IFNS is pleased to share all submitted abstracts and the submitting author name. Please note that not all abstracts were presented or accepted.

Presented abstracts can be found in the Facial Nerve 2017 Mobile Event App which can be downloaded in the iTunes Store or Google Play.

 

 

 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Raquel Salomone

Title: Human bone marrow mesenchymal stem cells regenerate rat facial nerve from isolated stumps

PURPOSE OF THE STUDY: Severe lesions in the facial nerve may have extensive axonal loss leaving isolated stumps that impose technical difficulties for nerve grafting. Animal-derived mesenchymal stem cells have been successfully employed to achieve nerve regeneration in a variety of animal models. Bone marrow mesenchymal stem cells (BMSCs) may differentiate in vitro into Schwann-like cells, and have disclosed favorable outcomes when associated to the gold-standard surgical procedure of nerve gap tubulization to align isolated stumps. We previously employed rat BMSC (rBMSC) aiming at the rat facial nerve regeneration from isolated stumps. Superior functional outcome has been observed for undifferentiated cells (uBMSC). The application of human cells in animal models of nerve injury is an essential aspect before considering clinical trials.     METHODS: Here, we evaluated uBMSC of human origin (huBMSC) in the former rat facial nerve model. HuBMSC were analyzed by flow cytometry. Cells embedded in acellular gel were applied within a silicone conduit communicating isolated stumps of the rat facial nerve. Three and six weeks later, compound muscle action potentials (CMAP) were compared to previously reported groups. Immunofluorescence assays were performed to evaluate the presence of HuBMSC in the nerve section distal to the grafting six weeks following surgery.   RESULTS:  HuBMSC (>90%) expressed adhesion marker CD29 and mesenchymal markers CD73, CD90, CD105 and CD166; whereas negative labeling (<1%) was reported in these cells for hematopoietic marker CD45 and endothelial markers CD31 and CD34. CMAP amplitude, duration and stimulus intensity did not differ between ruBMSC and huBMSC (Mann-Whitney;p >0.05), whereas huBMSC presented significantly better functional results (p<0.05) than the control groups. HuBMSC were not detected in the distal segment of the repaired nerve.   CONCLUSION: In the rat model of acutely injured facial nerve leading to isolated stumps, favorable results observed for ruBMSC are similar to those reported here for huBMSC.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Raquel Salomone

Title: Does Chemical Suture work in non-immediate acute facial nerve cut-severence?

Studies involving earthworms and rats revealed that early plasmalemmal resealing is the main factor predicting survival and regeneration of neurons after severance. In turn, plasmalemmal restoration is regulated by Ca+2 exocitosis. Bittner et.al, interfering with Ca+2 exocitosis and treating neural stumps with methylene blue and microsutures, accomplished a 70-80% return to normal neural function after 12 weeks of crush or cut-severance of rat sciatic nerves, in a process named chemical suture. Therefore, chemical suture may have great potential in facial nerve lesions, especially of the traumatic kind. However, in a real case scenario, there is generally a time lapse of several hours between nerve lesion and repair, reason why facial nerve regeneration was evaluated after chemical suture done at 24 and 72 hours after neurotmesis.    METHODS   Fifty-four rats were divided into 4 groups. Groups A and C were submitted to facial nerve cut severance and, after 24h and 72h, respectively, neural stumps were reopened and apposed with microsutures. Groups B and D received similar treatments, plus chemical suture. This process involves bathing of axonal ends with Ca+2-free saline solution containing methylene blue for 3min. Afterwards, a hypotonic solution of polyethylene glycol was applied to the closely apposed ends. Finally, an isotonic Krebs solution containing Ca+2 was applied. Compound   muscle   action   potentials   (CMAPs)  were   registered.    RESULTS   The   CMAP   results   obtained   previous   to   surgery   (p≥0.615) and three weeks after (p≥0.488) did not differ among groups. At 6 weeks there was no difference between groups AxB (p≥0.200), CxD (p≥0.488) and AxC   (p≥0.549).    CONCLUSION   There is no electrophysiological difference between suturing the rat facial nerve at 24 and 72 hours after a cut severance.  Despite being promising for acute axonal cut lesions, chemical suture did not yield results in rat facial nerve regeneration when axonal ends where apposed 24 and 72 hours post-trauma.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Heloisa Juliana Zabeu Rossi Costa

Title: Dental pulp stem cells versus bone marrow stem cells in facial nerve regeneration

PURPOSE OF THE STUDY: post-traumatic lesions of the facial nerve, which are frequent in the daily routine of the otolaryngologist, even when repaired with the best microsurgical techniques still present limited functional outcome. Bone marrow stem cells(BMSC) and dental pulp stem cells (DPSC) have proven to enhance facial nerve regeneration, but there aren’t papers that compare the effects of these two cellular types for future clinical trials with this purpose. Here, we compare the functional (compound muscle action potential-CMAP) and histological (axon morphometrics) effects of DPSC or BMSC combined with polyglycolic acid tube in autografted rat facial nerves. METHODS : after a 5mm gap in the mandibular branch of rat facial nerve, autograft was performed, surrounded by a polyglycolic acid tube and filled with purified basement membrane matrix (groups A-D), without (control group A) and with transplantation of undifferentiated BMSC (group B), Schwann-like cells differentiated from BMSC (group C) or DPSC (group D). After six weeks, the animals were sacrificed and the analyzes performed. Immunofluorescence assays were carried out with Schwann cell marker S100 and anti-β-galactosidase to label exogenous cells. RESULTS: six weeks after surgery, animals from either cell-containing group had mean CMAP amplitudes significantly higher than control group and DPSC group was the one with highest values. Mean axonal diameters were also significantly higher in cell-containing groups than control group, without difference between treatment groups. Mean axonal densities were significantly higher in control group than in cell-containing groups. CONCLUSION: regeneration of the mandibular branch of rat facial nerve was improved by DPSC and BMSC within polyglycolic acid tube, yet DPSC were associated with superior functional outcomes.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Yosuke Niimi

Title: Surgical anatomy of the facial nerve and hypoglossal nerve in ovine.

