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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 10-12

Peripheral facial nerve palsy-A rare complication of tonsillectomy

1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Division of Microbiology, ICMR-NIOH, Ahmedabad, Gujurat, India

Date of Submission01-Nov-2018
Date of Acceptance19-May-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aiao.aiao_26_18

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Tonsillectomy is a common surgical procedure often done by otolaryngologist in his/her routine surgical practice. Transient facial nerve palsy is an extremely rare complication of tonsillectomy. The cause of the facial nerve palsy may be due to infiltration of local anesthetic agent into parapharyngeal space and affecting facial nerve. Infiltration of local anesthetic solution into the peritonsillar tissue is commonly used for reduction of pain, although the benefit and risk of complication of this technique have not yet been well established. Here, we presented a rare incidence of facial nerve palsy seen in a 14-year-old boy who underwent tonsillectomy under general anesthesia with local infiltration of bupivacaine at peritonsillar space. The facial nerve palsy was completely recovered by conservative treatment.

Keywords: Facial nerve palsy, local anesthetic, peritonsillar space, tonsillectomy

How to cite this article:
Swain SK, Anand N, Sahu MC. Peripheral facial nerve palsy-A rare complication of tonsillectomy. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:10-2

How to cite this URL:
Swain SK, Anand N, Sahu MC. Peripheral facial nerve palsy-A rare complication of tonsillectomy. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2023 Mar 26];4:10-2. Available from: https://www.aiaohns.in/text.asp?2020/4/1/10/288173

  Introduction Top

Tonsillectomy is a common surgical procedure performed in ear, nose, and throat department. Tonsillectomy is a routine surgical procedure often practiced by otolaryngologist for treating recurrent tonsillitis. It is commonly performed in all age group although more in the pediatric age. Tonsillectomy has overall complications of 2%–10% and the mortality rate is around 1 in 16,000.[1] Immediate postoperative complications are pain, hemorrhage, vomiting, dehydration, and pulmonary edema. Their indications are variable and include recurrent or chronic tonsillitis, obstructive sleep apnea syndrome, chronic tonsillitis causing ear infections, and hearing impairment. This surgical procedure is often done under general anesthesia. Many surgeons inject local anesthetic like lidocaine with epinephrine (1:200,000) or bupivacaine into peritonsillar space or peritonsillar tissue for reducing bleeding and postoperative pain. Peritonsillar infiltration during tonsillectomy is a common technique used by many otolaryngologists as an adjuvant therapy to reduce postoperative pain.[2] Rarely, patients present with transient facial nerve palsy after tonsillectomy due to infiltration of local anesthetic agent into the peritonsillar space due to direct effect on facial nerve. Here, we are presenting a case of transient facial palsy developed after tonsillectomy due to deep infiltration of bupivacaine into peritonsillar tissue. Due to the rarity of this case, we presented here with discussion of possible causes and methods of prevention.

  Case Report Top

A 14-year-old boy presented with recurrent throat pain for 5 years. On examination, it showed large Grade-IV parenchymatous tonsils. He was planned for tonsillectomy under general anesthesia. The patient was placed in Rose's position and Boyles-Davis mouth gag was inserted for opening of the mouth. Tonsillectomy was performed using Coblation technique. Both tonsils were removed without any blood loss. For preventing postoperative pain in the throat, the tonsillar bed was infiltrated with around 2 ml of 0.5% bupivacaine hydrochloride. The patient was extubated smoothly. After few minutes at recovery room, the patient presented with right-sided facial palsy of Grade-III House–Brackmann grade [Figure 1]. The patient was started with immediate steroid injection and improvement of the facial muscles began 3 h of the surgery. The facial nerve palsy was resolved completely after 4 h of the surgery. The patient did normal activities postoperatively like taking fluids by mouth on the same day. The patient was discharged following the day of surgery.
Figure 1: Patient presenting right-side lower motor neuron facial palsy after tonsillectomy

