|Year : 2019 | Volume
| Issue : 1 | Page : 22-25
Modified Stennert's infusion protocol for posttraumatic delayed facial nerve palsy
Dipak Ranjan Nayak1, Tulasi Kota Karanth1, Shalini S Menon1, Dheeraj Kondamudi2
1 Department of ENT-HNS, Kasturba Medical College, Manipal, India
2 Department of ENT-HNS, INHS Asvini, Mumbai, Maharashtra, India
|Date of Web Publication||19-Jun-2019|
Dr. Shalini S Menon
Department of ENT- HNS, Kasturba Medical College, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: The objective of the study is to validate the role of modified Stennert's infusion protocol in posttraumatic delayed facial nerve palsy. Materials and Methods: A retrospective chart review of 21 patients with delayed onset posttraumatic facial nerve palsy was carried out in a tertiary teaching hospital. All patients with delayed onset facial nerve palsy were treated with modified Stennert's protocol. It is a combination therapy which includes tapering doses of hydrocortisone, pentoxifylline, and low-molecular-weight dextran provided over 13 days. If the patient did not show signs of improvement with modified Stennert's protocol by the 10th day of therapy, they were advised to undergo transmastoid decompression of facial nerve. Analysis was performed based on House–Brackmann (HB) grading performed at the time of diagnosis and after 30 days of follow-up. Improvement was considered to have taken place if HB grading improved by minimum of two or reached normal value of one. Results: Twenty-one patients were started on modified Stennert's protocol of which 15 improved and 6 did not improve. They underwent transmastoid decompression of facial nerve and improved significantly afterward. Conclusion: A trial of modified Stennert's infusion protocols is a safe option in patients with posttraumatic delayed facial nerve palsy.
Keywords: Facial nerve palsy, hydrocortisone, modified Stennert's, posttraumatic, Stennert's protocol
|How to cite this article:|
Nayak DR, Karanth TK, Menon SS, Kondamudi D. Modified Stennert's infusion protocol for posttraumatic delayed facial nerve palsy. Indian J Otol 2019;25:22-5
|How to cite this URL:|
Nayak DR, Karanth TK, Menon SS, Kondamudi D. Modified Stennert's infusion protocol for posttraumatic delayed facial nerve palsy. Indian J Otol [serial online] 2019 [cited 2019 Sep 19];25:22-5. Available from: http://www.indianjotol.org/text.asp?2019/25/1/22/260724
| Introduction|| |
Posttraumatic facial nerve palsy is the second most common cause of unilateral facial nerve palsy. Facial nerve decompressive surgeries are usually performed in delayed onset facial palsy to release the edema or hematoma and accelerate the recovery of the nerve.
Decompressive surgery of facial nerve can be performed by transmastoid, middle cranial fossa, or translabyrinthine approaches or their combination. Performing such a surgery requires a lot of infrastructure, expertise and presents the patient with the risk of injury to sigmoid sinus, dura, labyrinth, and brain parenchyma. Studies done by Mahesh et al. and Darrouzet et al. have shown that treatment of delayed posttraumatic facial palsies with steroids may provide an alternative to surgery.,
Stennert's protocol was initially described for idiopathic facial nerve palsy (Bell's palsy). Modified Stennert's protocol was described by Mahesh et al., where hydrocortisone was used instead of prednisolone. This was tried in patients with idiopathic facial nerve palsy and in patients with delayed posttraumatic facial nerve palsy. Good improvement was seen equally in both the groups.
We describe 21 cases of delayed onset, posttraumatic facial nerve palsy who were treated with modified Stennert's protocol (Hydrocortisone antiphlogistic-rheologic infusion therapy) and decompressive surgery if no improvement was seen.
| Materials and Methods|| |
The study was conducted in a tertiary teaching hospital Kasturba Medical College and Hospital, Manipal, India. Medical records of patient diagnosed to have posttraumatic facial nerve palsy were analyzed retrospectively. Patients with immediate facial nerve palsy and who had steroid therapy with other protocols were excluded from the study. Twenty-one sequentially available eligible patients were included in the study. Approval for this study was obtained from the Institutional Ethical Committee.
Modified Stennert's protocol
Modified Stennert's protocol is a 13-day regimen of tapering doses of dextran, hydrocortisone, and pentoxifylline. Dextran was initially given as 1000 kilodaltons over 16 h, which was tapered after 3 days to 500 kilodaltons over 8 h. Hydrocortisone was given on the 1st day as 200–250 mg/dL (as per patient's weight) and was tapered every 3 days to stop. Pentoxifylline was continued as 10 mg/kg for 13 days. Serum potassium levels and random blood sugar levels were monitored daily and were corrected accordingly. The protocol has been detailed in [Table 1].
|Table 1: Hydrocortisone antiphlogistic-rheologic infusion therapy (modified Stennert's infusion protocol)|
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Grading and evaluation of facial nerve palsy
All the patients were graded according to the House–Brackmann (HB) grading before beginning the protocol and at each stage of assessment. They also underwent high-resolution computed tomography scanning of temporal bones (HRCT temporal bone), topognostic tests, such as Schirmer's test and stapedius reflex test to identify and confirm the site of lesion.
