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Long-term Outcomes After Middle Fossa Approach for Traumatic
Facial Nerve Paralysis
Richard B. Cannon, Rhett S. Thomson, Clough Shelton, and Richard K. Gurgel
Division of Otolaryngology–Head and Neck Surgery, The University of Utah School of Medicine, Salt Lake City, Utah
Objectives: Controversy exists regarding the role of surgery
for patients with skull base trauma and facial paralysis. Our
goal is to report the long-term outcomes of early facial nerve
decompression and repair via the middle fossa (MF)
approach for patients with traumatic paralysis.
Study Design: Retrospective case series.
Setting: Academic medical center.
Patients: There were 18 patients who met surgical criteria:
immediate complete paralysis, greater than 90% degeneration
on electroneurography (ENoG), and no voluntary electro-
myography (EMG) potentials within 14 days after trauma
and 1 year minimum follow-up.
Intervention: MF approach for traumatic facial paralysis
and for irreversible injuries nerve grafting was performed.
Main Outcome Measure: Long-term facial function, hear-
ing results, and surgical complications.
Results: At MF decompression, 11 patients had an anatomi-
cally intact facial nerve. Of these patients with intact nerves,
72.7% obtained normal to near normal facial function (HB I
or II) at 1 year: 27.3% to HB I, 45.5% to HB II, and 27.3%
to HB III. At surgery, seven patients were found to have
injuries that required nerve grafting and 100% improved to
HB III. For all patients, facial nerve function significantly
improved after surgery ( p < 0.01). The average difference in
pure tone average and word recognition after surgery was
þ 2.9 dB and þ3.3%, respectively ( p ¼ 0.44; p ¼ 0.74).
Minor, transient complications occurred in three patients and
an abscess required drainage in one patient, but no other
major complications.
Conclusion: In our series, all patients with traumatic complete
paralysis and poor facial prognosis achieved a long-term
outcome of HB III or better after MF approach for decompres-
sion and repair of the facial nerve. Key Words: Facial
nerve decompression—Facial nerve repair —Long-term
outcomes —Middle fossa approach —Surgical criteria—
Temporal bone fracture—Traumatic facial nerve paralysis.
Otol Neurotol 37:799–804, 2016.
Traumatic facial nerve paralysis can result from
many blunt and penetrating injuries to the temporal
bone. The most common causes of temporal bone
fractures are motor vehicle accidents, recreational
activities, falls, or assaults and can result in stretching,
compression, or transection of the facial nerve (1,2).
These patients with significant skull base trauma caus-
ing facial nerve paralysis often have multiple, complex
medical issues, which makes their management
challenging.
One of the most devastating aspects of temporal bone
trauma is paralysis of the facial nerve, which occurs in 7
to 10% of cases (3). Some patients with posttraumatic
facial paralysis may recover normal or near normal facial
function with observation or medical management alone,
including steroids to minimize posttraumatic neural
edema. If the onset of facial nerve dysfunction was
delayed from the traumatic incident, then the prognosis
is excellent (4–6). However, a subset of patients who
have immediate-onset, complete facial nerve paralysis
after a skull base trauma are at risk for a poor long-term
outcome. The long-term consequences of facial paralysis
result in functional limitations, are emotionally distress-
ing, and have significant psychosocial implications (7).
Patients who are high risk for poor outcomes, as deter-
mined by electrodiagnostic testing, may benefit from
surgical management (8–10).
Appropriate surgical candidates after temporal bone
trauma have poor long-term prognosis of their facial
nerve function. Coupling a function-based clinical evalu-
ation, the House-Brackmann (HB) facial nerve grading
system, with electrodiagnostic testing has been effective
in determining long-term prognosis (11,12). Specifically,
electroneurography (ENoG) and voluntary electromyog-
raphy (EMG) can provide prognostic information when
there is complete paralysis (HB VI) on clinical exam
(13). Patients with any posttraumatic facial movement
rarely need surgical intervention and several studies
show that patients with <90% degeneration on their
ENoG testing have excellent long-term outcomes, with
Address correspondence and reprint requests to Richard K. Gurgel,
M.D., The University of Utah, Otolaryngology Head and Neck Surgery,
50 North Medical Dr., SOM 3C-120, Salt Lake City, UT 84132, U.S.A.;
E-mail:
No sources of support or funding were received for this work.-
Presented at the 2015 AAO-HNSF Annual Meeting and OTO EXPO.
None of the authors has a conflict of interest.
Otology & Neurotology
37 :799–804 2016, Otology & Neurotology, Inc.
Reprinted by permission of Otol Neurotol. 2016; 37(6):799-804.
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