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摘要: 目的 总结外伤性面神经麻痹的临床特点及治疗效果。方法 对2015年1月至2023年5月间68例(69耳)外伤性面神经麻痹病例进行回顾性分析。结果 就诊时中位病程33 d；就诊时患者的面神经功能HB-Ⅱ级2例，HB-Ⅲ级4例，HB-Ⅳ级16例，HB-Ⅴ级37例(38耳)，HB-Ⅵ级9例；42例为伤后即刻发生，26例为迟发性；纵行骨折51例(52耳)，横行骨折6例，混合型骨折4例，7例未发现明确颞骨骨折线；损伤节段49例(50耳)为膝状神经节及邻近，7例为垂直段，7例为水平段，2例为水平段、垂直段，3例无法评估。23耳采用以糖皮质激素为主的保守治疗，46耳采用手术治疗。治疗后6~24个月对患者进行随访，HB-Ⅰ级20例，HB-Ⅱ级19例，HB-Ⅲ级23例(24耳)，HB-Ⅳ级4例，HB-Ⅴ级1例；失访1例。治疗前后，患者面神经功能明显改善(P < 0.05)，保守治疗组和手术治疗组患者在面神经麻痹病程、伤后即刻面瘫比率、治疗前面神经功能、治疗后面神经功能差异有统计学意义(P < 0.05)；年龄、性别、听力情况、颞骨骨折情况、面神经损伤节段、面神经功能良好率差异无统计学意义(P>0.05)；对神经变性>90%和≤90%的病例比较显示治疗前神经变性>90%的患者面神经功能明显更差(P < 0.05)，但两者治疗后的面神经功能差异无统计学意义(P>0.05)；颅中窝入路组和乳突入路组治疗前后面神经功能差异无统计学意义(P>0.05)。结论 外伤性面神经麻痹病例应进行个体化的评估，面神经麻痹程度轻、神经变性比率低、病程短的患者可先行保守治疗并严密随访，对于面神经麻痹程度重、神经变性率高、病程超过6周的患者可积极考虑手术治疗；正确的评估、治疗可获得良好预后。Abstract: Objective To summarize the clinical characteristics and therapeutic effect of traumatic facial nerve palsy.Methods Sixty-eight cases of traumatic facial nerve palsy were retrospectively analyzed from January 2015 to May 2023.Results The median course of disease was 33 days. The facial nerve function of the patients was grade HB-Ⅱin 2 cases, grade HB-Ⅲ in 4 cases, grade HB-Ⅳin 16 cases, grade HB-Ⅴ in 37 cases(38 ears), and grade HB-Ⅵ in 9 cases. 42 cases occurred immediately after injury and 26 cases were delayed. CT examination of temporal bone revealed longitudinal fractures in 51 cases(52 ears), transverse fractures in 6 cases and mixed fractures in 4 cases. No definite temporal bone fracture was found in the remaining 7 cases. The segments of facial nerve injury in 49 cases(50 ears) were geniculate ganglion and adjacent, in 7 cases were vertical segment, in 7 cases were horizontal segment, in 2 cases were horizontal segment and vertical segment; and the other 3 cases could not be evaluated. Conservative treatment with glucocorticoids was used in 23 ears and surgery was used in 46 ears. Patients were followed up 6-24 months after treatment, including 20 cases of grade HB-Ⅰ, 19 cases of grade HB-Ⅱ, 23 cases(24 ears) of grade HB-Ⅲ, 4 cases of grade HB-Ⅳ, and 1 case of grade HB-Ⅴ.One patient was lost to follow-up. After treatment, the facial nerve function of patients was significantly improved(P < 0.05), and there were significant differences between conservative treatment group and surgical treatment group in the course of facial nerve palsy, the ratio of facial palsy immediately after injury, the nerve function before treatment and the nerve function after treatment(P < 0.05). There were no significant differences in age, sex, hearing condition, temporal bone fracture, facial nerve injury segment and rate of favorable neurologic outcomes(P>0.05). The comparison of patients with neurodegeneration rate>90% and ≤90% showed that the facial nerve function of patients with neurodegeneration rate>90% before treatment was significantly worse(P < 0.05), but there was no significant difference between the facial nerve function after treatment(P>0.05). There was no significant difference in facial nerve function between middle fossa approach group and mastoid approach group(P>0.05).Conclusion Patients with traumatic facial nerve palsy should be evaluated individually. Patients with mild facial nerve palsy, low neurodegeneration rate and short course of disease can be treated conservatively and followed up closely. Patients with severe facial nerve palsy, high neurodegeneration rate and more than 6 weeks of disease can be actively considered surgery. Good prognosis can be obtained by correct evaluation and treatment.
