Global assessment of outcomes after varying reinnervation techniques for patients with facial paralysis subsequent to acoustic neuroma excision

Hypoglossal Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-Analysis

Background: Hypoglossal-facial nerve (12-7) anastomosis can restore symmetry and voluntary movement on the face in patients with facial nerve paralysis. Traditional 12-7 transfer includes direct end-to-end nerve anastomosis, sacrificing the entire hypoglossal nerve. Contemporary, end-to-side anastomosis, or split anastomosis techniques limit tongue morbidity by preserving some hypoglossal nerve. Direct outcome comparisons between these techniques are limited. Objective: To compare reported outcomes of facial movement, tongue, speech, and swallow outcomes among the different types of hypoglossal-facial nerve anastomosis schemes. Evidence Review: For this systematic review and meta-analysis, a comprehensive strategy was designed to search PubMed, Scopus, and the Cochrane Database from inception to January 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, reporting guideline yielding 383 results. Any participant who underwent 12-7 transfer using any of the three techniques, with or without an interposition graft, and had documented preoperative and postoperative evaluation of facial nerve function with a validated instrument such as House-Brackmann (HB), was considered for inclusion. Secondary outcomes of synkinesis, tongue atrophy, and speech or swallowing dysfunction were also compared. Forty-nine studies met inclusion criteria, representing data from 961 total patients who underwent 12-7 transfer. Results: The proportion of good HB outcomes (HB I-III) did not differ by anastomosis type: End-to-side and end-to-end anastomosis (73% vs. 59%, p = 0.07), split and end-to-end anastomosis (62% vs. 59%, p = 0.88), and end-to-side anastomosis and split anastomosis (73% vs. 62%, p = 0.46). There was no difference in reported synkinesis rates between the anastomosis types. However, end-to-side anastomosis (z = 6.55, p < 0.01) and split anastomosis (z = 3.58, p < 0.01) developed less tongue atrophy than end-to-end anastomosis. End-to-side anastomosis had less speech/swallowing dysfunction than end-to-end anastomosis (z = 3.21, p < 0.01). Conclusion: End-to-side and split anastomoses result in similar HB facial nerve outcomes as the traditional end-to-end 12-7 anastomosis. End-to-side anastomosis has decreased complications of tongue atrophy and speech/swallow dysfunction compared to end-to-end anastomosis. In addition, split anastomosis has decreased rates of tongue atrophy compared to end-to-end anastomosis.

Assessing the Efficacy of Anastomosis between Ansa Cervicalis and Facial Nerve for Patients with Concomitant Facial Palsy and Peripheral Neuropathy

Background: For decades, patients with facial asymmetry have experienced social interaction difficulties, leading them to seek treatment in the hope of restoring facial symmetry and quality of life. Researchers evaluated numerous surgical techniques, but achieving results remains a significant hurdle. Specifically, anastomosis between the ansa cervicalis (AC) and facial nerve (FN) can hinder the patient's physical appearance. Objective: Our study goal was to examine the efficiency of anastomosis between AC and FN for facial motor function recovery even in the presence of peripheral neuropathy. Materials and Methods: Four patients diagnosed with facial palsy grade VI on the House & Brackmann Scale (HB) after vestibular schwannoma (VS) resection (Koos grade IV) via the retrosigmoid approach underwent AC and FN anastomosis. Outcomes were related to tumor grade, previous therapy, and the time between postoperative facial palsy and anastomosis. Images and neurophysiological data were evaluated. Results: After vs. resection, all four patients demonstrated HB grade VI facial palsy for an average of 17 months. During the follow-up program, lasting between 6 and 36 months, two patients were evaluated as having HB grade III facial palsy; the other two patients were diagnosed with grade IV HB facial palsy. None of the patients developed tongue atrophy, speech disorder, or masticatordys function. Conclusions: Anastomosis between the AC and FN is a safe and effective treatment for facial paralysis after cerebellopontine tumor resection. Nerve reanimation may be feasible even for patients with peripheral polyneuropathy. This study also offers a new option for patients with a progression-free status.

Quality of life reporting in the management of posterior fossa tumours: A systematic review

Introduction

Survival amongst posterior fossa tumour (PFT) patients is improving. Clinical endpoints such as overall survival fail to depict QoL. There is yet to be a review of current QoL instruments used for adult PFTs. Aim of this review is to outline the QoL reporting in the management of PFTs and measure participation level.