Patient was taken to have considerably improved if the HB grading improved by two grades or reached the normal levels (HB Grade I).
Decompressive surgery of facial nerve
Patients who did not show considerable improvement after 10 days of modified Stennert's protocol underwent transmastoid decompression of facial nerve.
Data were collected regarding HB grading at initial consult and at follow-up 30 days after therapy. Follow-up was continued till 1 year if the considerable improvement was not found at the end of 30 days.
| Results|| |
Twenty-one sequentially eligible records of patients with delayed posttraumatic facial nerve palsy were studied in detail of which 12 (57.1%) were male and 9 (42.8%) were female. They were distributed by age between 15 and 77 years. All of the patients had unilateral facial nerve palsy. Palsy on the right was seen in 11 (52.3%) than to the left 10 (47.6%). Majority of the patients had HB grading of III 9 (42.8%) at the time of diagnosis. HB Grade V facial nerve palsy was found in 2 (9.52%), Grade IV in 6 (28.6%), and Grade II in 4 (19%). Seventeen of 21 patients had undisplaced longitudinal fracture of the temporal bone. Two had normal CT findings and two had mixed comminuted fracture [Figure 1] and [Figure 2].
|Figure 1: A coronal cut of high-resolution computed tomography scan of temporal bone showing mixed comminuted longitudinal and transverse fractures of right petrous temporal bone (mastoid part) is noted with anterior and posterior fracture lines extending to the squamous temporal bone. Bony facial canal is intact|
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|Figure 2: Axial cut of high-resolution computed tomography scan of temporal bone showing fracture line in squamous part of temporal bone with intact facial canal|
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All 21 were given modified Stennert's infusion protocol as detailed in [Table 1]. Fifteen patients improved considerably by the end of 30 days of beginning therapy. Six were found to have no improvement by the 10th day of modified Stennert's regimen and were advised to undergo decompressive surgery [Figure 3]. All the patients who failed modified Stennert's infusion protocol underwent transmastoid decompression of facial nerve. All improved considerably at the end of 30 days postoperatively.
|Figure 3: Pie chart representing treatment options which improved facial nerve palsy. Patients who underwent transmastoid decompression of facial nerve were initially treated with modified Stennert's infusion protocol. They were taken up for surgery on day 10 of protocol as no improvement in facial nerve palsy was seen. The bar diagram represents the initial House–Brackmann grade of patients who underwent decompressive surgery|
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| Discussion|| |
Facial nerve palsy is seen in approximately 50% of temporal bone fractures. Darrouzet et al. described a retrospective study of 115 posttraumatic facial nerve palsies. The incidence of posttraumatic facial nerve palsy was 34.3% of patients with fracture of the temporal bone. Patients were treated both medically and surgically. Surgical treatment was preferred in cases of immediate posttraumatic facial nerve palsies, when electromyographic assessment suggested transected facial nerve or when patient did not respond favorably to medical treatment. The most common surgery advocated was transmastoid and middle cranial fossa approach decompression of facial nerve. Medical treatment was preferred for patients with delayed onset facial nerve palsies. Methylprednisolone was given at the dose of 2 mg/kg/day for 3 weeks. Addition of vasodilator was advised, but Stennert's or modified Stennert's was not followed. Use of steroid therapy for posttraumatic facial nerve palsy was also studied by Lee et al. They conducted a retrospective chart review of 26 patients and concluded that starting steroid therapy within 24 h of diagnosis and continuing it for a minimum of 14 days significantly improve the outcome.
Panda et al. in the review on treatment of posttraumatic facial nerve palsy have suggested to take into account the rate of progression of the palsy over the time of onset of palsy to decide on the need for surgical treatment. The approach to be used to perform decompression was advised to be based over topographic tests like Schirmer's test, assessment of stapedial reflex and gustometry. Rotondo et al. described the clinical presentation and management of five delayed facial nerve palsies. They preferred magnetic resonance imaging to look for edema if no fracture was found on HRCT temporal bone imaging. They suggested that surgical intervention is to be avoided in patients with delayed onset facial nerve palsy where electromyography and electroneurography do not suggest transection of the facial nerve although they did not comment on the type of steroid therapy to be used.
