Learning Objectives:

Facial palsy is a presenting feature of approximately 1% of middle ear cholesteatomas but can be present in up to 50% of cases where the disease involves the petrous apex. The risks of apical disease are thus much higher than for disease confined to the middle ear. Despite greater awareness the diagnosis is often delayed and although prompt treatment usually results in a good outcome the prognosis in established facial paralysis can be difficult to predict.

Middle ear cholesteaomas typically cause paralysis by involvement of the horizontal segment of the nerve whereas the labyrinthine segment is the site most frequently involved in apical disease.

All cases presenting to the author have undergone surgical treatment and patients with middle ear disease and treated surgically within 2 months of presentation all showed some recovery in facial nerve function. In those with apical disease the palsy was often present for many years and facial nerve function did not improve but nor did it deteriorate post-operatively in these more long-standing cases.

Facial nerve palsy associated with cholesteatoma should be treated surgically as early as possible but recovery can still be anticipated, even if treatment is delayed for up to 2 months.