Methods

This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis. A search strategy to identify adult patients with PFTs who took part in QoL metrics was conducted. Observational and experimental studies published from 1990 to date were included. Studies with a sample size less than 10 and performance measures such as Karnofsky Performance Status were not considered.

Results

A total of 116 studies were included in the final analysis. Vestibular schwannomas were the most common tumour pathology (n = 23,886, 92.6%) followed by pilocytic astrocytomas (n = 657, 2.5%) and meningiomas (n = 437, 1.7%) Twenty-five different QoL measures were used in the study pool. SF-36 was the most common (n = 55, 17 47.4%) QoL metric in the whole study pool, followed by the Penn Acoustic Neuroma QoL scale (n = 24, 20.7%) and Dizziness Handicap Inventory (n = 16, 13.8%). Seventy-two studies reported less-than 100% participation in QoL evaluation. The commonest reason for non-participation was a lack of response (n = 1,718, 60.8%), incomplete questionnaires (n = 268, 9.4%) and cognitive dysfunction (n = 258, 9.1%).

Conclusion

Informed clinical decision-making in PFT patients requires the development of specific QoL outcomes. Core outcome sets, and minimal clinically important differences (MCID) are essential for these metrics to show clinically significant improvements in patient QoL.

Contribution and safety of the side-to-end hypoglossal-to-facial transfer in multidisciplinary facial reanimation

BACKGROUND

This study evaluates facial and tongue function in patients undergoing side-to-end hypoglossal-to-facial transfer (HFT) with additional techniques.

METHODS

Thirty-seven patients underwent a side-to-end HFT. Twelve had additional cross-face grafts, and 9 had an additional masseter-to-facial transfer. Facial was assessed with House-Brackmann (HB), Sunnybrook Facial Grading Scale (SFGS), and eFACE. Martins scale and the Oral-Pharyngeal Disability Index (OPDI) were used to assess tongue function.

RESULTS

Ninety-four percent of cases reached HB grades III-IV. Mean total SFGS score improved from 16 ± 15 to 59 ± 11, while total eFACE score from 52 ± 13 to 80 ± 5. Dual nerve transfers were a predictor for a better eFACE total score p = 0.034, β = 2.350 [95% CI, 0.184-4.516]), as well as for a higher SFGS total score (p = 0.036, β = 5.412 [95% CI, 0.375-10.449]). All patients had Martin's grade I. Mean postoperative OPDI scores were 84 ± 17 (local physical), 69 ± 16 (simple and sensory motor components), 82 ± 14 (complex functions), and 73 ± 22 (psychosocial).

CONCLUSIONS

The side-to-end HFT offers predictable facial function outcome and preserves tongue function in nearly all cases. Dual nerve transfers appear to improve the final outcome.

Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives

Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury.

Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base.

Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones.

Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.

Hypoglossal and Masseteric Nerve Transfer for Facial Reanimation: A Systematic Review and Meta-Analysis

Background: Hypoglossal and masseteric nerve transfer are currently the most popular cranial nerve transfer techniques for patients with facial paralysis. The authors performed a systematic review and meta-analysis to compare functional outcomes and adverse effects of these procedures. Methods: A review of online databases was performed to include studies with four or more patients undergoing hypoglossal or masseter nerve transfer without muscle transfer or other cranial nerve transposition. Facial nerve outcomes, time to reinnervation, and adverse events were pooled and studied. Results: A total of 71 studies were included: 15 studies included 220 masseteric-facial transfers, and 60 studies included 1312 hypoglossal-facial transfers. Oral commissure symmetry at rest was better for hypoglossal transfer (2.22 ± 1.6 mm vs. 3.62 ± 2.7 mm, p = 0.047). The composite Sunnybrook Facial Nerve Grading Scale was better for masseteric transfer (47.7 ± 7.4 vs. 33.0 ± 6.4, p < 0.001). Time to first movement (in months) was significantly faster in masseteric transfer (4.6 ± 2.6 vs. 6.3 ± 1.3, p < 0.001). Adverse effects were rare (<5%) for both procedures. Conclusions: Both nerve transfer techniques are effective for facial reanimation, and the surgeon should consider the nuanced differences in selecting the correct procedure for each patient.

Functional Outcome and Quality of Life After Hypoglossal-Facial Jump Nerve Suture

Background: To evaluate the face-specific quality of life after hypoglossal-facial jump nerve suture for patients with long-term facial paralysis.

