Management of the facial nerve following temporal bone ballistic injury.

Objective: To understand the patterns of temporal bone fracture and facial nerve injury from ballistic trauma. Study Design: Retrospective case series. Methods: Retrospective review of 42 patients evaluated following temporal bone ballistic injury at a single institution, university-based level-one trauma center between 2012 and 2021. Demographics, facial nerve status, CT images, interventions, complications, and outcomes were reviewed. Results: Mean age 30.3 years (range 5-58 years); 79% male. Racial demographics reflected the surrounding community. Seven mortalities occurred. Nineteen patients (54%) demonstrated facial nerve injury. Of those, 13/19 displayed immediate paralysis, 1 delayed, 5 unknown (due to altered mental status). On consultation, House-Brackmann grade 6 paralysis was common (13/19). Fracture was otic capsule-sparing in 17/19 (90%), universally comminuted, with significant disruption along the mastoid tip (16/19), external auditory canal (EAC) (15/19), and periauricular soft tissues (13/19). Nine patients underwent surgical intervention: Transmastoid facial nerve decompression to remove compressive bony spicules (n = 5); eye protection surgery (n = 3); and peripheral facial nerve exploration (n = 1), noting transection at the pes. One required middle cranial fossa and transmastoid repair of cerebrospinal fistulae in setting of severe meningitis. House-Brackmann scores improved in 80% following transmastoid nerve decompression despite CT evidence of likely additional injury in its extratemporal course. Conclusions: Common patterns of temporal bone fracture seen in blunt trauma (longitudinal/transverse, otic capsule-sparing/disrupting) were not found in patients with ballistic facial nerve injury. Rather, injury was commonly apparent in the EAC, mastoid tip, and periauricular soft tissues. Clinicians should have high suspicion for extratemporal facial nerve injury following ballistic trauma.

Pediatric nasal surgery: timing and technique.

PURPOSE OF REVIEW: Timing of pediatric nasal surgery has always been a controversial topic. Concern over disrupting growing parts of the face and causing permanent facial deformity has led to a primarily conservative approach. Many surgeons feel that it is prudent to wait until the patient has completed nasal growth after puberty to pursue nasal surgery. RECENT FINDINGS: Recently, this attitude has been challenged with evidence that not only is nasal surgery in the pediatric age group not a detriment to facial growth, but failure to correct significant nasal deformity may actually cause dysmorphic facial growth secondary to obligate mouth breathing. Because of this, recent studies have focused on determining safe surgical techniques for pediatric nasal surgery, including inferior turbinate reduction, septoplasty and rhinoplasty. Research focus on this topic has also been expanded to include quality-of-life measures after nasal surgery. SUMMARY: Pediatric nasal surgery prior to puberty is not only safe, but may prevent facial deformity in certain patients.