one week. The dosage was then decreased by 10 mg every two days. Total facial nerve decompression (middle cranial fossa combined with transmastoid approach) was given to the cases who showed more than 90% degeneration of nerve fibers revealed by ENoG. 2.4. Facial nerve function evaluation House–Brackmann (HB) grading system was used for facial nerve function evaluation [6]. Before treatment, 4 cases were classified as Grade VI, 10 cases as Grade V, 26 cases as Grade IV, and 5 cases as Grade III. 3. Result Of the 45 children with delayed facial palsy after head trauma, 31 cases were males and 14 cases were females, aged 4– 14 years old (average, 6 5.6 years). Facial palsy appeared on day 3–7 in 30 cases, day 8–14 in 10 cases, and day 15–21 in 5 cases (Fig. 1). And the mean period of delay was 7.2 4.8 days (range, 3–21 days). 28 cases were caused by car accident and 17 by falling from the height. All of them reported an explicit history of head trauma and they were sent to hospital within 24 h after injury. 30 cases had different degrees of coma, and 13 cases lost consciousness. Ear and nose bleeding were noticed in 24 cases and 6 cases, respectively.
Radiological examinations showed that there were 15 cases (33.3%) with temporal bone fractures, and 7 cases with cerebral contusion with dispersive hemorrhage. Fracture lines were not observed at the fallopian canal among the 30 cases with temporal bone fractures. According to ENoG of facial nerve, 40 cases had less than 90% degeneration of nerve fibers and 5 cases had greater than 90% degeneration. Pure tone audiometry showed that 25 cases had conductive hearing loss on the affected side, with hearing loss of 25–50 dB in speech frequencies (500 Hz, 1000 Hz and 2000 Hz), 4 cases had moderate to severe sensorineural hearing loss, and 24 cases had normal hearing. 21 cases had decreased secretion of tears on the affected side and 28 cases had taste loss on the affected side. All the cases were followed up for one year. Among the 40 cases receiving conservative treatment, 29 of 40 cases (72.5%) completely recovered within one month, 2 cases (5%) recovered to Grade I between one month and two months, and 1 case recovered to Grade I between two months and three months. One year later, 38 of 40 cases (95%) recovered to Grade I or Grade II (good recovery). Specifically, 33 cases (82.5%) completely recovered, and 5 cases (12.5%) recovered to Grade II (Table 1). Only 5 of 45 cases who showed more than 90% degeneration of nerve fibers revealed by ENoG underwent total facial nerve decompression. Among the 5 cases receiving surgical decompression, edema of facial nerve was found in all the 5 cases, and micro-bony spicules were found in 1 case (20.0%). For the 5 surgically treated cases, one case recovered to Grade I (Fig. 2), three cases recovered to Grade II, and one case recovered to Grade III, with a good recovery rate of 80.0% (Table 2). No cases developed obvious complications due to surgical procedures. Only one of the five cases developed synkinesis, and none of the five cases showed contracture. 4. Discussion Facial palsy following head trauma may be immediate or delayed. Sometimes, it is difficult to identify immediate or delayed facial palsy when the patient is in deep coma. Actually, we could not exclude the possibility that few immediate facial palsy cases might be contained in this study because of deep coma. The immediate onset of facial palsy after head trauma is mainly caused by temporal bone fractures which compress or transect facial nerve, while the reasons of delayed facial palsy are much more complicated. In our study, HRCT revealed temporal bone fractures in only 33% cases. Delayed facial palsy may be caused by fierce shock injury and subsequent edema of facial nerve or micro-bony spicules which are not revealed by high-resolution CT [5]. Sanus et al. [3] performed surgical exploration and decompression on 13 cases who had delayed facial palsy without gross temporal bone fractures on HRCT, Table 1 Facial nerve function of 40 pediatric cases before and after conservative treatment (one year later).
Fig. 1. Onset distribution of pediatric delayed facial palsy after head trauma. Facial palsy appeared on day 3–7 in 30 cases, day 8–14 in 10 cases, and day 15– 21 in 5 cases.