Methods: A single-center retrospective cohort study was performed. Forty-one adults (46% women; median age: 55 years) received a hypoglossal-facial jump nerve suture. Sunnybrook and eFACE grading was performed before surgery and at a median time of 42 months after surgery. The Facial Clinimetric Evaluation (FaCE) survey and the Facial Disability Index (FDI) were used to quantify face-specific quality of life after surgery.

Results: Hypoglossal-facial jump nerve suture was successful in all cases without tongue dysfunction. After surgery, the median FaCE Total score was 60 and the median FDI Total score was 76.3. Most Sunnybrook and eFACE grading subscores improved significantly after surgery. Younger age was the only consistent independent predictor for better FaCE outcome. Additional upper eyelid weight loading further improved the FaCE Eye comfort subscore. Sunnybrook grading showed a better correlation to FaCE assessment than the eFACE. Neither Sunnybrook nor eFACE grading correlated to the FDI assessment.

Conclusion: The hypoglossal-facial jump nerve suture is a good option for nerve transfer to reanimate the facial muscles to improve facial motor function and face-specific quality of life.

Comparison between VII-to-VII and XII-to-VII coaptation techniques for early facial nerve reanimation after surgical intra-cranial injuries: a systematic review and pooled analysis of the functional outcomes

The surgical injury of the intracranial portion of the facial nerve (FN) is a severe complication of many skull base procedures, and it represents a relevant issue in terms of patients' discomfort, social interactions, risk for depression, and social costs. The aim of this study was to investigate the surgical and functional outcomes of the most common facial nerve rehabilitation techniques. The present study is a systematic review of the pertinent literature, according to the PRISMA guidelines. Two different online medical databases (PubMed, Scopus) were screened for studies reporting the functional outcome, measured by the House-Brackman (HB) scale, and complications, in FN early reanimation, following surgical injuries on its intracranial portion. Data on the VII-to-VII and XII-to-VII coaptation, the surgical technique, the use of a nerve graft, the duration of the deficit, and complications were collected and pooled. The XII-to-VII end-to-side coaptation seems to provide higher chances for functional restoration (HB 1-3) than the VII-to-VII (68.8% vs 60.6%), regardless of the duration of the palsy deficit, the use or not of a nerve graft, and the use of stitches or glues. However, its complication rate was as high as 28.6%, and a second procedure is then often needed. The XII-to-VII side-to-end coaptation is the most effective in providing a functional outcome (HB 1-3), even though it is associated to a higher complication rate. Further trials are needed to better investigate this relevant topic, in terms of health-related social costs and patients' quality of life.

Deep Temporal Nerve Transfer for Facial Reanimation: Anatomic Dissections and Surgical Case Report

BACKGROUND

Facial nerve palsy is a disabling condition that may arise from a variety of injuries or insults and may occur at any point along the nerve or its intracerebral origin.

OBJECTIVE

To examine the use of the deep temporal branches of the motor division of the trigeminal nerve for neural reconstruction of the temporal branches of the facial nerve for restoration of active blink and periorbital facial expression.

METHODS

Formalin-fixed human cadaver hemifaces were dissected to identify landmarks for the deep temporal branches and the tension-free coaptation lengths. This technique was then utilized in 1 patient with a history of facial palsy due to a brainstem cavernoma.

RESULTS

Sixteen hemifaces were dissected. The middle deep temporal nerve could be consistently identified on the deep side of the temporalis, within 9 to 12 mm posterior to the jugal point of the zygoma. From a lateral approach through the temporalis, the middle deep temporal nerve could be directly coapted to facial temporal branches in all specimens. Our patient has recovered active and independent upper facial muscle contraction, providing the first case report of a distinct distal nerve transfer for upper facial function.

CONCLUSION

The middle deep temporal branches can be readily identified and utilized for facial reanimation. This technique provided a successful reanimation of upper facial muscles with independent activation. Utilizing multiple sources for neurotization of the facial muscles, different potions of the face can be selectively reanimated to reduce the risk of synkinesis and improved control.

