This is an interesting paper. The authors recommend a transmastoid facial decompression for patients with complete facial nerve paralysis with House Brackman HB 5/6 who do not show any sign of recovery after two weeks of treatment following a diagnosis of Ramsay Hunt syndrome (RHS). The inclusion criteria for surgery were: HB grade V or VI on initial examination; electroneurological tests ENoG degeneration of over 90%; evident approximately two weeks after the onset of facial weakness; no voluntary electromyographic motor unit potential evident 14 days after the onset of facial palsy. Also patients should have failed medical treatment (steroids and antiviral agents) for two weeks at least and diagnosis within one week of onset, and yet showing over 90% degeneration. Twenty five patients underwent surgery. Facial nerve paralysis and hearing outcomes were monitored at 12 months following surgery using clinical and electroneurological tests. The study shows a successful outcome in 52% of cases. They also suggest that surgery done within 50 days of onset of facial nerve paralysis and patients who show a positive intraneural response during surgery achieve a better successful outcome. This is a debatable subject and decisions are often biased by local expertise. Only an RCT can answer the question but in our experience, at least in the UK, surgery is rarely offered to RHS patients. An RCT on this rare condition, as with many ENT conditions, would prove very challenging.

Delayed transmastoid facial nerve decompression surgery in patients with Ramsay-Hunt syndrome presenting with neurophysiologically complete paralysis.
Kumai Y, Ise M, Miyamaru S, Orita Y.
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Sangeeta Maini

FRCS ORL-HNS, Aberdeen Royal Infirmary, Forresterhill, Aberdeen, AB25 2ZN.

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Bhaskar Ram

FRCS (EDIN) , FRCS ORL-HNS, Department of Otolaryngology Head & Neck Surgery, Aberdeen Royal Infirmary, Forresterhill, Aberdeen AB25 2ZN, UK.

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