|Year : 2022 | Volume
| Issue : 1 | Page : 77-83
A retrospective analysis of facial palsy in patients of squamosal chronic suppurative otitis media with diabetes mellitus
Jitendra Kerba Rathod, Lakshmi Vasavi Manjusha Bavisetty, Rajendra B Bohra
Department of E.N.T., MGM Medical College and Hospital, N6, CIDCO, Aurangabad 431003, Maharashtra, India
|Date of Submission||12-Sep-2021|
|Date of Acceptance||24-Feb-2021|
|Date of Web Publication||23-Mar-2022|
Dr. Lakshmi Vasavi Manjusha Bavisetty
Department of E.N.T., MGM Medical College and Hospital, N6, CIDCO, Aurangabad 431003, Maharashtra.
Source of Support: None, Conflict of Interest: None
Background: Facial nerve palsy is a common intra-temporal complication of untreated chronic suppurative otitis media (CSOM) causing erosion of the fallopian canal and its pressure effects leading to facial weakness. There is a less favorable outcome in patients of CSOM with diabetes as they are more prone to neural degeneration. In such patients, early surgical decompression of the facial nerve helps in resolving facial palsy to some extent. In our study of 22 patients, we analyzed the prognosis and advantage of doing early surgical facial nerve decompression along with modified radical mastoidectomy in patients of unsafe CSOM with diabetes mellitus. Materials and Methods: We present a retrospective study of 22 patients with a squamosal type of CSOM with diabetes mellitus who came to the outpatient department, from June 2019 to March 2021, with complaints of ear discharge and facial palsy grades 3–5, in whom we did early surgical facial nerve decompression along with modified radical mastoidectomy. We observed the incidence of facial palsy and recovery after facial nerve decompression with limited use of steroids in patients with diabetes mellitus. Results: In our retrospective study of 22 patients with squamosal type of CSOM with diabetes mellitus with complaints of facial palsy, 10 were males and 12 were females. Patients were assessed clinically using House–Brackmann grading: 55% are of grade III, 31% are of grade IV, and 14% are of grade V. About 82% of the patients from our study had lesions at the tympanic segment, 9% patients had lesions at the vertical segment, 4.5% patients had lesion at the first genu, and 4.5% patients had lesion at the second genu. In our study, 95% of the patients from the study improved with early facial nerve decompression along with modified radical mastoidectomy, 55% of the patients improved to grade I, 36% of the patients improved to grade II, and 9% of the patients improved to grade III. Conclusion: In squamosal-type CSOM patients with facial palsy, early facial nerve decompression along with modified radical mastoidectomy within 12 weeks of development of facial palsy provides better results than just modified radical mastoidectomy as it increases recovery rate and reduces the need for post-operative steroids which is an advantage in diabetics.
Keywords: Chronic suppurative otitis media, diabetes mellitus, facial nerve decompression, facial paralysis, fallopian canal, modified radical mastoidectomy, tympanic segment
|How to cite this article:|
Rathod JK, Bavisetty LV, Bohra RB. A retrospective analysis of facial palsy in patients of squamosal chronic suppurative otitis media with diabetes mellitus. MGM J Med Sci 2022;9:77-83
|How to cite this URL:|
Rathod JK, Bavisetty LV, Bohra RB. A retrospective analysis of facial palsy in patients of squamosal chronic suppurative otitis media with diabetes mellitus. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:77-83. Available from: http://www.mgmjms.com/text.asp?2022/9/1/77/340590
| Introduction|| |
The facial nerve travels in a long bony canal in the temporal bone. Any dehiscence in this bony canal can be congenital or by otitis media, especially cholesteatoma erodes the bony canal making the nerve more vulnerable to injury. Many studies have shown that facial palsy in patients of chronic suppurative otitis media (CSOM) with diabetes mellitus has a less favorable outcome; the reason being that there is more vascular pathogenesis due to diabetes which causes small vessel disease resulting in nerve ischemia commonly affecting distal nerve fibers, mostly in favor of mononeuropathy. Facial palsy management should be done either conservatively or surgically at the earliest, irrespective of its etiology. In our study, we did early facial nerve decompression releasing pressure over the affected segment along with mastoidectomy with the use of intra-operative steroids and analyzed the outcome in patients of CSOM with diabetes mellitus.
| Aims and objectives|| |
The aim of this article is to study facial palsy in patients of unsafe CSOM with diabetes mellitus and to study their prognosis on doing early facial nerve decompression and reducing post-operative steroids to attain good glycemic control.
| Materials and methods|| |
Between March 2019 and March 2021, a retrospective study of facial palsy in patients of CSOM with diabetes was undertaken at a tertiary teaching hospital. With reference number IEC/MGM-ECRHS/2021/99 dated December 15, 2021, the Institutional Ethics Committee approved this study. We present a study of 22 patients with squamosal-type CSOM who came to the ENT OPD, with complaints of ear discharge and facial palsy grades III–V, with uncontrolled sugar levels in whom early facial nerve decompression is done along with modified radical mastoidectomy.
