A 74-year-old man had a facial nerve tumor resected elsewhere 9 months ago based on a 6 month clinical history of facial palsy (unclear if complete or partial) and a radiological suspicion of a mastoid facial nerve schwannoma. No tumor was described in the pathological report (angioma?). The nerve defect was reconstructed with a greater auricular nerve graft with no recovery. The patient was seen in our unit with 15 months of flaccid paralysis. Otoscopy shows canal wall down a cavity obliterated with soft tissue (tiny meatoplasty). Diffusion MRI suggests cholesteatoma in the cavity. What would you do now?
This is a challenging case, with duration of the paralysis in the limit for a reinnervation technique.
As a recurrent or residual cholesteatoma is suspected, revision surgery should be performed, probably a canal wall down mastoidectomy with resection of the cholesteatoma, and enlargement of the meatoplasty. Resection of any suspicion remnants of the tumor or tumor-like previous lesion should be performed.
About the facial reanimation, with 15 months of facial paralysis in a 74-year-old patient, a good result with a reinnervation technique is still possible, but in this case the patient’s expectations and attitude should be considered. Also, EMG to rule out fibrillation potentials could be useful.
If reinnervation is decided:
– If the mastoid portion is preserved and reaches the 12: side to end 12-7 transfer + masseter to facial (zygomatic or buccal branch)
– If the mastoid portion is not preserved: masseter to facial (zygomatic or buccal branch) with a fascia lata to the nasolabial fold and a rhytidectomy.
If the patient prefers an easier and faster solution, and/or signs of muscle atrophy are present, a temporal muscle elongation (Labbe’s technique) in addition to specific eye care could be offered.