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 morale. 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 COMPLICATING OTITIS MEDIA 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.