The inclusion criteria for the study were patients’ age greater than 30 years, having squamosal-type CSOM with acute onset facial palsy and history of diabetes or raised HbA1c levels, those who have given consent for the study and came for regular follow-up. The exclusion criteria were those who developed facial palsy post-trauma, a history of facial palsy in the past. A detailed history of the patient was taken regarding the onset of symptoms, any other associated complaints, past, family, and personal history, history of diabetes or any other comorbidities, and history of ongoing medications. Proper clinical examination was done, ear findings noted, the systemic examination done, facial nerve examined along with other cranial nerves, facial palsy grading done using the House–Brackmann (HB) grading system. As a part of routine blood check-up, sugar levels were also checked. Audiometry along with high-resolution computed tomography (HRCT) temporal bone was done for patients with squamosal-type CSOM. In our study of 22 patients, early surgical facial nerve decompression was done along with modified radical mastoidectomy with only one dose of intra-operative steroids and one dose of post-operative steroids. Intra-operative findings were also compiled. Regular follow-ups were taken at 7 and 15 days, 1, 3, 6, and 9 months, blood sugar levels were monitored on every visit. The outcome was graded by the HB grading system, and improvement of the function of the facial nerve to grades II and I was taken as a good outcome.
| Observations and results|| |
In our study of 22 patients with squamosal-type CSOM with diabetes mellitus with facial palsy, 10 were males and 12 were females [Figure 1]. The most common age group affected is between 40 and 50 years. Patients were assessed clinically using the HB grading system: 55% are of grade III, 31% are of grade IV, and 14% are of grade V [Figure 2]. The most commonly involved segment was the tympanic segment of facial nerve: 82% of the patients from our study had lesions at the tympanic segment, 9% of the patients had lesions at the vertical segment, 4.5% of the patients had lesions at the first genu, and 4.5% of the patients had lesions at the 2nd genu. In our study, stapedial reflex was lost in 18% of the patients and intact lacrimal function was lost in all the patients. About 95% of the patients from the study improved with early facial nerve decompression along with modified radical mastoidectomy. Approximately 55% of the patients improved to grade I, 36% of the patients improved to grade II, and 9% of the patients improved to grade III [Table 1].
|Figure 2: Study subjects’ distribution as per HB grading of facial palsy at the time of presentation (n = 22)|
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| Discussion|| |
Facial paralysis is due to numerous etiologies, the foremost common reason being cholesteatoma, in unsafe CSOM. The occurrence of facial palsy in CSOM accounts for 3.1% of all instances. The most widely recognized reason for facial paralysis is Bell’s paralysis, which is most commonly found in diabetes mellitus patients. The frequency of facial paralysis related to cholesteatoma in the current literature is around 0.04–0.16%. Bony erosion is brought about by microbes of chronic otitis media, neurotoxic substances, or different enzymatic activities secreted by cholesteatoma matrix that damages epineurium of nerve successively causing inflammation of the nerve. As there is no space to accommodate within the bony canal, it causes compression of distal nerve fibers. Savić and Djerić in their study concluded that cholesteatoma was ascertained in 51/64 patients (80%) of chronic otitis media causing facial paralysis. For management, one ought to understand the pathology and consider age, sugar levels, and any previous surgical history of the ear for better prognosis. Topodiagnostic tests are carried out as a prerequisite to finding the level of the facial nerve segment involved by testing the function of the peripheral facial nerve that features Schirmer’s test, stapedial reflex, electrogustometry, and submandibular salivary flow test. Also, electrophysiological tests include minimal nerve excitability test, maximal stimulation test, electroneuronography, and electromyography., Surgical approaches commonly used are the trans-mastoid approach and the middle cranial fossa approach.,, Conjointly as a necessity before surgery, HRCT temporal bone [Figure 3]A and B is done to see the extent of disease and to identify facial canal dehiscence, and the diseased segment can be anticipated pre-operatively as reported by Choi and Park, who did a study on 13 patients found that the foremost commonly involved site of the facial nerve was the tympanic segment and concluded that the radiologic affectability for facial canal dehiscence was 91%. Always keep in mind the time of onset of facial palsy till surgery, which is important to assess the prognosis as per Ikeda et al. Also a study done by Kim et al. reported that outcomes depend on the duration of onset to surgery as longer duration causes further deterioration of the facial nerve and poor surgical outcomes. In our study, early