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  Discussion Top

Tonsillectomy is a commonly performed surgery by otorhinolaryngologist which is often done under general anesthesia. Reduction of the pain after tonsillectomy is an important part for the patient undergoing surgery. Postoperative pain is often challenging for otorhinolaryngologist in tonsillectomy where the patient usually refuses oral administration of medications. Peritonsillar infiltration of local anesthetics is a technique that can be used to overcome this obstacle.[2] Bupivacaine is a long-acting potent local anesthetic drug commonly used as peritonsillar infiltration for controlling postoperative pain.[3] The usefulness of the peritonsillar infiltration of local anesthetic agent is still controversial. Many studies are supporting for reducing the post-tonsillectomy pain after infiltration of local anesthtic agent,[4] whereas few studies are against pain relief or no effect.[5] There are several complications after tonsillectomy such as bleeding, infections, dehydration, breathing difficulties, and disturbances in taste.[6] Peripheral facial nerve paralysis is an extremely rare complication documented in the medical literature. The first case of facial palsy in tonsillectomy was documented by Perekrest and Rakotoarinivo where a young boy developed facial palsy just after peritonsillar infiltration of local anesthetics.[7] They reported development of peripheral facial palsy immediately after infiltration of local anesthetic agent into the peritonsillar tissue. They stopped tonsillectomy and found that facial nerve paralysis resolved after around 4 h. In the next week, again planned for tonsillectomy under local anesthesia and saw again facial palsy after surgery but resolved after few hours. One more case was reported by Shlizerman and Ashkenazi where facial palsy seen in the 4-year-old boy improved after 4 h.[8] In the present-day clinical practice, many otolaryngologists infiltrate local anesthesia at the peritonsillar area to reduce postoperative pain.[2] Postoperative pain control is still controversial by applying local anesthesia at the tonsillar bed or peritonsillar area; however, it has other advantages such as reduced reflex responses, decreased analgesics need, reduced blood loss, easy dissection, and less operative time.[9] Hence, we often do tonsillectomy under general anesthesia with local bupivacaine injection at the peritonsillar space before the dissection. This local anesthetic agent is also infiltrated at the tonsillar fosaa after tonsillectomy for postoperative pain reduction. Bupivacaine is a local anesthetic which is chosen as it has high potency and long action.[8] It has tendency for blocking sensory fibers than motor fibers. It is used in the concentrations of 0.25%, 0.5%, or 0.75% mixed with or without vasoconstrictor. It will take 15–35 min for complete sensory anesthesia.[8] For preventing this rare complication like facial palsy during tonsillectomy, the surgeon should know the exact anatomy of the peritonsillar area and course of the facial nerve. The facial nerve leaves the skull base through the stylomastoid foramen, seen superficially to the mandibular ramus. Then, it enters into the parotid gland and gives rise to five branches. The peritonsillar space is bounded medially by capsule of the palatine tonsil, laterally by superior constrictor muscle, anteriorly by palatoglossus muscle, and posteriorly by palatopharyngeus muscle. If the local anesthetics will be injected properly into the peritonsillar space, the tonsil will be pushed medially and it will be easy to dissect the tonsil from the tonsillar bed. However if the tonsillar bed is penetrated by local anesthetics, it may deeply infiltrate into the parapharyngeal space and act on the facial nerve by diffusion into the parotid gland or may directly touch the facial nerve at the retromandibular space, if congenital anomaly of the parotid gland unable to envelope the facial nerve.[10] If a local anesthetic agent is injected into the peritonsillar tissue, can be spreaded to the superior constrictor muscle and enter into the region of the facial nerve and its branches. After tonsillectomy, subcutaneous emphysema at the upper part of neck was reported in the medical literature which reflect the pathway from the tonsillar bed to the interstitial spaces of the upper neck.[11] The facial palsy reported during the dental surgery under local anesthesia gives further support for the assumption toward peritonsillar infiltration with local anesthesia, resulting in facial palsy.[12] There are some reported cases of facial palsy after forceful jaw-thrust manipulation or prolonged instrumental mouth opening just before tonsillectomy.[12] In these clinical situations, facial paralysis is confined to the lower branches of the nerve and seen a few days after the surgery and lasted for weeks. There are few complications other than facial palsy reported in the medical literature with local anesthesia injection in tonsillectomy are life-threatening upper airway obstruction, vocal cord palsy, neck abscess, brain stem stroke.[13] The facial nerve palsy can be avoided during or after tonsillectomy by injecting local anesthetics exactly into peritonsillar space, avoiding overdose of local anesthetics, avoiding repeated infiltration, and gentle infiltration of local anesthetics. Peripheral facial palsy is an extremely rare complication of the tonsillectomy with local infiltration using local anesthetic agent of bupivacaine. The transient nature of the facial palsy due to this complication is reassuring. Facial disfigurement due to facial nerve paralysis causes distress of the patients and family members. Hence, the surgeons should be careful for not causing facial nerve paralysis by not infiltrating excess amount of local anesthetic agent at peritonsillar space. Although facial nerve paralysis is extremely a rare complication, it should be kept in mind of the surgeon during tonsillectomy.

