The digital doctor: telemedicine in facial plastic surgery

PURPOSE OF REVIEW

In the setting of the COVID-19 global pandemic, the demand for and use of telemedicine has surged in facial plastic and reconstructive surgery. This review aims to objectively review and summarize the existing evidence for the use of telemedicine within facial plastic surgery.

RECENT FINDINGS

Telemedicine has been successfully implemented among subsets of facial plastic surgery patients, with high patient and provider satisfaction. Although the technology to facilitate telemedicine exists and preliminary studies demonstrate promise, multiple technological, financial, and medical barriers may persist in the postpandemic era.

SUMMARY

Telemedicine will likely continue to grow and expand within facial plastic surgery moving forward, and we should continue to critically evaluate patient selection, access to care, and strategies for effective implementation to enhance current clinical practices.

Automated objective and marker-free facial grading using photographs of patients with facial palsy

PURPOSE

An automated, objective, fast and simple classification system for the grading of facial palsy (FP) is lacking.

METHODS

An observational single center study was performed. 4572 photographs of 233 patients with unilateral peripheral FP were subjectively rated and automatically analyzed applying a machine learning approach including Supervised Descent Method. This allowed an automated grading of all photographs according to House-Brackmann grading scale (HB), Sunnybrook grading system (SB), and Stennert index (SI).

RESULTS

Median time to first assessment was 6 days after onset. At first examination, the median objective HB, total SB, and total SI were grade 3, 45, and 5, respectively. The best correlation between subjective and objective grading was seen for SB and SI movement score (r = 0.746; r = 0.732, respectively). No agreement was found between subjective and objective HB grading [Test for symmetry 80.61, df = 15, p < 0.001, weighted kappa = - 0.0105; 95% confidence interval (CI) = - 0.0542 to 0.0331; p = 0.6541]. Also no agreement was found between subjective and objective total SI (test for symmetry 166.37, df = 55, p < 0.001) although there was a nonzero weighted kappa = 0.2670; CI 0.2154-0.3186; p < 0.0001). Based on a multinomial logistic regression the probability for higher scores was higher for subjective compared to objective SI (OR 1.608; CI 1.202-2.150; p = 0.0014). The best agreement was seen between subjective and objective SB (ICC = 0.34645).

CONCLUSIONS

Automated Sunnybrook grading delivered with fair agreement fast and objective global and regional data on facial motor function for use in clinical routine and clinical trials.

Prognostic Value of the Blink Reflex in Acoustic Neuroma Surgery

OBJECTIVE: The study goal was to demonstrate that blink reflex analysis can predict postoperative facial nerve outcome in cerebellopontine angle tumor surgery.

STUDY DESIGN, SETTING, AND PATIENTS: In an open and prospective study conducted at a single tertiary care center over 3 years, 91 subjects with a vestibular schwannoma filling the internal auditory meatus were enrolled and operated on via a translabyrinthine approach. The difference in latency of the early response (δR1) of the blink reflex between the pathologic side and the healthy side was calculated in every patient during a complete electrophysiologic examination of the facial nerve performed on the day before surgery.

MAIN OUTCOME MEASURES: δR1 was compared with the other preoperative data (tumor volume, facial function), with the perioperative observations (difficulties with the dissection of the facial nerve), and especially with the postoperative status after 1 year. The statistical study was conducted using polynomial regression.

RESULTS: Patients with a negative or zero δR1 have normal facial function at 1 year. For those with a positive δR1 the outcome is not favorable unless the tumor is small. For patients presenting with an immediate complete facial paralysis, the value of δR1 is also indicative of facial function outcome.

CONCLUSION: Statistical analysis shows that the blink reflex, through δR1, has an excellent prognostic value in anticipating the difficulties with facial nerve dissection and postoperative facial function after 1 year.

Total Facial Paralysis after Vestibular Schwannoma Surgery: Probability of Regaining Normal Function

The aim of the present study was to ascertain the precise fraction of vestibular schwannoma cases that recover to normal function after postoperative total facial nerve paralysis and to compare our results with those presented in the literature. This was a retrospective case review of 631 cases. Among the 132 cases with immediate postoperative facial nerve palsy (House Brackmann [HB] grade VI), only 2 (1.5%) recovered to normal function (HB grade I). In an attempt to compare our results with those of other series in the literature, we found a large variation in the incidence of recovery of this group of patients to grade I, ranging from 0% to 50%. Our analysis of the reported data revealed widely varying methods of data collection and presentation, making a scientifically valid comparison particularly difficult. According to our data, complete (HB grade I) or near-complete (HB grade II) facial nerve function recovery from an immediate postoperative grade VI palsy is extremely rare.

Sunnybrook and House-Brackmann Facial Grading Systems: Intrarater repeatability and interrater agreement

OBJECTIVE: To assess repeatability and agreement of the House-Brackmann (H-B FGS) and the Sunnybrook (SFGS) Facial Grading Systems.

STUDY DESIGN AND SETTING: Eight video-recorded facial palsy patients were graded in 2 sittings by 28 doctors. Repeatability and agreement for SFGS were measured by intraclass correlation coefficient (ICC) and coefficient of repeatability (CR), and for H-B FGS by agreement percentage and kappa coefficients.

RESULTS: Repeatability for SFGS was from good to excellent and for H-B FGS from fair to good. Agreement between doctors for SFGS was moderate by CR and nearly perfect by ICC. For H-B FGS, the agreement percentage was 50%, and generalized kappa indicated only fair agreement.