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Key words:
- facial nerve palsy /
- temporal bone fracture /
- facial nerve function
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表 1 患者就诊时一般情况
项目 病例数 占比/% 性别 男 57 83.82 女 11 16.18 侧别 左 36 52.94 右 31 45.59 双 1 1.47 就诊年龄 ≤10岁 11 16.18 11~20岁 6 8.82 21~30岁 14 20.59 31~40岁 13 19.12 41~50岁 12 17.65 51~60岁 10 14.70 > 60岁 2 2.94 面神经麻痹病程 ≤30 d 33 48.53 31~60 d 25 36.76 61~90 d 8 11.77 > 90 d 2 2.94 伤后即刻发生 是 42 61.76 否 26 38.24 HB分级 Ⅱ级 2 2.90 Ⅲ级 4 5.80 Ⅳ级 16 23.19 Ⅴ级 38 55.07 Ⅵ级 9 13.04 
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表 2 患者治疗前后的面神经功能配对非参数检验
项目 例数 Z P 总体 68 -7.197 < 0.001 保守治疗组 22 -4.169 < 0.001 手术治疗组 46 -5.911 < 0.001 乳突入路 31 -4.910 < 0.001 颅中窝入路 14 -3.220 0.001
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表 3 保守治疗组与手术治疗组各因素比较
项目 保守治疗组(22耳) 手术治疗组(46耳) Z P 中位年龄/岁 27.5 37.5 -1.509 0.131 性别(男︰女)/例 19︰3 39︰7 -1.171 0.864 侧别(左︰右)/例 14︰8 23︰23 -1.048 0.294 面神经麻痹中位病程/d 7.0 43.5 -4.045 < 0.001 发病时间/例(即刻︰迟发) 6︰16 36︰10 -2.959 0.003 治疗前HB功能/例 727.000 0.001 Ⅰ 0 0 Ⅱ 2 0 Ⅲ 2 2 Ⅳ 8 8 Ⅴ 10 27 Ⅵ 0 9 治疗后HB功能/例 354.000 0.041 Ⅰ 12 8 Ⅱ 8 11 Ⅲ 2 22 Ⅳ 0 4 Ⅴ 0 1 Ⅵ 0 0 面瘫改善满意率/% 100.00 89.13 -1.595 0.111
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表 4 不全变性组与完全变性组面神经功能比较
例 HB功能 完成面神经电图(n=60) 21 d内完成面神经电图(n=17) 治疗前 治疗后 治疗前 治疗后 不全变性组 完全变性组 不全变性组 完全变性组 不全变性组 完全变性组 不全变性组 完全变性组 Ⅰ 0 0 7 8 0 0 4 3 Ⅱ 2 0 6 11 2 0 5 1 Ⅲ 2 0 2 21 0 0 1 3 Ⅳ 4 7 0 4 3 0 0 0 Ⅴ 6 30 0 1 5 6 0 0 Ⅵ 1 8 0 0 0 1 0 0 Z 675.000 608.000 60.000 31.500 P < 0.001 < 0.001 0.014 0.740
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表 5 不同手术入路治疗组面神经功能比较
例 HB功能 治疗前 治疗后 颅中窝入路 乳突入路 颅中窝入路 乳突入路 Ⅰ 0 0 2 4 Ⅱ 0 0 3 6 Ⅲ 0 1 6 12 Ⅳ 2 4 3 1 Ⅴ 11 11 0 0 Ⅵ 1 7 0 0 Z 126.500 181.000 P 0.284 0.546
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