Facial Nerve Stimulation Following Cochlear Implantation: Efficacy of a Stepped Management Approach

Purpose: Facial nerve stimulation (FNS) represents a significant complication of cochlear implantation (CI), yet its risk factors and optimal management strategies remain incompletely understood. Method: This study investigated 3750 CI recipients, identifying 265 cases (7.07%) of FNS, to evaluate its incidence and therapeutic outcomes using a novel stepped management protocol. Results: Analysis revealed a significant association between FNS and specific underlying etiologies (χ² = 27.10, P < .001), with large cavity malformation emerging as the predominant anatomical risk factor (Adjusted Residual = +3.12). Temporal distribution analysis demonstrated that 34.7% of FNS cases occurred within 1 week of device activation, while 26.0% manifested more than 1 year postimplantation, suggesting progressive etiologies such as electrode fibrosis. A four-tiered stepped management strategy was employed based on FNS severity: Grade 2 (mild, n = 62) achieved 100% resolution through programming adjustments, including pulse width reduction and bipolar stimulation; Grade 3 (moderate, n = 97) exhibited a 46.4% complete remission rate (45/97) with adjunctive steroid therapy; Grade 4 (severe, n = 87) showed improvement following selective electrode deactivation, with 55.2% downgraded to Grade 3 and 44.8% to Grade 2; and Grade 5 (refractory, n = 19) necessitated surgical revision. Conclusion: These findings underscore the importance of preoperative imaging in identifying high-risk patients, such as those with cochlear malformations, and demonstrate the efficacy of a stratified management approach in achieving symptom control. This study also establishes a robust, patient-centered framework for managing FNS in CI recipients, emphasizing adaptability to individual clinical profiles and optimizing therapeutic outcomes. Level of Evidence for the Manuscript: Level 3.