Combined Subtemporal–Supralabyrinthine Approach to Geniculate Ganglion for Management of Facial Paralysis in Temporal Bone Fracture

Abstract

ObjectiveTo investigate the clinical outcomes of facial never decompression via a combined subtemporal–supralabyrinthine approach to geniculate ganglion for management of facial paralysis in temporal bone fracture. MethodsEighteen patients with unilateral facial paresis due to temporal bone fracture were treated between March 2003 and March 2011. Facial function was House–Brackmann(HB) grade III in 6 patients, HB grade V in 9 patients and HB grade VI in 3 patients. The preoperative mean air conduction threshold was 52 dB HL for the 15 cases with longitudinal temporal bone fracture and showed severe sensorineural hearing loss in the 3 cases with transverse temporal bone fracture. Fracture lines were detected in 15 cases on temporal bone axial CT scans and ossicular disruption was determined in 11 cases by virtual CT endoscopy. The geniculate ganglion or the tympanic mastoid segment of the facial nerve showed an irregular morphology on curved planar reformation images of the facial nerve canal. After an intact canal wall mastoido–epitympanectomy, the ossicular chain damage was evaluated. If the ossicular chain was intact, the supralabyrinthine recess was opened by drilling through the cells between the tegmen tympani and ossicular chain. If the ossicular chain was disrupted, the incus was removed to access the supralabyrinthine recess. The geniculate ganglion and the distal labyrinthine segment of the facial nerve were exposed. After completing facial nerve decompression, the dislocated incus was replaced, or a fractured incus was reshaped to bridge the space between the malleus and the stapes. ResultsPronounced ganglion geniculatum swelling was found in 15 cases of longitudinal temporal bone fracture, with greater petrosus nerves damage in 3 cases and bleeding in 5 cases. Disrupted ossicular chains were seen in 11 cases, including dislocated incus resulting in crushing of the horizontal portion of the facial nerve in 3 cases and fracture of the incus long process in 1 case. In 3 cases of transverse fractures, dehiscence on the promontory, semicircular canal or oval window was found. All cases had primary healing with no complication. At follow–ups ranging from 0.5 to 3 years (average 1.2 years) , facial nerve function recovered to HB grade I in 11 cases, II in 5 cases and III in 2 cases. Overall hearing recovery was 33 dB. ConclusionThe clinical outcomes concerning facial nerve function and hearing recovery are satisfactory via a combined subtemporal–supralabyrinthine approach to the geniculate ganglion for facial nerve decompression in temporal bone fracture patients with facial paralysis.