Delayed facial nerve decompression in a mastoid cavity.
We present an unusual case where a 70 year old gentleman who had mastoid surgery for cholesteatoma 25years ago. Presented with grade 6 House Brackman weakness. Initially he presented to emergency department with facial weakness mimicking Bell’s palsy. Though he had mastoid cavity over 25 years, at the time of facial weakness, the cavity was dry and there was no signs of active infection to consider infection as a cause for his facial weakness. Hence, he was treated with oral steroids and reviewed after 3 months in ENT clinic. There was no improvement in facial weakness, he had CT scan which confirmed osteitis of facial canal at multiple places. There were no signs of any infection clinically or biochemically to suspect acute infection or malignant otitis externa. Due to unusual presentation, it took time to make decision for surgery. He underwent full length facial nerve decompression 6 months after his initial presentation.
Due to his mastoid cavity, his hearing was poor for many years. It was easy for patient to make a decision for surgical decompression.
Surgical techniques: radical mastoidectomy steps were followed to remove any disease in the mastoid cavity. Canal wall down technique for full length exposure of facial nerve, Eustachian tube was blocked with bone dust and muscle plug. Facial nerve was decompressed from 1st part just outside IAM (internal auditory meatus) to tip of mastoid (styloid foreman). Whole facial nerve was mobilised outside the bony canal, covered with silastic sheet and external auditory canal was closed (blind sac closure).
Post-operatively: unfortunately, due to size of external meatus from primary surgery – the external meatus part of blind sac closure was not successful. As cavity lining was healthy, hence he has been followed up in the clinic once a year.
1. post-auricular incision
2. tympanometal flap elevated
3. posterior based flap raised
4. radical mastoidectomy steps followed - extended mastoidectomy, canal wall down all the way to facial canal, removing all skin and disease from middle ear and mastoid cavity
5. facial canal opened from IAM to tip of mastoid bone (styloid foreman)
6. facial nerve mobilised out of fallopian / facial canal
7. cavity obliterated with bone dust and muscle flap.
8. Eustachian tube blocked with muscle plug and bone dust.
9. external canal meatus closed
facial palsy - grade 6. not responding to any medical treatment
none
Zeiss microscope
medtronic mastoid drill
medtronic drill tips
Karl Storz middle ear instruments.
supine
under GA
head tilted opposite side
Pure tone audiometry
CT scan mastoid
routine blood test for GA. FBC, Clotting, U&E, LFT
Standard post-auricular incision - same incision line as primary mastoid surgery
mastoid cavity was open
tympanomeatal flap - in ear canal
Lateral semicircular canal for second gene facial nerve
mastoid tip and sterno-mastoid muscle at the tip
IAM as superior and medial limit
failure of blind sac closure - resulting in recurrent infection and ? facial weakness
infection or bleeding
No conflicts to disclose
1. IIyes Berania, Mohamed Awad, et al. Delayed facial nere decompression for severe refractory cases of Bell's palsy: a 25-years experience. J Otolaryngol Head Neck Surgery. 2018 Jan 4;47:1.
2. Joanna Marszal, Anna Bartochowska, et al., Facial nerve paresis in the course of masked mastoiditis as a revelator of GPA. Eur Arch Otorhinolaryngol. 2021 Nov 19;279(9).
3. Harun Gur, Kemal Gorur et al., Surgical outcomes of Transmastoid facial nerve decompression for patient with traumatic facial nerve paralysis. Journal international adv Otol. 2021 Jul 1; 17(4) 294-300.
4.Joanna Marszal, Anna Bartochowska, et al. Is facial nerve decompression justified in Malignant External otitis? Literature review and own experience. Journal international adv Otol. 2023 May 1;19(3): 191-198.
Sign in to write a review
Reviews are open to CSurgeries members. Sign in to share your feedback on this case.
Sign in Don’t have an account? Create one freeHave a question about this case? Send a note to Dr. Sreeshyla Basavaraj — they'll reply by email.
Register today to continue watching
Sign up for our free membership to watch and submit videos today! If you are already a member please log in to access your account.
Sign Up NowAlready a member? Click here to log in
Register today to submit a video
Sign up for our free membership to watch and submit videos today! If you are already a member please log in to access your account.
Sign Up NowAlready a member? Click here to log in
Upgrade your membership to continue watching
Please upgrade to membership to continue watching more videos.
Upgrade NowRenew your subscription to continue watching
Please renew your subscription to continue watching.
Renew Now