Endoscopic Transcanal Approach to Geniculate Ganglion Hemangioma and Simultaneous Facial Nerve Reinnervation: A Case Report

Hemangioma of the facial nerve (FN) is a very rare benign tumor whose origin is the vascular plexi that surround the nerve. The transpetrous, retrosigmoid, and middle cranial fossa (MCF) routes are the traditional and most widely used approaches to reach these lateral skull base neoformations. However, this very complex region can be reached through an exclusive transcanal endoscopic procedure in selected cases. One of these was a 42-year-old patient who had been presenting a worsening left FN paralysis (grade VI according to the House-Brackmann scale at the time of visit) for 22 months without a history of trauma or infection. Radiological studies showed a lesion in the region of the geniculate ganglion. A suprageniculate endoscopic approach was performed to remove the lesion, with the sacrifice of the FN and a simultaneous hypoglossal-facial anastomosis. The aim of this minimally invasive surgery is the complete excision of the disease, maintaining the hearing function intact and restoration of facial function, whenever possible, avoiding more invasive approaches.

Comparison of 4 Different Methods for Direct Hypoglossal-Facial Nerve Anastomosis in Rats

BACKGROUND

Classic hypoglossal-facial nerve anastomosis inevitably causes hemitongue atrophy and dysfunction. Thus, many variants have been developed to reduce tongue-related morbidities. A comparative study concerning these techniques was conducted in rats to systematically evaluate long-term functional and histologic outcomes of the recipient and donor systems.

METHODS

Rats (8 per group) were treated by end-to-end neurorrhaphy (EEN), EEN using the hemisectioned and longitudinally split donor nerve (EEN-Hemi), end-to-side neurorrhaphy through a perineurial window (ESN-PW), or 30% to 40% partial neurotomy (ESN-PN). Four additional rats were left intact. At 8 months postoperatively, behavioral, electrophysiologic, and morphologic studies were carried out to compare the groups.

RESULTS

All techniques resulted in partial functional recovery, but complete restoration was not obtained. There were no significant differences between the experimental groups in axon diameter or myelin thickness. The facial nerve fiber count after ESN-PN, but not after EEN-Hemi or ESN-PW, was comparable with that after EEN, which agreed with the behavioral and electrophysiologic results. The hypoglossal nerve fiber count after ESN-PN was slightly less than that after ESN-PW, but markedly more than that after EEN-Hemi, corresponding to the electrophysiologic examination. Quantitative measures of muscle fiber cross-sectional area and connective tissue area density of the tongue demonstrated severe muscle atrophy on the operated side after EEN and EEN-Hemi when compared with ESN-PW and ESN-PN.

CONCLUSIONS

ESN with 30% to 40% partial donor neurotomy offers the best balance between motor reinnervation and donor deficits. The method of nerve split for provision of hemihypoglossal nerve stump may not effectively preserve the tongue function.

Nonmotor disabilities in patients with facial palsy measured by patient-reported outcome measures

OBJECTIVES/HYPOTHESIS

To describe changes of motor and nonmotor disabilities in patient with peripheral facial palsy (FP) during treatment using the patient-reported outcome measures (PROMs) Facial Clinimetric Evaluation (FaCE), Facial Disability Index (FDI), and Short Form 36-Item Questionnaire (SF-36) and to analyze predictors for these changes

STUDY DESIGN

Prospective, single-center longitudinal study.

METHODS

One hundred twenty patients with FP underwent at least two PROMs between 2012 and 2015. Predictors for changes of the PROMs were analyzed univariately using Pearson's correlation and multivariately using linear regression models.

RESULTS

The mean interval between onset of FP to first presentation was 29 ± 64 months and between first and final assessment 8.7 ± 7.2 months. Initial House-Brackmann grading was 4.0 ± 1.3 and final House-Brackmann grading was 2.8 ± 1.6 (P < .001). All mean FaCE and FDI but only some SF-36 subscores improved over time (all P < .05). Adjuvant treatment was an independent predictor for improvement of the FaCE Facial Comfort subscore (P = .015) and a malignant tumor as primary disease for improvement of the FaCE Oral Function subscore (P = .044). Unemployment was a predictor for improvement of the FDI Social/Well-Being Function (P = .035). First assessment <90 days after onset was a predictor for improvement of the SF-36 Bodily Pain subscore (P = .025), a primary malignant disease for improvement of the SF-36 General Health perception (P = .004), and idiopathic FP for improvement of the SF-36 Social Functioning subscore (P = .017).

CONCLUSIONS

Changes of motor function revealed by classical grading systems mostly do not correlate with changes of nonmotor disabilities during treatment of FP. Many other factors are associated with changes of PROMs during the FP treatment.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1516-1523, 2016.

