It has been over three decades since Fisch popularised facial nerve (FN) decompression for Bell’s Palsy. Studies further exploring this have been few since, partly due to the major complications that can occur following this type of surgery. The current study looked at a retrospective cohort of 14 Bell’s patients with grade six HB FN palsy that are known to have poorer FN prognosis. Surgical criteria included greater than 90% degeneration on ENoG testing and no voluntary EMG potentials. This would normally mean at best a 50% chance of recovery to HB one or two.
Previous studies have shown the meatal foramen and the labyrinthine segment to be the narrowest segment of the bony canal and it is these parts of the facial nerve that were decompressed via the middle fossa approach. High dose steroids were given as routine and surgery carried out within 14 days of onset.
Results were impressive with no major complications and match other studies. Three patients experienced gustatory hyperlacrimation. Ten patients (71%) regained good FN function (HB one or two) within a year, the remaining to HB three. Patients over 60 years of age did worse, when compared to decompression over 14 days, results were significantly better when surgery was undertaken within 14 days (only 20% return to HB1/2 if surgery over 14 days). ENoG needs to be undertaken within two weeks to be predictive and also enable early surgery. There was no change in hearing pre and post surgery. This is a convincing argument for early investigation and intervention and I wonder how many skull base surgeons would be keen to adopt this protocol?