surgical intervention was done despite the severity of the facial function. Facial nerve decompression was done along with modified radical mastoidectomy to eradicate the disease and to prevent further neural degeneration as seen in Quaranta et al., who showed that a study of 13 patients who underwent late decompression surgery for facial palsy reported HB Grade I and II improvement in 78% of the patients. Depending on the site of involvement, facial nerve surgical approach differs. In our study, we did a trans-mastoid approach as it is easy to expose the vertical and partial tympanic segments of the facial nerve. A good outcome for facial nerve decompression was reported by Terzis et al., even when relatively small varieties of small axons were regenerated. Their study reported that nerve decompression to be done even in severe cases who are at high risk of permanent total palsy, with poor prognosis being better than not doing any surgical intervention. Gantz et al. found good recovery rates to grades I and II facial palsy if surgical decompression was done within 14 days. Savić and Djerić reported complete recovery in 70%, partial in 24%, and failure in 6% of the cases, 19 patients following decompression surgery.
|Figure 3: A: HRCT temporal bone of the patient showing erosion of tympanic segment of the facial canal. B: HRCT temporal bone of the patient showing erosion of tympanic segment of the facial canal|
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In our study of 22 patients, after taking a post-aural incision, we did modified radical mastoidectomy and then facial nerve decompression in which we released the pressure by taking incision over a nerve sheath of 2 mm each proximally and distally to the lesion in all patients who are under study. Cawthorne reported that taking incision over a nerve sheath ought to be performed for all complete paralysis patients for a good outcome. We found very good results and improvement of 11 patients to HB grades III-I [Figure 4], [Figure 5]A and B, [Figure 6]A and B, and 5 patients showed improvement to HB grades IV-II on 1-year follow-up. In our study of 22 patients, for 18 patients the tympanic segment is involved [Figure 7], for 2 patients vertical segment, for 1 patient the first genu is involved, and for 1 patient the second genu is involved. Our study also found that diabetic patients are more prone to facial nerve paralysis. In squamosal-type CSOM, patients who were diabetic had more edema of the affected nerve segment; in patients with canal dehiscence, there is granulation tissue all around. Unlike many previous studies, we performed facial nerve decompression taking incision over epineural sheath along with modified radical mastoidectomy which not only increased recovery rate, but also reduced the need for post-operative administration of steroids (our patients received only one dose of steroids intra-operatively and one dose of injection on post-operative day). Dexamethasone 8 mg benefited diabetic patients. Patients’ follow-up was obtained on 2nd and 8th week, and there was monthly follow-up also. About 95% of our subjects showed complete recovery. Cases with a long history of unsafe CSOM and total facial paralysis have a poor prognosis that is why more aggressive management (nerve decompression with granulation excision) has been proposed but may not be universally acceptable. Our study had one patient whose recovery was not complete.
|Figure 4: A: Pre-operative picture of grade III facial palsy patient. B: Post-operative picture of the subject|
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|Figure 5: A: Pre-operative picture of grade III facial palsy patient. B: Post-operative picture of the subject|
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|Figure 6: A: Pre-operative picture of grade IV facial palsy patient. B: Post-operative picture of the subject|
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|Figure 7: Intra-operative picture showing lesion at the tympanic segment|
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| Conclusion|| |
Our study of 22 patients with squamosal-type CSOM with facial nerve palsy who have undergone modified radical mastoidectomy with segmental facial nerve decompression showed a better recovery rate than those who have undergone modified radical mastoidectomy alone. Especially early decompression is done within 12 weeks of development of facial nerve palsy, as it decreases the pressure over nerve fibers allowing the nerve to expand. It additionally benefited diabetics as taking incision over epineural sheath helps in reducing edema of an affected nerve segment. There was no need for post-operative steroids, which in turn helps patients in maintaining good glycemic control.
The Institutional Ethics Committee for Research on Human Subjects (ECRHS) has approved the proposal to undertake the clinical study entitled: “A retrospective analysis of facial palsy in patients of squamosal chronic suppurative otitis media with diabetes mellitus” vide their letter no. MGM_ECRHS/2021/99 dated December 15, 2021.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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