Stitchless fibrin glue-aided facial nerve grafting after cerebellopontine angle schwannoma removal: technique and results in 15 cases

AIM OF THE STUDY

To evaluate the results of facial nerve (FN) grafting using great auricular cable graft and fibrin glue without suturing to palliate FN disruption after removal of large cerebellopontine angle (CPA) vestibular schwannoma (VS) or facial nerve schwannoma (FNS). To assess whether tumor size and origin influenced the results.

STUDY DESIGN AND SETTING

Retrospective review of all patients having undergone removal of FNS/VS and needing intraoperative FN repair between 2001 and 2011.

INTERVENTION

FN was rehabilitated using great auricular nerve cable graft and fibrin glue (Tisseal) without stitching suture.

MAIN OUTCOME MEASURES

All data recorded were reviewed to access age, sex, tumor type, and tumor size according to the Koos classification and presenting symptoms. FN function was evaluated preoperatively and at 18 months using the House-Brackmann (HB) grading system.

RESULTS

Among the 595 patients operated for CPA schwannomas in this period, 15 patients (2.5%) underwent FN repair, including 7 cases of FNS and 8 cases of VS. Tumor removal was total in all cases. FN recovery was HB3 in 13 cases (86.7%) and HB4 in 2. The mean time to the first clinical signs of facial reinnervation was 10 months (6-12 mo). No significant relation was found between postoperative facial function and tumor size or type, even if all cases of preoperative FP were noted in FNS.

CONCLUSION

Immediate FN reconstruction with fibrin glue-aided greater auricular nerve graft can effectively restore FN function with excellent outcomes. The results seem better than those observed by other authors using sutured grafts or delayed hypoglossal-facial nerve anastomosis.

Functional and social limitations after facial palsy: expanded and independent validation of the Italian version of the facial disability index

BACKGROUND

The Facial Disability Index (FDI) is widely used for self-assessment of functional impairment and quality of life in patients with facial palsy.

OBJECTIVE

The study aim was to complete the validation of the FDI by generating an Italian version (IT-FDI) and evaluating its clinimetric properties.

DESIGN

This was a longitudinal, observational measurement study.

METHODS

The questionnaire was translated, cross-culturally adapted, and administered to 100 consecutive participants (outpatients) with facial palsy. The clinical severity of facial palsy, impairments in physical and social function, and quality of life were evaluated with the Sunnybrook Facial Grading System, IT-FDI, and 12-Item Short-Form Health Survey.

RESULTS

The IT-FDI showed excellent test-retest reliability for every item and for total scores (intraclass correlation coefficients of .93 and .84 for physical function subscale and social/well-being function subscale, respectively). The IT-FDI confirmed the high internal consistency of the original version, with theta coefficients of .82 for the physical function subscale and .78 for the social/well-being function subscale. The physical function subscale correlated with the Sunnybrook Facial Grading System composite score (r=.44), and the social/well-being function subscale correlated with the 12-Item Short-Form Health Survey mental component (r=.55). The IT-FDI confirmed the good responsiveness of the original version, as expressed by effect size, standardized response mean, and responsiveness ratio of, respectively, 1, 1.03, and 1.21 for the physical function subscale and 0.75, 0.83, and 1.15 for the social/well-being function subscale.

LIMITATIONS

Responsiveness was evaluated with a limited number of participants.

CONCLUSIONS

The results demonstrated the test-retest reliability for all items of the FDI and confirmed its internal consistency, construct validity, and responsiveness with an independent and larger clinical subset. This study completes the validation of the FDI and provides the first validated questionnaire in Italian for assessment of disability and quality of life specifically in patients with facial palsy.

End-to-Side Interposed Donor Grafting as a Facial Nerve Reinforcement Technique after Vestibular Schwannoma Surgery

Objectives:

This retrospective case review was performed to determine the facial function outcome of an end-to-side interposed donor grafting technique in patients who had a nonresponsive and partially injured facial nerve during a translabyrinthine approach for vestibular schwannoma resection.

Methods:

The study included patients with silent electrophysiological tests after partial injury of the facial nerve during translabyrinthine schwannoma resection surgery in a tertiary referral hospital. The patients underwent end-to-side interposed donor grafting as a facial nerve reinforcement technique, and we evaluated their facial function after 1 year of follow-up.

