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June 3, 2026Neurosurgery0 citations

Antiviral Prophylaxis for Delayed Facial Nerve Palsy Following Vestibular Schwannoma Resection: Single Institutional Series With Systematic Literature Review and Meta-Analyses of 7136 Patients

RBRachel BlueUniversity of Colorado Anschutz Medical Campus RAReinier AlvarezUniversity of Colorado Boulder BHBrianna HinesTulane University

Key Points

This research aims to evaluate the incidence and risk factors of delayed facial nerve palsy following vestibular schwannoma resection and assess the effectiveness of antiviral prophylaxis.
Retrospective analysis of 301 patients undergoing vestibular schwannoma resection from October 2014 to October 2024.
Systematic review and meta-analysis of 28 studies, including relevant data on DFNP incidence and prophylactic strategies.
Valacyclovir administered 1000 mg TID for 7 days, starting 3 days preoperatively.
DFNP occurred in 5% of the institutional cohort; no significant difference between valacyclovir and non-valacyclovir groups (6% vs. 3%, P=0.42).
Early postoperative House-Brackmann grades III-IV were strong predictors of DFNP (odds ratio 6.07, P=0.01).
Pooled analysis of 28 studies showed a reduced risk of DFNP with antiviral prophylaxis (relative risk 0.73, CI 0.60-0.88; number needed to treat 16).

Abstract

BACKGROUND AND OBJECTIVES: Delayed facial nerve palsy (DFNP) is a recognized complication of vestibular schwannoma resection, with proposed mechanisms including viral reactivation, inflammation, and ischemia. Elevated herpes simplex virus and varicella zoster virus titers and responses to antiviral therapy have been reported, but evidence supporting prophylactic antiviral use remains limited. We evaluated DFNP incidence, risk factors, and outcomes following antiviral prophylaxis using a systematic review, meta-analysis, and institutional cohort. METHODS: We conducted a 2-part study: (1) retrospective analysis of patients undergoing vestibular schwannoma resection by a single surgeon (October 2014-October 2024) and (2) systematic review and meta-analysis of DFNP incidence and prophylactic strategies. A standardized valacyclovir protocol (1000 mg TID for 7 days starting 3 days preoperatively) was implemented in June 2015. DFNP was defined as a ≥2-grade House-Brackmann (HB) worsening occurring between postoperative days 5 to 30. PubMed and Embase were searched in February 2025 per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: In the institutional cohort (n = 301), DFNP occurred in 5%, with no significant difference among patients receiving valacyclovir (6% vs 3%, P = .42). Early postoperative HB grades III-IV was the strongest predictor of DFNP with odds ratio 6.07 (P = .01). Meta-analysis of 28 studies (n = 6835), combined with our cohort (total n = 7136), demonstrated a background DFNP incidence of 12.8%. Over 80% of patients recovered to HB grades I-II regardless of treatment. Five studies, including our cohort, provided comparative prophylaxis data; pooled analysis of antiviral prophylaxis showed a significantly reduced risk of DFNP (relative risk 0.73, CI 0.60-0.88; number needed to treat 16). CONCLUSION: DFNP is an unpredictable but typically self-limited postoperative complication. Although no significant prophylactic effect was observed in our institutional cohort, pooled data suggest that antiviral prophylaxis may meaningfully reduce DFNP incidence, supporting its perioperative use and the need for larger prospective studies.

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