CONCLUSIONS: SFGS was at least as good in repeatability as H-B FGS and showed more reliable results in agreement between doctors.

SIGNIFICANCE: While waiting for an ideal scale for facial grading, the usage of SFGS can be encouraged over H-B FGS.

Reliability of the “Sydney,” “Sunnybrook,” and “House Brackmann” Facial Grading Systems to Assess Voluntary Movement and Synkinesis after Facial Nerve Paralysis

OBJECTIVE: To investigate the extent of within-system reliability and between-system correlation for the “Sydney” and “Sunnybrook” systems of grading facial nerve paralysis, and to examine the interobserver reliability and agreement of the “House Brackmann” grading system.

STUDY DESIGN: A fixed-effects reliability study in which 6 otolaryngologists viewed videotapes of patients with facial nerve paralysis.

SETTING: University and medical Centers.

PATIENTS: Patients with unilateral lower motor neurone facial nerve dysfunction greater than 1 year after onset, none of whom had undergone surgical reanimation procedures.

INTERVENTION: Twenty-one patients with facial nerve paralysis were videotaped while they performed a protocol of facial movements. Six otolaryngologists viewed the videotapes and scored them with the Sydney and Sunnybrook systems, and then gave a House Brackmann grade.

MAIN OUTCOME MEASURE: The 3 systems of grading facial nerve paralysis were evaluated and compared with the use of intraclass correlation coefficients, Pearson's weighted kappa, and percentage exact agreement values.

RESULTS: The Sydney and the Sunnybrook systems had good intrasystem reliability and high intersystem association for the assessment of voluntary movement. Grading of synkinesis was found to have low reliability both within and between systems. The House Brackmann system had substantial reliability as shown by weighted kappa but had a percentage exact agreement of 44%.

CONCLUSIONS: For clinical grading of voluntary movement, there is good correlation between ratings given on the Sydney and Sunnybrook systems, and within each system there is good reliability. The assessment of synkinesis was far less reliable within, and less related between, systems. Although the reliability of the House Brackmann system was found to be high, examination of individual grades revealed some wide variation between trained observers.

[Hypoglossofacial anastomosis for facial palsy treatment: Indications and results]

Hypoglossofacial anastomosis is a classical surgical procedure for the treatment of facial paralysis when the trunk of the facial nerve cannot be repaired and its peripheral branches are normal.

PATIENTS AND METHODS

Between 2004 and 2015, 77 patients were able to benefit from an hypoglossofacial anastomosis. The etiology of the paralysis was mainly the surgery of vestibular schwannoma, tumors of the facial nerve and diseases of the brainstem. A specific and premature speech therapy remediation was realized for all patients in order to preserve the tongue function and to upgrade the facial motricity.

RESULTS

Sixty-nine patients could be studied. The House Brackmann grading scale was used to appreciate the result. Thirty-one patients are grade III, 34 grade IV and in only one case the result is a grade V despite the anastomosis works. The main predictive factor for a good result is a small delay between the onset of the paralysis and the surgery for the rehabilitation. The specific physiotherapy upgrades the result with less side effects of the anastomosis.

CONCLUSION

Hypoglossofacial anastomosis is a simple and reliable surgical procedure for rehabilitation of paralysed face. The quality of the result is linked with an early surgery and a specific physiotherapy.

Quantifying facial paralysis using the Kinect v2

Assessment of facial paralysis (FP) and quantitative grading of facial asymmetry are essential in order to quantify the extent of the condition as well as to follow its improvement or progression. As such, there is a need for an accurate quantitative grading system that is easy to use, inexpensive and has minimal inter-observer variability. A comprehensive automated system to quantify and grade FP is the main objective of this work. An initial prototype has been presented by the authors. The present research aims to enhance the accuracy and robustness of one of this system's modules: the resting symmetry module. This is achieved by including several modifications to the computation method of the symmetry index (SI) for the eyebrows, eyes and mouth. These modifications are the gamma correction technique, the area of the eyes, and the slope of the mouth. The system was tested on normal subjects and showed promising results. The mean SI of the eyebrows decreased slightly from 98.42% to 98.04% using the modified method while the mean SI for the eyes and mouth increased from 96.93% to 99.63% and from 95.6% to 98.11% respectively while using the modified method. The system is easy to use, inexpensive, automated and fast, has no inter-observer variability and is thus well suited for clinical use.

Objective assessment of the severity of unilateral facial palsy using OKAO Vision® facial image analysis software

CONCLUSION

Severity of ipsilateral facial palsy (UFP) can be assessed objectively by use of OKAO Vision®. Facial symmetry percentage (FSP) values were well correlated with the results by two conventional grading systems.

OBJECTIVES

To introduce the basic principle of facial motion analysis using OKAO Vision®, to represent the data measured in patients with UFP, and to show the correlation between the severity of facial palsy assessed by this method and conventional systems.

METHODS

Two independent facial motions, closing the eyes and grinning, were recorded with a video camera. By comparing the movement distances between right and left sides, the eye symmetry ratio (ESR) and grin symmetry ratio (GSR) were obtained. The degree of UFP was assessed by FSP, which was calculated by the formula: FSP = (ESR + GSR)/2 × 100 (%). FSP was measured in 12 normal volunteers and in 30 patients with UFP.