  Conclusion Top

Peritonsillar injection of local anesthetic agent during tonsillectomy helps to reduce hemorrhage with short operative period and less postoperative pain. As tonsillectomy is a common surgical procedure performed by otolaryngologist, they should know the exact anatomy of the injection site. During performing tonsillectomy, the surgeon must manipulate gently with the exact amount of local anesthetic agent. Peripheral facial nerve palsy is extremely a rare complication of the tonsillectomy, which most often recovers spontaneously without much of the treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

McCormick ME, Sheyn A, Haupert M, Thomas R, Folbe AJ. Predicting complications after adenotonsillectomy in children 3 years old and younger. Int J Pediatr Otorhinolaryngol 2011;75:1391-4.  Back to cited text no. 1
Cook SP. Bupivacaine injection to control tonsillectomy pain. Arch Otolaryngol Head Neck Surg 2001;127:1279.  Back to cited text no. 2
Covino BG. Pharmacology of local anaesthetic agents. Br J Anaesth 1986;58:701-16.  Back to cited text no. 3
Strub KA, Tschopp K, Frei F, Kern C, Erb T. Local infiltration of epinephrine and bupivacaine before tonsillectomy. HNO 1996;44:672-6.  Back to cited text no. 4
Podoshin L, Gerstel R, Goldsher M, Fradis M, Vaida S, Malatskey S, et al. Effects of peritonsillar infiltration on post-tonsillectomy pain: A double-blind study. Ann Otol Rhinol Laryngol 1996;105:868-70.  Back to cited text no. 5
Uzun C, Adali MK, Karasalihoglu AR. Unusual complication of tonsillectomy: Taste disturbance and the lingual branch of the glossopharyngeal nerve. J Laryngol Otol 2003;117:314-7.  Back to cited text no. 6
Perekrest AI, Rakotoarinivo ZM. Neuritis of the facial nerve as a complication of local anesthesia and tonsillectomy. Vestn Otorinolaringol 1983. p. 77-8.  Back to cited text no. 7
Shlizerman L, Ashkenazi D. Peripheral facial nerve paralysis after peritonsillar infiltration of bupivacaine: A case report. Am J Otolaryngol 2005;26:406-7.  Back to cited text no. 8
Boliston TA, Upton JJ. Infiltration with lignocaine and adrenaline in adult tonsillectomy. J Laryngol Otol 1980;94:1257-9.  Back to cited text no. 9
Lee KS, Lin KL, Chen YC. Peripheral facial palsy after adenotonsillectomy in children. Int J Pediatr Otorhinolaryngol 2012;76:1379-81.  Back to cited text no. 10
Watanabe K, Kunitomo M, Yamauchi Y, Kimura M, Masuno S, Aoki H, et al. Subcutaneous emphysema after tonsillectomy: A case report. J Nippon Med Sch 2004;71:111-3.  Back to cited text no. 11
Kountakis SE. Effectiveness of perioperative bupivacaine infiltration in tonsillectomy patients. Am J Otolaryngol 2002;23:76-80.  Back to cited text no. 12
Alsarraf R, Sie KC. Brain stem stroke associated with bupivacaine injection for adenotonsillectomy. Otolaryngol Head Neck Surg 2000;122:572-3.  Back to cited text no. 13


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