Is Early Traumatic Facial Nerve Surgery a Priority during the COVID-19 Pandemic?

Abstract

As otolaryngologists are exposed to high risk of coronavirus disease 2019 (COVID-19) infection, logic and evidence-based prioritization for surgeries is essential to reduce the risk of infection amongst healthcare workers. Several clinical guidelines and surgery prioritizing recommendations have been published during the COVID-19 pandemic. They recommended the surgery in the setting of immediate facial nerve paralysis within 72 hours after trauma, but none of the previous studies in the literature suggests that the optimal timing of operation should be less than 2 weeks from injury.

Keywords facial nerve; COVID-19; pandemic

Dear Editors,

Recently, two prioritizing recommendations on otologic surgeries during the coronavirus disease 2019 (COVID-19) pandemic have been published. Topsakal et al. recommended that the appropriate time for facial nerve decompression after temporal bone trauma is within 48 to 72 hours of the injury.¹ Also, in the clinical guideline from the Royal College of Surgeons of England and the ENT UK, at the request of the National Health Service (NHS) England, it is suggested that the time for the operation should be within 72 hours from trauma.²

A literature review shows that there is controversy about the timing and indication of surgical intervention after temporal bone trauma. Some experts believe that patients with more than 90 to 95% of facial nerve degeneration, confirmed by electroneurography (ENoG), are suitable candidates for facial nerve decompression,^3,4 while other studies claimed that early decompression is more likely to result in better facial nerve function. A systematic review of 6 studies showed that early facial nerve decompression before 2 weeks after temporal bone trauma leads to better results than late surgical intervention.⁵ In another study, Hato et al. found that facial nerve operation within 2 weeks from injury leads to significantly better recovery, whereas if performed 2 months after temporal bone trauma, it results in unfavorable outcomes.⁶

Conversely, there are those who believe that delayed decompression, even up to 3 months after trauma, may lead to acceptable facial nerve function.⁷ Yadav et al. stated that conservative management, even up to 3 months, in patients with complete facial nerve paralysis is justifiable even if the ENoG and nerve excitability testing (NET) suggest poor prognosis. Hence, they concluded that it surgical intervention it is justified to postpone surgical intervention for up to three months even in patients with facial nerve degeneration < 90%. They also found that about 50% of patients with ENoG < 90% have acceptable facial nerve recovery via conservative management.⁷ In a prospective cohort study by Thakar et al., from 2018, 28 patients with head injury associated with complete unilateral facial nerve paralysis with poor ENoG outcomes received a high dose of prednisolone (1 mg/kg) for 3 weeks. Interestingly, all the patients had full recovery of facial nerve function after 20 weeks of conservative management. They concluded that surgical exploration should be considered only if there was no facial nerve recovery 4 months after temporal bone trauma.⁸

The current COVID-19 pandemic has imposed global changes in team dynamics, department workload organization, personal protective equipment (PPE) measures, and facilities preparedness.⁹ Due to the exposure of otolaryngologists to patient's aerosols, they are at the forefront of the battle against COVID-19, with greater risks of infection.¹⁰ However, the use of PPE may affect the surgical team members' performance. A survey by Benítez et al. shows that surgeons perceived impediment in both visibility and communication while using PPE on emergency surgery in COVID-19 patients.¹¹ Also, an international study shows that a considerable portion of surgical team members had not received training in the use of PPE for airborne infectious risk.¹² Therefore, it is time for rethinking and rescheduling elective surgical procedures.

Logic and evidence-based prioritization for surgeries is essential to reduce the risk of infection amongst healthcare workers, in addition to reducing the risks of patient's contamination within healthcare facilities.¹³ On the other hand, the study by Lei et al. showed that patients undergoing surgeries during the incubation period of COVID-19 infection have higher risk of postoperative intensive care unit admission or even death¹⁴; hence, surgeons should consider this risk factor during the current pandemic. In conclusion, surgeons should ponder two issues before decision making. First, none of the reviewed literature recommended the timing of operation of less than 2 weeks. Secondly, the body of evidence is inconclusive for facial nerve surgery not only within 72 hours but also within 2 weeks. Hence, surgeons should be cautious with respect to the aforementioned recommendations for prioritized facial nerve surgery during the COVID-19 pandemic.