RESULTS

In patients with UFP, varying degrees of FSP were noted corresponding to the grade of facial palsy. The severity of facial palsy assessed by FSP was closely correlated with the Yanagihara score (r = 0.88, p < 0.05) and was inversely related to the House-Brackmann grade (r = -0.90, p < 0.05).

[Advantage of facial rehabilitation after facial palsy]

Visible and immediate trauma, facial palsy (FP) covers functional but also psychological damage and it is essential to evaluate before a comprehensive therapeutic care tailored. Few patients, however, are emerging with a prescription for rehabilitation after a consultation. Why? This rehabilitation is it ignored? Is it absolutely necessary? It is evident in the extension of medical care to minimize the effects. Yet the foundation of rehabilitation is sadly little known and often poorly enforced. In addition to its specificity, this therapy preceded by a report called "pretreatments offers a prognosis for recovery to patient" regardless of the origin and degree of involvement of the PF.

[Facial palsy: update for the practitioner]

The clinical significance of facial palsy hinges on its psychosocial consequences. While its causes are very numerous, several infections account for a majority of cases: Lyme disease, geniculate zoster (Ramsay Hunt syndrome), while the role of HSV-1 in essential (Bell's) palsy remains controversial. Essentials of facial palsy management are discussed, including the importance of the functional grading of palsy, the complexity of Lyme disease serological diagnosis, and its treatment using doxycycline, antiviral and steroids treatment of geniculate zoster, while regarding essential facial palsy, only steroids, but not antiviral have been shown to improve functional recovery.

New classification of rating facial nerve dysfunction

In consideration of the complexity of the physiopathology of the facial nerve and to get a standard model of classification of his dysfunction, it appears evident the necessity in the clinical practice to have a rapid, simple and easy system. Grading of facial function is necessary for evaluating and communicating the spontaneous course and the results of medical and surgical treatment. Different grading scales have been proposed but none has been universally accepted; the author revises the principal systems of classification and proposes a new and easy model.

Primary tumours of the facial nerve: diagnostic and surgical treatment experience in Chinese PLA General Hospital

CONCLUSIONS

The commonest manifestation of facial nerve tumours was facial paralysis, followed by hearing loss. During tumour resection facial nerve continuity should be maintained and reconstructed in one stage wherever possible. If this is not a viable option, second-stage surgery should be performed as soon as possible after surgery.

OBJECTIVE

To summarize the clinical characteristics of tumours of the facial nerve and discuss their diagnosis and treatment.

PATIENTS AND METHODS

Twenty-two cases of primary facial nerve tumours were reviewed. These cases were confirmed pathologically and treated in the Chinese PLA General Hospital during the period 1986-2003, where the clinical manifestations, diagnosis and treatment of this series were analysed.

RESULTS

Among the 22 cases, 14 were facial neurilemmomas, 6 were facial neurofibromas and 2 were facial nerve haemangiomas. The commonest presenting symptom in all cases was facial paralysis (14/22) followed by hearing loss (10/22). Facial paralysis was also the commonest sign of a facial nerve tumour (18/22), followed by a swollen mass in the tympanic cavity (8/22) and a swollen mass in the external auditory canal (5/22). The 22 tumours were totally resected surgically. The function of the facial nerve was normal (grade I) in two cases where the integrity of the nerve was preserved during the operation, grade II in one case and grade III in another case where it was possible to maintain partial continuity of the facial nerve. The facial nerve was reconstructed in one stage when the tumours were resected, with facial-great auricular-facial nerve cable grafting (10 cases) and facial-lateral femoral cutaneous-facial nerve cable grafting (1 case). The facial nerve function consequently recovered to grade II-IV. The second stage facial-hypoglossal nerve anastomosis was carried out in two cases, and facial function consequently recovered to grade II in one case at 3 years and grade III in another with 2 years follow-up. In five cases, the facial nerve remained discontinuous and the facial nerve function showed no recovery (grade VI).

Prospective Study of Facial Nerve Function After Surgical Procedures for the Treatment of Temporomandibular Pathology

PURPOSE

The aim of this prospective study was to report facial nerve injury following surgical procedures for the treatment of temporomandibular pathology, using the House-Brackmann facial nerve grading system (HBFNGS) as a means of classifying and measuring the degree and type of injury.

PATIENTS AND METHODS

The sample consisted of 32 patients who underwent temporomandibular joint (TMJ) surgery. A total of 50 approaches were carried out. Surgical procedures consisted of TMJ reconstruction, gap arthroplasty, eminectomy, bone plates for the treatment of chronic mandibular luxation, and disc plication. Facial nerve function of all patients was evaluated preoperatively and 24 hours after surgery. Patients who presented postoperative facial nerve injury were likewise examined using the HBFNGS at 24 hours, 1 week, 1 month, and 3 months.

RESULTS

Of the 32 patients, 12.5% (ie, 8% of the 50 approaches) showed signs of facial nerve injury after TMJ surgery. The prevalence of postoperative facial nerve injury was significantly greater in the patients who had ankylosis (P = .014) and in those submitted to gap arthroplasty (P = .011). At 24 hours, none of the patients showed total nerve paralysis or severe dysfunction, only a moderately severe dysfunction (50%), or moderate dysfunction (50%). The forehead was the most affected area measured. At 3 months, all patients had recovered their normal facial nerve function. The overall improvement in facial nerve function was 40% for the patients classified initially with moderately severe dysfunction and 60% for those with moderate dysfunction.

