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346                                          THE EAR

may be supported and prevented from stretching by a small plastic hook
cemented to the upper teeth. Active facial exercises are only of value during
the stage of recovery. In all patients suffering from facial paralysis an explan-
ation of the nature of the illness must be given at the outset, and regular
attendance at the clinic is necessary to evaluate progress and to maintain

Medical treatment may be limited to patients with a complete paralysis,
of whom a number, less than 50 per cent, would recover spontaneously.
Where complete paralysis is associated with severe pain, or if there is an
electrogustometric threshold (p. 347) difference of 100/-&A or more between the
two sides of the tongue treatment is clearly indicate^ Stapedius paralysis
also indicates a more complete loss of function, and calls for treatment.
Unless special contra-indications are present the administration of oral
prednisolone should be given as soon as possible after the onset of the palsy.
It is given hi a dose of 20 mg four times daily for 5 days and then reduced
by 20 mg each day thereafter. This treatment has replaced the administration
of ACTH and other methods of inducing vasodilatation. Surgical decom-
pression of the facial nerve is not now recommended in the treatment of
; Bell's palsy.


Facial paralysis is esr^cLalJYjigJbk^tQ .occur.. in., tuberculous, Jnfection and
malignant disease of The middle ear. It is not a common complication* of
soptmrafivelotifis media, but iifma^^                                                   It

may be due to a congenilat""denlscenceof the bony wall of theTacial canal,
or may result from erosionlST^e wall by cholesteatoma.JFacial paralysis
may_ appear after ir|^Qid,,^uxgexy, -and be due to section of the nerve
""or to compression of the nerve^by haemorrhage or oedema, or by an inward
fracture of the bony wall oTtfie canal If a paralysis of the nerve is observed
Immediately after the patient regains consciousness following surgery the
condition is serious, and the wound should be explored so that repair may
be effected. The nerve supplies the dilator muscle of the ala nasi, and this
may reveal its involvement. If the paralysis does not appear until 2 or 3
days after operation a gradual return of function may be expected.

SURGICAL TREATMENT. When facial paralysis occurs in the course of
chronic suppuration radical mastoid surgery is indicated and is frequently
followed by a return of function once the granulations and cholesteatoma
surrounding the nerve have been removed. Facial paralysis due to operative
trauma is usually an indication for the early re-exploration of the cavity.
If electrical tests do not show muscle degeneration nerve surgery may be
delayed for a month or more. There are four policies in surgery:

1.  The mastoid is opened, the nerve decompressed or the cut ends placed
in apposition.

2.  A nerve graft may be employed. Autoplastic nerve graft, using the
lateral cutaneous nerve of the thigh, is inserted after the nerve sheath has
been opened and the damaged nerve ends have been excised. The inlay graft
is longer than the gap to be bridged, and it is held in place by fibrinogen
or human thrombin. Some recovery of function may be expected in 6-8
weeks, although full recovery may take 6-9 months or even longer.