References

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• ² Clinical guide to surgical prioritisation during the coronavirus pandemic (ENT specific) [Internet]. [cited 2020 Aug 7]. Available from: https://www.entuk.org/clinical-guide-surgical-prioritisation-during-coronavirus-pandemic-ent-specific
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• ³ Liu Y, Han J, Zhou X, et al. Surgicalmanagement of facial paralysis resulting from temporal bone fractures. Acta Otolaryngol 2014; 134(06):656–660https://pubmed.ncbi.nlm.nih.gov/24665853/ cited 2020 Jul 8 [Internet]
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• ⁴ Darrouzet V, Duclos JY, Liguoro D, Truilhe Y, De Bonfils C, Bebear JP. Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases. Otolaryngol Head Neck Surg 2001;125(01):77–84https://pubmed.ncbi.nlm.nih.gov/11458219/ cited2020Jul8 [Internet]
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• ⁵ Xie S, Wu X, Zhang Y, Xu Z, Yang T, Sun H. The timing of surgical treatment of traumatic facial paralysis: a systematic review [Internet]. Vol. 136, Acta Oto-Laryngologica Taylor and Francis Ltd; 2016 [cited 2020 Jul 8]. p. 1197–200. Available from: https://pubmed.ncbi.nlm.nih.gov/27387924/
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• ⁶ Hato N, Nota J, Hakuba N, Gyo K, Yanagihara N. Facial nerve decompression surgery in patients with temporal bone trauma: analysis of 66 cases. J Trauma 2011;71(06):1789–1792, discussion 1792–1793
• ⁷ Yadav S, Panda NK, Verma R, Bakshi J, Modi M. Surgery for posttraumatic facial paralysis: are we overdoing it? Eur Arch Otorhinolaryngol 2018;275(11):2695–2703. Doi: 10.1007/s00405-018-5141-y
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• ⁸ Thakar A, Gupta MP, Srivastava A, Agrawal D, Kumar A. Nonsurgical Treatment for Posttraumatic Complete FacialNerve Paralysis. JAMA Otolaryngol Head Neck Surg 2018;144(04):315–321https://pubmed.ncbi.nlm.nih.gov/29470563 [Internet]
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• ⁹ BenÍtez CY, Pedival AN, Talal I, et al. Adapting to an unprecedented scenario: surgery during the COVID-19 outbreak. Rev Col Bras Cir 2020;47:e20202701. Epub August 12, 2020. Doi: 10.1590/0100-6991e-20202701
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• ¹⁰ Lima DS, Ribeiro Junior MF, Vieira-Jr HM, Campos T, Saverio SD, SaverioSD.Alternatives for establishing a surgical airwayduring the COVID-19 pandemic. Rev Col Bras Cir 2020;47:e20202549. Epub 03 de junho de 2020. Doi: 10.1590/0100-6991e-20202549
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• ¹¹ Yánez Benítez C, Güemes A, Aranda J, et al; International Cooperation Group on PPE and Emergency Surgery. Impact of Personal Protective Equipment on Surgical Performance During the COVID-19 Pandemic. World J Surg 2020;44(09):2842–2847. Doi: 10.1007/s00268-020-05648-2
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• ¹² Yánez Benítez C, RibeiroMAF Jr, Alexandrino H, et al. International cooperation group of emergency surgery during the COVID-19 pandemic. Eur J Trauma Emerg Surg 2020;•••;. Doi: 10.1007/s00068-020-01521-y
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• ¹³ Couloigner V, Schmerber S, Nicollas R, et al; French Society of Otorhinolaryngology, Head, Neck Surgery (SFORL) French College of Otorhinolaryngology, Head, Neck Surgery French Syndicate of ENT Specialists (SNORL) COVID-19 and ENT Surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2020;137(03):161–166https://pubmed.ncbi.nlm.nih.gov/32362564/ cited2020Aug7 [Internet]
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• ¹⁴ Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine 2020;21:100331

Publication Dates

• Publication in this collection
  14 June 2021
• Date of issue
  Apr-Jun 2021

History

• Received
  21 Sept 2020
• Accepted
  07 Dec 2020