CONCLUSION

The frequency of facial nerve injury was related to the diagnosis of the temporomandibular pathology and surgical procedures. Facial nerve impairment was shown to be of a temporary nature. Moreover, there is a need to standardize the reporting of facial nerve recovery.

Grading Facial Nerve Function

OBJECTIVE

To compare the interobserver variability of a new grading system to the currently recommended House-Brackmann Grading Scale.

STUDY DESIGN

Prospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

All patients with a facial nerve paresis/paralysis (whatever the cause).

INTERVENTION

All patients were evaluated for their facial nerve function by three observers, independently, using both the new system and the House-Brackmann Grading Scale.

MAIN OUTCOME MEASURE

The level of agreement between the three observers using both scales.

RESULTS

With the movement, rest, secondary defects, and subjective scoring grading scale, a higher percentage of agreement between the observers was noticed than with the House-Brackmann Grading Scale.

CONCLUSION

The movement, rest, secondary defects, and subjective scoring grading system is more useful for grading facial nerve dysfunction in clinical practice than the House-Brackmann Grading Scale.

The localization of facial motor impairment in sporadic Mobius syndrome

OBJECTIVE

To investigate the neurophysiologic aspects of facial motor control in patients with sporadic Möbius syndrome defined as nonprogressive congenital facial and abducens palsy.

METHODS

The authors assessed 24 patients with sporadic Möbius syndrome by performing a complete clinical examination and neurophysiologic tests including facial nerve conduction studies, needle electromyography examination of facial muscles, and recording of the blink reflex and of the trigeminofacial inhibitory reflex.

RESULTS

Two distinct groups of patients were identified according to neurophysiologic testing. The first group was characterized by increased facial distal motor latencies (DMLs) and poor recruitment of small and polyphasic motor unit action potentials (MUAPs). The second group was characterized by normal facial DMLs and neuropathic MUAPs. It is hypothesized that in the first group, the disorder is due to a rhombencephalic maldevelopment with selective sparing of small-size MUs, and in the second group, the disorder is related to an acquired nervous injury during intrauterine life, with subsequent neurogenic remodeling of MUs. The trigeminofacial reflexes showed that in most subjects of both groups, the functional impairment of facial movements was caused by a nuclear or peripheral site of lesion, with little evidence of brainstem interneuronal involvement.

CONCLUSION

Two different neurophysiologically defined phenotypes can be distinguished in sporadic Möbius syndrome, with different pathogenetic implications.

Graphic-visual adaptation of House-Brackmann facial nerve grading for peripheral facial palsy

OBJECTIVE

To determine if the diagram with schematic drawings of the face based on House-Brackmann facial nerve grading scale can be of easier use than the original grading scale for facial palsy patients.

STUDY DESIGN

Prospective case study of 32 patients with facial palsy.

SETTING

Tertiary referral center-university hospital.

PATIENTS

Patients with different degrees of acute peripheral facial palsy from any cause.

MAIN OUTCOME MEASURES

The patients were photographed and then classified by degree of facial palsy through analysis of the pictures. At first, three of the authors individually utilised the original classification described by House-Brackmann facial nerve grading and then, after 7 days, they employed the illustration table proposed. After 30 days, the same methods were again used by the same authors for both House-Brackmann facial nerve grading and the illustration table.

RESULTS

The analysis of the obtained data reveals that the classification described by House and Brackmann (Otolaryngol. Head Neck Surg. 1985;93:146) presents several items to be evaluated, making it difficult to use and demanding greater time for correct application. On the contrary, the proposed illustration table allows faster evaluation and easier memorisation, not being subject to possible interpretation or translation mistakes, as illustrations are a universal language. Neither method presented absolute reproducibility, however, we found slightly larger concordance indexes among the authors for the proposed illustration table. We noticed average values of reproducibility were approximately 65% in the House-Brackmann classification, and 75% in the evaluation using the diagram of the schematic drawings.

CONCLUSIONS

The authors concluded that the illustration table could be utilised in substitution for the original description of House-Brackmann facial nerve grading; they also concluded that the illustration table allows faster evaluation and easier memorisation.

Functional profile in patients with facial paralysis treated in a myofunctional approach

BACKGROUND

Clinical rehabilitation of peripheral facial paralysis (PFP).

AIM

To delineate the contributions of myofunctional exercises during the flaccid phase of the disorder, before any sequelae.

METHOD

147 promptuaries of patients with facial paralysis were analyzed and divided in two groups according to the period in which rehabilitation began. For the analysis of development, the classifications proposed by House and Brackmann (1985) and Ross et al. (1994) were used.

RESULTS

According to the classification of House and Brackmann (1985), all of the individuals who had sequelae reached level III. However, it was observed that even in cases of severe nerve lesion, cases in which the sequelae were non-acceptable, patients who started treatment at an early stage, revealed a better functional result when evaluated according to the classification of Ross et al. (1994).

CONCLUSION

The myofunctional approach demonstrated to be an effective method for the functional reestablishment in cases of facial paralysis.