Although literature supports the use of steroids in patients with delayed onset posttraumatic facial nerve palsy, a standardized protocol has not been described. We have combined the use of steroids with low-molecular-weight dextran and pentoxifylline. Low-molecular-weight dextran acts as a plasma expander. Pentoxifylline, a xanthine derivative, is a competitive nonselective phosphodiesterase inhibitor. It can reduce inflammation and acts as a hemorheological agent., It is used in conditions involving a defective regional microcirculation. It increases red blood cell deformability, decreases blood viscosity, the potential for platelet aggregation, and thrombus formation.
Stennert's protocol was the first protocol to use this combination to treat idiopathic facial nerve palsy. It was an antiphlogistic-rheologic infusion therapy regimen that included infusion of high dose of prednisolone, dextran, and pentoxifylline over a time period of 18 days. He reported a recovery rate of 96% in patients with idiopathic facial nerve palsy. Kinishi et al. in 1989 used an infusion of 500 mg of hydrocortisone instead of prednisolone along with low-molecular-weight dextran for idiopathic facial nerve palsy. They found a recovery rate of 90%, which was a result significantly better than oral steroids. Watanabe et al. in 1996 used hydrocortisone sodium succinate along with hydroxymethylated starch and D-mannitol to lower the gastric, hepatic, and renal side effects of steroids. He found the regimen produced a recovery rate of 96.2% in the 24th week.
We have, for the first time in literature, used a combination infusion protocol in delayed onset post-traumatic facial nerve palsy with promising results. Fifteen of the 21 patients improved significantly with modified Stennert's infusion protocol alone. Six of 21 patients did not improve with medical management alone but all improved with transmastoid surgical decompression of facial nerve. We postulate that a bony chip or displaced incus may have been impinging on the facial nerve, which was released during decompression. Therefore, we suggest using modified Stennert's protocol for the treatment of delayed onset posttraumatic facial nerve palsy.
We encourage further studies that analyze steroid or other combination protocols for delayed onset posttraumatic facial nerve palsy.
| Conclusion|| |
Modified Stennert's protocol provides a safer and easy-to-use alternative to decompressive surgery in patients with delayed onset posttraumatic facial nerve palsy. More studies are needed that compare different steroid therapies for the treatment of posttraumatic facial nerve palsy.
We would like to thank the medical records department for its earnest help in providing us with essential records to conduct this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baumann BM, Jarecki J. Posttraumatic delayed facial nerve palsy. Am J Emerg Med 2008;26:115.e1-2.
Mahesh SG, Nayak DR, Balakrishnan R, Pavithran P, Pillai S, Sharma A, et al.
Modified Stennert's protocol in treating acute peripheral facial nerve paralysis: Our experience. Indian J Otolaryngol Head Neck Surg 2013;65:214-8.
Darrouzet V, Duclos JY, Liguoro D, Truilhe Y, De Bonfils C, Bebear JP, et al.
Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases. Otolaryngol Head Neck Surg 2001;125:77-84.
Ghorayeb BY, Yeakley JW, Hall JW 3rd
, Jones BE. Unusual complications of temporal bone fractures. Arch Otolaryngol Head Neck Surg 1987;113:749-53.
Panda NK, Mehra YN, Mann SB, Mehta SK. Post traumatic facial paralysis – A review. J Pak Med Assoc 1991;41:105-7.
Lee PH, Liang CC, Huang SF, Liao HT. The outcome analysis of traumatic facial nerve palsy treated with systemic steroid therapy. J Craniofac Surg 2018;29:1842-7.
Rotondo M, D'Avanzo R, Natale M, Conforti R, Pascale M, Scuotto A, et al.
Post-traumatic peripheral facial nerve palsy: Surgical and neuroradiological consideration in five cases of delayed onset. Acta Neurochir (Wien) 2010;152:1705-9.
Essayan DM. Cyclic nucleotide phosphodiesterases. J Allergy Clin Immunol 2001;108:671-80.
Peters-Golden M, Canetti C, Mancuso P, Coffey MJ. Leukotrienes: Underappreciated mediators of innate immune responses. J Immunol 2005;174:589-94.
Ward A, Clissold SP. Pentoxifylline. A review of its pharmacodynamic and pharmacokinetic properties, and its therapeutic efficacy. Drugs 1987;34:50-97.
Kinishi M, Hosomi H, Amatsu M. Conservative treatment of bell's palsy – High dose steroid infusion with low-molecular dextran. Nihon Jibiinkoka Gakkai Kaiho 1989;92:694-702.
Watanabe S, Kenmochi M, Kinoshita H, Kato I. Effects of administration of high dose hydrocortisone on bell's palsy. Acta Otolaryngol Suppl 1996;522:108-10.
[Figure 1], [Figure 2], [Figure 3]