Results:

Four cases with intact preoperative facial function were included (3 men and 1 woman). All patients had a lack of electrical response from the facial nerve and partial anatomic injury after a translabyrinthine approach. An end-to-side interposed donor grafting technique was performed. The donor grafts used were the sural nerve (2 patients), superior vestibular nerve (1 patient), and greater auricular nerve (1 patient). All patients achieved a good House-Brackmann grade. Ocular adjuvant procedures were performed in all patients.

Conclusions:

Immediate repair of the facial nerve with an interposed donor graft may provide better facial function in patients who have no electrical response from a partially injured facial nerve after vestibular schwannoma surgery.

Hemihypoglossal-facial nerve anastomosis for facial nerve palsy

BACKGROUND AND PURPOSE

Commonly used classic hypoglossal (CN XII) to facial nerve (CN VII) anastomosis has the disadvantage of tongue hemiatrophy. Thus, various attempts have been made to modify this method to reduce the tongue damage. The aim of this report was to present the results of hemihypoglossal-facial nerve anastomosis (HHFA) technique in relation to facial muscles reanimation and hemitongue atrophy.

MATERIAL AND METHODS

The first 7 consecutive patients who underwent CN VII anastomosis with half of the CNXII, for which the follow-up period exceeded 12 months, were analysed. During the procedure, CN VII was transected as proximally as possible after drilling the mastoid process. CN XII was separated longitudinally into two parts at a short distance to allow suture of the stumps without any tension. One half of CN XII was transected and sutured to the distal stump of CN VII. Recovery from facial palsy was quantified with the House-Brackmann grading system (HB). Tongue function was assessed according to the scale proposed by Martins.

RESULTS

Features of initial reinnervation of facial muscles were visible after 6 months in all 7 patients. All patients achieved satisfactory outcome of CN VII regeneration (HB grade III) until the last control examination (12-27 months after surgery, mean 16). No or minimal tongue atrophy without deviation (grades I-II according to the Martins scale) was found in 4 patients. Mild hemiatrophy with tongue deviation < 30 degrees (grade III) was visible in 3 patients.

CONCLUSIONS

In our experience, HHFA is effective treatment of facial palsy and gives a chance to reduce damage of the tongue.

Sunnybrook and House-Brackmann Systems in 5397 Facial Gradings

Objectives. To study the correlation between Sunnybrook and House-Brackmann facial grading systems at different time points during the course of peripheral facial palsy.

Study Design. Prospective multicenter trial.

Setting. Seventeen otorhinolaryngological centers.

Subjects and Methods. Data are part of the Scandinavian Bell’s palsy study. The facial function of 1920 patients with peripheral facial palsy was assessed 5397 times with both Sunnybrook and House-Brackmann (H-B) facial grading systems. Grading was done at initial visit, at days 11 to 17 of palsy onset, and at 1 month, 2 months, 3 months, 6 months, and 12 months. Statistical evaluation was by Spearman correlation coefficient and box plot analysis.

Results. Spearman correlation coefficient varied from −0.81 to −0.96, with the weakest correlation found at initial visit. Box plot analysis for all assessments revealed that Sunnybrook scores were widely spread over different H-B grades. With 50% of the results closest to the median, Sunnybrook composite scores varied in H-B grades as follows: H-B I, 100; H-B II, 71 to 90; H-B III, 43 to 62; H-B IV, 26 to 43; H-B V, 13 to 25; and H-B VI, 5 to 14.

Conclusion. Gradings correlated better in follow-up assessments than at initial visit. As shown by the wide overlap of the grading results, subjective grading systems are only approximate. However, a conversion table for Sunnybrook and H-B gradings was obtained and is included in the article. It can be used for further development of facial grading systems.

Facial paralysis rehabilitation: state of the art

PURPOSE OF REVIEW

Surgical management of facial paralysis continues to undergo evolution. Advances made in management reflect the challenging nature of facial paralysis and the drive to ever improve outcomes.

RECENT FINDINGS

Recent advances have been made in neuronal transfers using the masseteric nerve, minimally invasive static procedures, and dynamic transfer of the temporalis tendon.

SUMMARY

Continued evolution of techniques for the management of facial paralysis is reflected in the current literature. Broader application of neuronal transfers, minimally invasive static procedures, and orthodromic temporalis tendon transfer, among other techniques, indicates a vibrant field of surgeons who pursue ever better results for patients with facial paralysis.