Bilateral simultaneous facial paralysis--differential diagnosis and treatment options. A case report and review of literature

Bilateral facial paralysis or paresis of peripheral origin is a rare condition and therefore represents a diagnostic challenge. We here present a case of a previously healthy woman who was hospitalized for symptoms of meningitis. On the second day of her hospital stay, she developed bilateral facial paresis. Later, the patient developed also tachycardia and dysrhythmias. A thorough diagnostic procedure including lumbar puncture, routine blood investigation with serological tests, MRI of the brain, Holter monitoring and transoesophageal echocardiographia, revealed meningitis with radiculitis, facial paresis and myocarditis. The clinical triad of meningitis, radiculitis and facial palsy is known as the Bannwarth Syndrome (Lyme disease). The patient was treated with ceftriaxone and recovered well. Despite repeatedly taken serological tests, Borrelia burgdorferi immunoglobulins were not detected. Acquired bilateral facial paralysis can occur in several diseases of infectious, neurological, idiopathic, iatrogenic, toxic, neoplastic or traumatic origin. In this article, we review the differential diagnoses and treatment options of bilateral facial paresis and present a scheme that is helpful in the diagnostic evaluation of this condition.

A New Classification System for Facial Paralysis in the Clinical Setting

A review of the literature on clinical manifestations of facial paralysis shows a lack of well-integrated, cohesive methods of classification. The aim of the classification system presented here is to provide a clinically relevant, generalized scheme for categorization, focusing on clinical presentation and general etiology. This article will also describe some of the more common conditions that have shaped the organization of the classification charts.

Facial nerve schwannoma

Facial nerve schwannomas are clinically challenging tumors. This is a case study of a young woman with an extensive facial nerve schwannoma. The clinical presentation, radiographic diagnosis, pathological confirmation, and treatment options for this relatively rare tumor are discussed.

Significance of House-Brackmann facial nerve grading global score in the setting of differential facial nerve function

OBJECTIVE

To determine the clinical significance of the House-Brackmann facial nerve grading scale (HBFNGS) in the setting of differential function along the branches of the facial nerve.

STUDY DESIGN

Prospective study of 38 patients with facial palsy who demonstrated differential facial function.

SETTING

Tertiary referral center.

PATIENTS

Patients with facial nerve dysfunction from any cause. Patients with complete facial nerve paralysis (House-Brackmann Grade 6) were excluded.

INTERVENTION

Physicians were provided with printed description of the HBFNGS and asked to report facial nerve function as a traditional global score and as a regional score based on the House-Brackmann scale for the forehead, eye, nose, and mouth. This was reported as F(w) E(x) N(y) M(z), where w, x, y, and z ranged from 1 to 6 based on the HBFNGS. Synkinesis was graded as none, mild, or severe.

MAIN OUTCOME MEASURES

The traditional HBFNGS score was compared with a regional grading facial nerve grading system based on the HBFNGS for the forehead, eye, nose, and mouth. Agreement between the traditional global score and the regional scores was analyzed.

RESULTS

In patients with variable facial weakness, the single House-Brackmann score did not fully communicate their facial function. Further, the single grade did not always correlate with the best or worst function along the four facial regions. The single House-Brackmann score most strongly correlated with the regional scoring of the eye (61%), followed by the nose/midface (40%), mouth (32%), and forehead (18%). The global score did not correlate with the worst regional score in 30 patients (79%). In 3 of 5 patients with synkinesis and an obligatory Grade 3 or higher in the global House-Brackmann grading system, the regional facial function was Grade 2 or better at one or more areas of the face.

CONCLUSIONS

In patients with differential facial function, a single global number is inadequate to describe facial function and primarily reflects the function of the eye. Regional assessment using the HBFNGS and reported as F(w) E(x) N(y) M(z) more fully communicates facial function.

Traumatic facial nerve injuries: review of diagnosis and treatment

Both blunt and penetrating craniofacial trauma may lead to severe facial nerve injury and sequelae of facial paralysis. Initial evaluation involves quantitation of motor deficits using a clinical grading system, such as the House-Brackmann scale. High resolution computed tomography is used for localization of nerve injury in suspected cases of temporal bone trauma. In the absence of gross radiographic abnormalities, electrophysiologic testing helps predict the likelihood of spontaneous recovery. In patients with deteriorating facial nerve injuries by electroneuronography, surgical exploration is the preferred management. Primary end-to-end neurorrhaphy is the preferred management for transection injuries, while facial nerve decompression may benefit other forms of high-grade nerve trauma. Secondary facial reanimation procedures, such as cranial nerve crossovers, dynamic muscle slings or various static procedures, are useful adjuncts when initial facial nerve repair is unsuccessful or impossible. A review of facial nerve trauma management and case illustrations are presented.

Reliability of the Sunnybrook Facial Grading System by novice users

OBJECTIVES

To evaluate the intrarater and inter-rater reliability of the Sunnybrook Facial Grading System (SFGS) by novice users.

DESIGN

Prospective interval study using one measurement instrument.

SETTING

Tertiary teaching hospital (Sunnybrook & Women's College Health Science Centre).

METHODS

Twenty-two patients with a wide spectrum of facial dysfunction recorded on videotapes were rated using the SFGS by eight novice observers independently in two different sittings separated by 3 weeks. The order of patients was randomized for the second sitting. Intraclass correlation coefficients were calculated for component scores and for total scores within and between raters.

RESULTS

The intrarater reliability coefficients for the eight raters ranged from .838 to .929. This largely overlaps with the data obtained in previous studies with expert raters. The inter-rater reliability for all eight raters at time 1 was .982 and for time 2 was .970. This is higher than what was previously obtained with expert raters.

CONCLUSION

The SFGS is as reliable when applied by novice users as by expert users.

Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale

OBJECTIVE

To develop and validate a patient-based instrument to measure both facial impairment and disability, the Facial Clinimetric Evaluation (FaCE) Scale.

