Transmastoid extralabyrinthine approach in traumatic facial palsy

Our experiences with thirty-six cases of intratemporal facial nerve palsies using the transmastoid extralabyrinthine (TMEL) approach are reported. Palsies were mostly traumatic in origin. The technique, first developed by us and reported in May 1980, spares the labyrinth and has the same indications for use as the middle cranial fossa approach to the seventh nerve. It avoids craniotomy and overcomes the limitations of the classic transmastoid approach, allowing exploration of the nerve from the descending portion to the geniculate ganglion and surrounding regions. When the ossicular chain is already damaged by trauma, surgery is made easier by removal of the head of the malleus and of the incus, which are then transposed at the end of surgery to reconstruct the chain. In particular cases the technique can also leave the chain intact. The TMEL approach has been used in 89% of patients with traumatic palsies due to longitudinal temporal bone fractures, with either an intact or, more often, a disconnected chain. Results of facial nerve and hearing function tests at twelve months are reported in detail. Our approach and similar techniques used by other authors represent an alternative to House's middle cranial fossa and Pulec's combined operations. Morbidity rate is lower and the operation can be performed by the majority of otologic surgeons.