Learning Objectives: To help the evolving surgeon to handle the facial nerve with confidence in extensive cholesteatoma, tips to preserve function and methods of handling injury.

Introduction: The facial nerve passes through the middle ear in its bony canal that is sometimes eroded in cholesteatoma, exposing the nerve trunk to injury during instrumentation. There are a few surgical tips to avoid injury and to repair after injury has happened.

Methods: In MESIARC, a tertiary otologic center, various cases of facial nerve palsy secondary to cholesteatoma , or attempted cholesteatoma surgery are handled. By careful understanding of anatomy,use of good magnification, proper instrumentation and meticulous care, we have been able to preserve facial nerve in most of the cases where it has been affected by disease or surgery. In rare cases where this could not be done, a variety of techniques have been used to correct the cosmetic effect of facial paralysis

Results: We have had 18 cases of facial nerve palsy secondary to cholesteatoma extension, six cases of surgical damage to the facial nerve during cholesteatoma surgery. Most of the cases of primary facial palsy due to disease were decompressed with near total recovery of function. Of the post surgical injury, two were managed with cable grafting, one with cross facial anastamosis, one with temporalis swing and the rest were decompressed with reasonable return to function.

Conclusions: A structured approach to the facial nerve helped with radiologic planning is of paramount importance in preservation of facial nerve function after injury either due to disease or previous surgery. A variety of techniques must be available in our armamentarium as no two patients are the same.

Learning Objectives: This presentation gives important tips to assess the facial nerve from a three dimensional view point, study of radiology of the facial nerve and the array of techniques at our disposal for preservation and repair.