STUDY DESIGN

Prospective instrument validation.

METHODS

Eighty-six patients with a documented history of facial paralysis completed a preliminary, 51-item instrument (alpha FaCE Scale), as well as the previously developed Facial Disability Index (FDI) and the Medical Outcomes Study Short Form 36 Item Questionnaire (SF-36). Two weeks after completing these instruments, 76 patients again completed the alpha FaCE Scale. Forty-one of the patients were also evaluated using the House-Brackmann Grading System (HBGS) and the Facial Grading System (FGS).

RESULTS

Exploratory principal component factor analysis grouped 15 FaCE Scale items into 6 impairment and disability categories (domains), forming the beta FaCE Scale. Overall, the test-retest reliability of the FaCE Scale was high (Spearman's correlation coefficient (r) = 0.88, P <.01), as were the reliability coefficients of the individual domains (r = 0.81-0.92, P <.01). The FaCE Scale domains showed appropriate correlation to global visual analogue scale questions posed on the original alpha FaCE Scale (r = 0.65-0.81, P <.01). Overall, the FaCE Scale showed significant correlation with HBGS and FGS scores (r = -0.55 and 0.57, respectively; P <.01). However, not all FaCE Scale domains correlated with the HBGS and FGS scores.

CONCLUSIONS

A reliable and valid patient-based system to measure impairment and disability in facial paralysis has been developed. This system appears to be better than traditional, physician-graded scales for evaluating quality-of-life issues affected by facial disability.

Early perioperative use of polytef suspension for the management of facial paralysis after extirpative skull base surgery

BACKGROUND

The satisfactory management of facial paralysis after extirpative skull base surgery has been notoriously difficult. To optimize physical and psychological recovery, early perioperative use of polytef (polytetrafluoroethylene [PTFE]) facial suspension has been used in patients with either profound electrophysiological or anatomical disruption of the facial nerve.

OBJECTIVE

To review the efficacy of this clinical algorithm.

STUDY DESIGN

Retrospective medical record review.

SETTING

Tertiary care University Hospital Inc, University of Cincinnati College of Medicine, Cincinnati, Ohio.

PATIENTS AND METHODS

Medical records review of 32 patients who underwent lateral skull base surgery with resultant facial paralysis who had facial rehabilitation using polytef suspension.

RESULTS

All patients who underwent polytef facial suspension reported improvement in both facial function as well as aesthetics. One patient had a late extrusion of the polytef implant.

CONCLUSION

The early peri-extirpative application of this technique provides psychological and physical support to patients with facial paralysis who are recovering from lateral skull base surgery. Arch Facial Plast Surg. 2000;2:243-248

Herpes zoster oticus treated with acyclovir and prednisolone: clinical manifestations and analysis of prognostic factors

Herpes zoster oticus is a cranial polyneuropathy with facial nerve involvement as its main feature. The prognosis of the facial palsy is usually poor. Thirty patients with herpes zoster oticus suffering from facial palsy were admitted for parenteral acyclovir and oral prednisolone. Multiple regression analysis of improvement of facial palsy showed three significant covariates: age, multiple nerve palsies, and the initial grading of the palsy. The recovery of the facial palsy treated with acyclovir and prednisolone was good, and possibility of a good outcome was greater when the initial grade of the palsy was higher. Multiple nerve palsies and age had negative effects on the improvement.

Rapid simultaneous comparison system for subjective grading scales grading scales for facial paralysis

OBJECTIVE

The senior authors developed a computer-assisted rapid, simultaneous comparison system for nine international grading scales for facial paralysis. The purpose of this study is to present the system and to compare the agreement of hand-performed House-Brackmann and Sunnybrook scales, two frequently used scales herein taken as the concurrent criterion test standards, with those like scales done simultaneously in the computed system.

STUDY DESIGN

The study design was a prospective concurrent criterion validity study. Test-retest reliability and interobserver agreement were assessed using the kappa statistic (k) for ordinal data and the intraclass correlation coefficient (ICC) for semidimensional data.

SETTING

The study was conducted at a university practice.

PATIENTS

Ten consecutive consenting subjects with varying degrees of facial paralysis were studied.

INTERVENTION

Each subject was measured, in random order, twice by each method by each of two independent observers.

MAIN OUTCOME MEASURES

House-Brackmann score, Sunnybrook score, and like-scale scores done simultaneously in the computed system were measured.

RESULTS

Agreement between the computed system and hand-performed criterion standards was equal to each scale compared against itself; for the House-Brackmann, agreement was moderate (k = 0.554); for the Sunnybrook, agreement was excellent (ICC = 0.976).

CONCLUSIONS

The computed system has the advantage of allowing an examiner to view a rapid, simultaneous display of multiple grading scale scores at a keystroke from one clinical assessment input, obviating the labor of repeating measures by hand.

Review of objective topographic facial nerve evaluation methods

OBJECTIVE

This study is a critical review of the described methods for objective topographic evaluation of facial nerve function to identify areas of consensus and point to future research topics. SOURCES AND STUDY SELECTION: Original research articles on the subject were identified through the Medline database and reference cross-checking.

DATA EXTRACTION AND SYNTHESIS

The articles were grouped according to the methodology used for topographic facial nerve evaluation. The advantages and shortcomings of each method are evaluated. The results obtained in each publication are presented in light of the method used.