HB grade
I
II
III
IV
V
VI
Before treatment After treatment
0 33
0 5
5 1
26 0
8 0
1 0
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
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Fig. 2. Recovery of one child with delayed facial palsy after head trauma. This case was found to have delayed facial palsy at the fourth day after head trauma (falling from the height with the occipital portion touching the earth), with the worst facial nerve function of Grade V before treatment (A). She recovered completely at 1 year after total facial nerve decompression (B).
and found edema in all patients and noticed micro-bony spicules in 4 cases (30.8%). In our study, among the 5 cases receiving surgical decompression, edema of facial nerve was found in all the 5 cases, and micro-bony spicles were found in 1 case (20.0%), similar to Sanus’s findings [3]. High-resolution CT of the temporal bone can clearly show the exact course of fracture lines of the temporal bone, although it is not reliable in revealing fractures at pyramid segment and mastoid segment [7–13]. MRI is better than HRCT in showing edema and hematoma of the facial nerve [14], although it was not performed on each case in our study. ENoG is quite significant for determining conservative treatment or surgical decompression, because it is widely accepted that surgical intervention is necessary for delayed traumatic facial palsy with more than 90% degeneration of nerve fibers revealed by ENoG [15–17]. In our study, surgical decompression was performed only on the 5 cases with over 90% degeneration of nerve fibers revealed by ENoG. Regarding to the extent of facial nerve decompression, we recommend total facial nerve decompression although some authors may choose small area decompression for traumatic facial palsy. Since micro-bony spicules may be found in some delayed facial palsy cases [3], it may well ignore the micro-bony spicules if only small area decompression is adopted. Moreover, surgery revealed that edema affected the geniculate ganglion, labyrinthine segment, horizontal segment and mastoid segment of facial nerve. Thus, we think small area decompression may be insufficient. Of course, our opinion remains to be validated by well-designed comparative studies. For the vast majority cases with delayed facial palsy, surgical decompression is not required, and conservative treatment is enough. Prednisolone is still the standard therapy for delayed facial palsy, although neuroprotective effects of other agents, such as TJ-23 (tokishakuyakusan) and vitamin E, have been reported in peripheral facial nerve injury of animal models [18]. The outcomes of pediatric delayed facial palsy after head trauma by conservative treatment were excellent in Table 2 Facial nerve function of 5 pediatric cases before and after surgical treatment (one year later). Before treatment After treatment HB grade
0 1 I
0 3 II
0 1 III
0 0 IV
2 0 V
3 0 VI
our study. 72.5% of the cases completely recovered within one month after conservative treatment. After one-year follow-up, up to 82.5% cases completely recovered, and 12.5% cases recovered to Grade II. According to Li et al.’s study [5], 81.8% adult cases with who accepted conservative treatment for delayed facial palsy after head trauma fully recovered, and 9.1% recovered to Grade II during the one-year follow-up. It seemed that outcomes of pediatric delayed facial palsy after head trauma were not different from those of adult delayed facial palsy after head trauma, both of which were generally good. For the cases with pediatric delayed facial palsy who met the surgical indication, the outcomes following surgery were acceptable. In our study, 80.0% of the cases recovered to Grade I or II one year after surgical decompression. It appeared that outcomes of delayed facial palsy related to various diseases were generally satisfactory after conservative or surgical treatment. As mentioned above, outcomes of both pediatric and adult cases with delayed facial palsy after head trauma were satisfactory. Xu et al. reported that all cases with delayed facial palsy after tympanomastoid surgery recovered completely within two months [19]. Similarly, outcomes of delayed facial palsy after microvascular decompression for hemifacial spasm were fairly good [20]. Moreover, outcomes of delayed facial palsy after cochlear implantation were also excellent, with a recovery rate of 90.5% [21]. Therefore, pediatric delayed facial palsy after head trauma has good prognosis after corresponding treatment. References [1] Ort S, Beus K, Isaacson J. Pediatric temporal bone fractures in a rural population. Otolaryngol Head Neck Surg 2004;131(4):433–7. [2] Holsti M, Kadish HA, Sill BL, Firth SD, Nelson DS. Pediatric closed head injuries treated in an observation unit. Pediatr Emerg Care 2005;21 (10):639–44. [3] Sanus GZ, Tanriverdi T, Tanriover N, Ulu MO, Uzan M. Hearing preserved traumatic delayed facial nerve paralysis without temporal bone fracture: neurosurgical perspective and experience in the management of 25 cases. Surg Neurol 2009;71(3):304–10. [4] Puvanendran K, Vitharana M, Wong PK. Delayed facial palsy after head injury. J Neurol Neurosurg Psychiatry 1977;40(4):342–50. [5] Li Q, Jia Y, Feng Q, Tang B, Wei N, Zhang Y, et al. Clinical features and outcomes of delayed facial palsy after head trauma. Auris Nasus Larynx 2016;43(5):514–7. [6] House JW, Brackmann DF. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93(2):146–7.
