Rare Case of Bilateral Facial Paralysis with Labrynthine Fistula in A Patient Diagnosed As Takayasu Syndrome

Complications of unsafe chronic otitis media are on decline since the advent of newer antibiotics & with the early referral to the specialists & the higher centres. The known complications are meningitis, sigmoid sinus thrombophlebitis, brain absceses, labyrinthine fistula, mastoiditis, facial nerve paralysis. Here we are citing a case having bilateral facial palsy with bilateral labyrinthine fistula in the patient having Takayasu’s syndrome. Takayasu’s disease is arteritis of unknown etiology. It is said to be secondary to tuberculosis. Mostly the young adult females are affected. Patient had history of tuberculosis ten years back. Then she was diagnosed as having Takayasu’s syndrome too. She was operated for ear pathology. Now she developed facial paralysis on both sides & also complaining of giddiness. IntroductionChronic supurative otitis media is of two types, safe & unsafe. The safe type is always secondary to upper respiratory tract infection. Unsafe is due to the blockage of Eustachian tube leading to negative middle ear pressure which causes retraction of the tympanic membrane. The natural cleansing mechanism is hampered. Thus developing retraction pocket which grows slowly. Enlarging pocket may lead to pressure necrosis & also due to enzymatic activity the bone gets eroded. Spread of the disease may also be through preformed pathways or through blood. If the dural plate is eroded there is first formation of subperiosteal abscess and then different brain abscesses may develop. If sinus plate is eroded, subperiosteal abscess develops. Then sinus thrombophlebitis develops. When the bone of semicircular canal is eroded patient gets vertigo due to pressure changes across the fistula. The lateral semicircular canal being anatomically closer to mastoid antrum and aditus gets eroded commonly. The facial nerve canal may also get eroded in its horizontal or vertical part leading to facial nerve paralysis. Our patient presented with bilateral cholesteatoma with bilateral labirynthine fistula and bilateral facial paralysis. Other causes of bilateral facial paralysis are as underTrauma Skull fracture, Parotid surgery, Mastoid surgery. Infection Postinfluenza, Infectious mononucleosis, HIV infection, Lyme disease, Banwarth’s syndrome, Guillain–Barre syndrome, Syphilis, Brainstem encephalitis HTLV-1 infection, poliomyelitis Metabolic Diabetes ,Acute porphyria Neoplastic Acute leukemia, Acoustic neuroma Autoimmune Sarcoidosis, Amyloidosis Neurological Multiple sclerosis, Pseudobulbar and bulbar palsy, Parkinson’s disease Idiopathic Bell’s palsy Takayasu arteritis commonly occurs in woman younger than age 50 years and can manifest as isolated, atypical, and/or catastrophic disease. It can involve any or all of the major organ systems. The disease has been reported in all parts of the world, although it appears to be more prevalent in Asians. Pathophysiology: Takayasu arteritis is an inflammatory disease of largeand medium-sized arteries, with a predilection for the aorta and its branches. Advanced lesions demonstrate a panarteritis with intimal proliferation. Lesions produced by the inflammatory process can be stenotic, occlusive, or aneurysmal. All aneurysmal lesions may have areas of arterial narrowing. Vascular changes lead to the main complications, including hypertension, most often due to renal artery stenosis or, more rarely, Case reportA 51 year old female patient came with the complaints of vertigo since last 6 mths, pain in both the ears with foul smelling discharge since 2 mths & facial weakness from one month. She was operated for right cholesteatoma 15 years back. Same old case papers were showing that she had pulmonary kochs that time. The old reports also revealed that she was diagnosed as having aortoarteritis. General examinationmasked facies, incomplete eye closure on both sides. Pulse in both the upper limbs was not felt.Lower lymb pulse was 78/min, Her carotid pulsations were felt prominently & she had a carotid bruit on right side. BP in lower limbs was 160/66 mm 0f Hg Bell’s phenomenon was positive in both the eyes.(Fig1) Fig.1: Bells phenomenon – preoperative