CONCLUSION

Measurements localized around the facial area under investigation show maximal displacement, whereas other sites exhibit much smaller displacements. Large displacements in these locations can be used to assess synkinesis and contractures. Large intersubject variability of the same measure is found. Both linear measurement and image-subtracting techniques hold promise. but until comparative studies are performed, the best method will remain controversial. Simple systems, accurately evaluating facial motor function, are yet to be developed.

House-Brackmann and Yanagihara grading scores in relation to electroneurographic results in the time course of Bell's palsy

The results of House Brackmann and Yanagihara grading were compared with electroneurographic (ENoG) data in 30 consecutive patients with Bell's palsy. The examinations were made on mean days 11, 36 and 99. Twenty-four patients had a favourable outcome (Yanagihara > or = 36 at three months). Based on our observations, 23 (96%) of these could have been predicted by ENoG, 18 (75%) by Yanagihara grading and 6 (25%) by House Brackmann grading. Initially, the relative House Brackmann scores showed a slightly milder palsy than the Yanagihara scores, but in the follow-up period the gradings were almost identical. The mild palsies, defined on the initial ENoG results, initially demonstrated relatively less nerve dysfunction on ENoG than the clinical grading; by the first follow-up, the ENoG and clinical grading had both returned to normal. The intermediate palsies had almost the same initial relative clinical and ENoG values, but at the first follow-up (mean day 36), the facial function had returned to normal despite abnormally reduced, but improved, ENoG values. In the severely affected patients, the follow-up studies showed an improved clinical function but ENoG values still demonstrated a high degree of degeneration (slightly improved at second follow-up). In this study, patients with a favourable outcome were best predicted with ENoG. Clinical identification of these patients was more accurate with Yanagihara than with House Brackmann. Furthermore, in all three groups a clinical improvement, due to the release of neurapraxia, was noted at the first follow-up. The slow ENoG improvement noted at follow-up was probably due to nerve regeneration by collateral sprouting. Based on the time course of our ENoG findings, it appears that patients with a high degree of degeneration at both the initial examination and first follow-up have a poorer prognosis.

Selective role of partial XI-VII anastomosis in facial reanimation

OBJECTIVES

Review techniques available for transposition of an alternative motor neuron if end-to-end anastomosis or interposition nerve grafting cannot be accomplished when there has been a complete facial nerve loss. Describe the selective use of a partial spinal accessory-facial nerve anastomosis and highlight cases when this may be a useful alternative. Describe the modifications of decompression of the facial nerve for tension-free anastomosis and the use of the muscle pedicle for repair of cerebrospinal fluid leakage.

STUDY DESIGN

Report of three cases and a review of the literature.

METHODS

Charts were reviewed and indications for the procedure were analyzed. The degree of facial movement was recorded as well as the resolution of any cerebrospinal fluid leak.

RESULTS

The results varied between Class III and Class IV on the House-Brackmann scale following initial complete paralysis. In the two cases in which spinal fluid leakage had occurred before surgery the leakage was resolved. No donor site morbidity was noted.

CONCLUSIONS

The potential of low morbidity associated with the use of the sternocleidomastoid branch, along with the potential for delivering a vascularized muscle pedicle to the temporal bone region, makes selective use of this procedure a valuable addition to the multiple reconstruction options for the paralyzed face.

Möbius syndrome: classification and grading system

Möbius syndrome is characterized by facial abnormalities, but the limbs, chest wall, spine, and soft tissues also can be involved. There is no system for categorizing the various anomalies, grading phenotypic severity, designing treatment protocols, or assessing therapeutic results. This is a retrospective analysis of 27 patients with Möbius syndrome seen in our craniofacial unit from 1980 to 1994. We categorized and graded the cranial nerve deficits and diverse musculoskeletal abnormalities of the face, upper and lower limbs, and trunk. The first letter for each of five potentially involved structures, i.e., cranial nerve, lower limb, upper limb, face, and thorax, formed the acronym CLUFT. The structural and/or functional deficits for each component were graded on a scale of 0 to 3. Complete facial nerve paralysis was documented in 11 patients and paresis in 16. Facial nerve paralysis was bilaterally symmetric in 17 of 26 patients. Sixth nerve paralysis was present in 23 of 27 patients; other cranial nerves were affected in 8 of 27 patients. Lower limbs were involved in 10 of 27 patients and upper limbs in 7 of 27 patients. Facial structures were affected in 17 of 27 patients (e.g., microtia, micrognathia, and microphthalmia), and chest wall deformities were found in 8 of 27 patients (e.g., scoliosis, hypoplasia of the breast, pectoral muscles, and scapula). We noted that microtia primarily involved second pharyngeal arch-derived structures. The CLUFT system permits categorization and comparison of Möbius patients for phenotypic and management outcome studies. Documentation of the widespread structural anomalies suggests that pathogenesis involves vascular disruption; a detailed prenatal history is indicated.

Evaluation of Facial Palsy by Moiré Topography Index

We investigated the usefulness of moiré topography for evaluating facial nerve function in 51 patients with facial palsy and 10 normal volunteers. This method visualizes the shape of objects in three dimensions. We devised three moiré indexes as a simple method of quantifying the severity of facial palsy: the nasolabial groove moiré index, the oral angle moiré index, and the inner canthus moiré index. We compared the results obtained by the moiré indexes with findings obtained using the House-Brackmann grading system and found that they were highly correlated. These three moiré indexes included all the standard factors of the House-Brackmann grading system, allowing us to develop the total moiré index.

