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CC BY-NC-ND 4.0 · Int Arch Otorhinolaryngol 2021; 25(02): e177-e178
DOI: 10.1055/s-0041-1724089
Letters to the Editor
Special Article COVID-19

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

Mohammad Faramarzi 
1   Department of Otorhinolaryngology-Head and Neck Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
2   Otolaryngology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
,
Ali Faramarzi 
2   Otolaryngology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
3   Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
,
Milad Hosseinialhashemi 
1   Department of Otorhinolaryngology-Head and Neck Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
3   Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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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.


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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 death[14]; 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.


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Conflict of Interests

The authors have no conflict of interests to declare.

Author Contributions

Concept – M. F.; supervision – M. F.; resources – A. F. and M. H.; literature search – M. F., A. F., and M. H.; writing of the manuscript – M. H. and A. F.; critical review – M. F.



Address for correspondence

Ali Faramarzi
Medical Student, Otolaryngology Research Center, Shiraz University of Medical Sciences
Shiraz, Iran 71348-14336

Publication History

Received: 21 September 2020

Accepted: 07 December 2020

Article published online:
15 March 2021

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