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012
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[7] Rotondo M, D’Avanzo R, Natale M, Conforti R, Pascale M, Scuotto A. Post-traumatic peripheral facial nerve palsy: surgical and neuroradiological consideration in five cases of delayed onset. Acta Neurochir (Wien) 2010;152(10):1705–9. [8] Swartz JD, Daniels DL, Harnsberger HR, Shaffer KA, Mark L. The temporal bone. Am J Neuroradiol 1996;17(1):201–4. [9] Yamaki T, Yoshino E, Higuchi T, Horikawa Y, Hirakawa K. Value of high-resolution computed tomography in diagnosis of petrous bone fracture. Surg Neurol 1986;26(6):551–6. [10] Schubiger O, Valavanis A, Stuckmann G, Antonucci F. Temporal bone fractures and their complications. Examination with high resolution CT. Neuroradiology 1986;28(2):93–9. [11] Chen SS, Lao CB, Chiang JH, Chang CY, Lirng F, Guo WY, et al. High resolution computed tomography of temporal bone fracture. Zhonghua Yi Xue Za Zhi (Taipei) 1998;61(3):127–33. [12] Rajati M, Pezeshki Rad M, Irani S, Khorsandi MT, Motasaddi Zarandy M. Accuracy of high-resolution computed tomography in locating facial nerve injury sites in temporal bone trauma. Eur Arch Otorhinolaryngol 2014;271(8):2185–9. [13] Guo A, Li S, Qin Z, Lu W, Jiang L. The diagnostic value of high resolution CT in assessment of temporal bone traumatic facial nerve paralysis. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2009;23 (22):1011–3.
[14] Sartoretti-Schefer S, Scherler M, Wichmann W, Valavanis A. Contrastenhanced MR of the facial nerve in patients with posttraumatic peripheral facial nerve palsy. Am J Neuroradiol 1997;18(6):1115–25. [15] Fisch U. Possibilities of microsurgery of the petrous bone and the base of the skull. Ther Umsch 1987;44(2):102–8. [16] Quaranta A, Campobasso G, Piazza F, Quaranta N, Salonna I. Facial nerve paralysis in temporal bone fractures: outcomes after late decompression surgery. Acta Otolaryngol 2001;121(5):652–5. [17] Ulug T, Arif Ulubil S. Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures. Am J Otolaryngol 2005;26(4):230–8. [18] Ito M, Ohbayashi M, Furukawa M, Okoyama S. Neuroprotective effects of TJ-23 (Tokishakuyakusan) on adult rat motoneurons following peripheral facial nerve axotomy. Otolaryngol Head Neck Surg 2007;136(2):225–30. [19] Xu P, Liu W, Zuo W, Wang D, Wang H. Delayed facial palsy after tympanomastoid surgery: a report of 15 cases. Am J Otolaryngol 2015;36(6):805–7. [20] Hua Z, Da TY, Hui WX, Tingting Y, Jin Z, Yan Y, et al. Delayed facial palsy after microvascular decompression for hemifacial spasm. J Craniofac Surg 2016;27(3):781–3. [21] Alzhrani F, Lenarz T, Teschner M. Facial palsy following cochlear implantation. Eur Arch Otorhinolaryngol 2016;273(12):4199–207.
Please cite this article in press as: Li L, et al. Outcomes of pediatric delayed facial palsy after head trauma. Auris Nasus Larynx (2017), http://dx. doi.org/10.1016/j.anl.2017.09.012