Evaluation of facial palsy by moiré topography index

We investigated the usefulness of moiré topography for evaluating facial nerve function in 51 patients with facial palsy and 10 normal volunteers. This method visualizes the shape of objects in three dimensions. We devised three moiré indexes as a simple method of quantifying the severity of facial palsy: the nasolabial groove moiré index, the oral angle moiré index, and the inner canthus moiré index. We compared the results obtained by the moiré indexes with findings obtained using the House-Brackmann grading system and found that they were highly correlated. These three moiré indexes included all the standard factors of the House-Brackmann grading system, allowing us to develop the total moiré index.

Comparative value of facial nerve grading systems

The Fisch Detailed Evaluation of Facial Symmetry (DEFS) and House-Brackmann grading system (HBGS) were compared by statistical examination for their reliability and interobserver variability. Furthermore, the correlation and agreement with a standard global evaluation were compared. Therefore 47 patients with facial palsy of different cause have been evaluated with the two systems, and the global overall evaluation was done by five otolaryngologists familiar with facial palsy. The DEFS showed a high reliability of 0.93 compared with a reliability of 0.77 with the HBGS (international standard requires a reliability of at least 0.8). The mean interobserver variability is 5.24% (SD = 3.2%) with the DEFS and 9.26% (SD = 5.0%) with the HBGS; with a confidence interval of 95%, it is 11.6% and 19.26%. The correlation of both gradings with the global evaluation was high, with r = 0.98 and r = 0.97. The DEFS shows an excellent agreement with the global overall evaluation in 41 (87%) of 47 cases and the HBGS in 32 (66%) of 47 cases.

Quantitative assessment of the variation within grades of facial paralysis

A completely objective, unambiguous outcome measure of facial function is now available. A new automated computer-assisted clinimetric system combines the crucial detection capabilities of the human observer and the unique capacity of the computer to quantify the image light reflectance difference observed during facial expression. The new system was applied to 27 patients with a variety of diseases affecting the facial nerve. All subjects could be individually and objectively ranked, and disease-specific profiles could be constructed. These tasks are not possible with the House-Brackmann scale, because of the wide variation within grades and the ambiguity between grades. With the automated objective, unambiguous outcome measure, it may be possible to define individual case progression, recovery, and outcome over the course of disease.

Development of a Sensitive Clinical Facial Grading System

Clinicians require a reliable and valid method of evaluating facial function after facial nerve injury. This tool should be clinically relevant and easy to administer, provide a quantitative score for reporting purposes, and be sensitive enough to detect clinically important change over time or with treatment. The proposed facial grading system has all essential information, including precise definitions for each item, presented on one page. The facial grading system is based on the evaluation of resting symmetry, degree of voluntary excursion of facial muscles, and degree of synkinesis associated with specified voluntary movement. Different regions of the face are examined separately with the use of five standard expressions. All items are evaluated on point scales, and a cumulative composite score is tabulated. Construct validity was addressed by comparing the proposed facial grading system to prerehabilitation and postrehabilitation treatment scores of 19 patients with varying degrees of facial nerve injury. All patients had documented change in a controlled study of feedback training. The proposed system reports results in a more continuous manner with a wider response range than the House-Brackmann grades. Each component of the grading system is sensitive to change and individually contributes to a change in the composite score. Tests of interrater reliability are currently near completion.

Treatment of facial muscles affected by Bell's palsy with high-voltage electrical muscle stimulation

OBJECTIVE

This report discusses high-voltage electrical muscle stimulation and chiropractic manipulation used to treat two patients who suffered from Bell's palsy.

CLINICAL FEATURES

Case A: A 15-yr-old with left sided facial palsy was seen 2 days after the onset of symptoms. Upon observation, the left upper and lower eyelids were drooping and the left eye had excessive tearing. Motion palpation indicated multiple fixations in the cervical spine. Laboratory studies showed a microcytic anemia. A clinical diagnosis of Bell's palsy (House-Brackmann Grade V) and microcytic anemia was made. Case B: A 17-yr-old with left sided facial palsy was seen 8 days after onset of symptoms. Upon observation, the patient showed left sided facial paralysis and an inability to close the left eye completely. Motion palpation indicated multiple fixations in the cervical spine. A clinical diagnosis of Bell's palsy (House-Brackmann Grade V) was made.

INTERVENTION AND OUTCOME

Both patients were treated with high-voltage pulsed galvanic current at 80 peaks/sec with a 7-inch hand-held held probe for 10 min each visit. In addition, the cervical spine fixations were mobilized using chiropractic manipulation. Case A was resolved after 6 wk of treatment and case B was resolved after 3 wk of treatment.

CONCLUSION

Both patients benefited from these procedures with complete resolution of symptoms. The techniques outlined should be used at an early stage to accelerate progress toward normal facial muscle function.

Facial weakness. A comparison of clinical and photographic methods of observation

The search for an internationally acceptable facial grading system has resulted in an assessment of existing methods by several investigators. These studies were based on observations of video film taken of patients with varying degrees of facial malfunction. Although the grading systems were evaluated, the use of videotape has never been compared with clinical examination and its suitability for this type of work is, therefore, unknown. We used nine facial grading systems to compare the results of clinical observation with those of photographic methods of presentation. The latter included videotape, photographic slides, and a combination of the two. The correlation between clinical examination findings and findings of any of the photographic methods was poor, suggesting the need for a standard form of presentation when grading patients. The most consistent results were found with either clinical examination or photographic slides; videotape was the least reliable.