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.
