What is the treatment for facial paralysis due to an ear infection?

Treatment for Facial Paralysis Due to Ear Infection

Facial paralysis due to ear infection requires prompt treatment with systemic antibiotics, corticosteroids, and possible surgical intervention depending on the underlying cause and severity.

Causes and Assessment

• Facial nerve paralysis can occur as a complication of acute otitis media (AOM) or as an early sign of necrotizing (malignant) otitis externa, with the latter predominantly affecting elderly, diabetic, or immunocompromised patients 1
• In necrotizing otitis externa, Pseudomonas aeruginosa is isolated from ear canal exudate in more than 90% of cases 1
• Facial paralysis is a rare complication of acute otitis media with an estimated incidence of 0.005% in the antibiotic era (compared to 0.5-0.7% in the pre-antibiotic era) 2
• The prevalence of facial paralysis in middle ear cholesteatoma patients is approximately 3.5%, with the tympanic segment being the most commonly involved site 3

Treatment Algorithm

For Necrotizing Otitis Externa with Facial Paralysis:

1. Immediate systemic antibiotics covering Pseudomonas aeruginosa and Staphylococcus aureus (including MRSA) 1
2. Surgical debridement of necrotic tissue 1
3. Diagnostic imaging with CT or MRI to confirm diagnosis and assess extent of disease 1
4. Laboratory testing including erythrocyte sedimentation rate 1
5. Avoid ear canal irrigation in diabetic or immunocompromised patients as it may predispose to necrotizing otitis externa 1

For Acute Otitis Media with Facial Paralysis:

1. Systemic antibiotics as first-line treatment 4, 2
2. Corticosteroid therapy to reduce inflammation and edema of the facial nerve 4
3. Myringotomy (surgical incision of the tympanic membrane) to drain middle ear fluid 4, 2
4. Mastoidectomy for cases with:
   • Acute or coalescent mastoiditis
   • Suppurative complications
   • Lack of clinical improvement with medical therapy 4, 2

Special Considerations

• Patients with diabetes, HIV infection, or immunocompromised states require special consideration as they are more susceptible to necrotizing otitis externa and otomycosis 1
• Both bacterial and viral etiologies can cause facial paralysis secondary to otitis media, but severe sequelae are typically found only in cases with proven bacterial origin 5
• Labyrinthine fistulas and destruction of cranial bases are more frequently observed in patients with facial paralysis due to chronic ear infections 3

Prognosis and Follow-up

• Surgical outcomes for facial paralysis due to chronic ear infections are generally satisfactory except in complex cases such as petrous apex cholesteatoma 3
• Complete recovery is possible with appropriate and timely intervention 4, 2
• Patients should be reassessed or referred to a facial nerve specialist if there is:
  • Incomplete facial recovery after 3 months
  • New or worsening neurologic findings
  • Development of ocular symptoms 1

Common Pitfalls to Avoid

• Delaying treatment, which can lead to permanent facial nerve damage 1, 2
• Failing to recognize necrotizing otitis externa in high-risk patients (elderly, diabetic, immunocompromised) 1
• Not implementing eye protection for patients with impaired eye closure, which can lead to corneal damage 6
• Irrigating the ear canal in diabetic or immunocompromised patients, which may predispose to necrotizing otitis externa 1