Introduction: Physicians face a significant challenge in treatment of facial nerve damage. A lack of clinically relevant animal model for facial nerve regeneration is attributable, at least in part, to the challenge. We aimed to investigate anatomy of ovine facial nerve focusing on hypoglossal nerve anatomy to establish a clinically relevant model that allows future research into end-to-side neurorrhaphy such as interpositional jump-graft.   Methods: To identify Facial nerve trunk (FNT) and its branches [upper branch (UB), buccal branch (BB) and marginal mandibular branch (MMB)] in cadaver sheep (n = 6), a preauricular to submandibular incision was made to dissect Platysma and parotid gland. Hypoglossal nerve (HN) was identified behind the digastric posterior belly. The distances from: 1) base of the external auditory canal to FNT; 2) stylomastoid foramen to its branches; 3) MMB to facial artery; and 4) HN to FNT. Diameters of FNT, UB, BB, MMB, and HN and the external length and width of the parotid gland were determined as well. UB, BB, MMB were mechanically stimulated.    Results: We determined that UB, BB, MMB innervated the forehead and orbicularis oculi muscle, upper lip and nasal muscle and lower lip muscle, respectively. The diameters of FNT, UB, BB, MMB, and HN were 2.8±0.3, 1.6±0.3, 1.5±0.2, 1.1±0.14 and 2.4±0.7mm, respectively. The distances between external auditory canal-FNT, stylomastoid foramen-branches, MMB-facial artery, and HN-FNT were 6±1.3, 9.2±1.5, 94±6.8, and 47±6.9mm, respectively. The size of parotid gland was 66±11 by 35±4.2mm.     Conclusions: The ovine facial nerve anatomy and innervation are similar to that are observed in human. Ovine model can be used as a clinically relevant and suitable model for facial nerve regeneration research.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Hajime Matsumine

Title: Multiple facial-nerve branch reconstruction using “end-to-side loop graft with axonal supercharge” in rat model.

Introduction: This study developed a new animal model for facial nerve reconstruction in rats to evaluate the combination of the “end-to-side loop graft” technique for reconstructing the four main facial nerve branches using the ipsilateral facial nerve trunk with axonal supercharge from the hypoglossal nerve, and physiologically and histologically evaluated the features of this technique and its ability to promote nerve regeneration.   Methods: Rats were divided into the intact, non-supercharge, and supercharge groups. Artificially created facial nerve defects were reconstructed with a nerve graft, which was end-to-end sutured from proximal facial nerve stump to the mandibular branch (non-supercharge group), or with the graft of which other end was end-to-side sutured to the hypoglossal nerve (supercharge group). And they were evaluated after 30 weeks.   Results: Axonal diameter was significantly larger in the supercharge group than in the non-supercharge group for the buccal and marginal mandibular branches, but the diameter was significantly larger in the intact group for all branches except the temporal branch. In the supercharge group, compound muscle action potential amplitude was significantly higher than in the non-supercharge group and similar to that in the intact group. Retrograde labeling showed the mimetic muscles were double-innervated by facial and hypoglossal nerve nuclei in the supercharge group.    Conclusion: Unilateral multiple facial nerve branch reconstruction with an end-to-side loop graft was able to achieve reinnervation and axonal distribution. Although a level of nerve regeneration obtained by end-to-side loop grafting alone was lower than that of the intact group, the addition of axonal supercharge from the hypoglossal nerve to end-to-side loop grafting significantly improved histological and physiological outcomes. The effect of axonal supercharge was more pronounced in branches closer to the hypoglossal nerve.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Mari Shimizu

Title: Facial Nerve Regeneration with PGA-collagen nerve conduit in a rat model

Objective: NerbridgeTM (Toyobo Co., Ltd., Osaka, Japan) is a resorbable, artificial nerve conduit with polyglycolic acid tubing and a collagenous interior. It is the only such device currently approved in Japan. NerbridgeTM is mainly used in clinical practice to bridge peripheral nerves after traumatic nerve injury, but there are few reports on its application in reconstruction and repair of the facial nerve. In the present study, we evaluated the utility of NerbridgeTM to promote nerve regeneration in a murine model of injury to the buccal branch of the facial nerve.   Methods: Under inhalational anesthesia and microscopic guidance, we exposed the buccal branch of the left facial nerve in 8-weeks-old Lewis rats and created a 7-mm gap in the nerve. The gap was then bridged with either NerbridgeTM of length 1 cm or with an autologous nerve graft (AG). At 13 weeks after the procedure, tissue samples were collected from both groups of rats and compared using Toluidine blue staining and electron microscopy.   Results: Mean nerve fiber diameter in the central region of the regenerated nerve was not significantly different between AG and NerbridgeTM rats (5.39 ± 2.42 μm vs. 4.88 ± 1.44 μm). However, myelin width differed significantly between both groups (0.82 ± 0.45 μm vs. 0.45 ± 0.12 μm). Also, AG rats showed significantly greater improvement in g-ratio, an index of nerve maturation, (0.70 ± 0.12 mm vs. 0.82 ± 0.04 mm).    Conclusion: This study demonstrates the utility of NerbridgeTM for facial nerve reconstruction following nerve injury. However, when used alone, the capacity of NerbridgeTM to promote nerve regeneration was inferior to that of AG. Therefore, future research is needed to investigate the use of NerbridgeTM in conjunction with stem cell and growth factor delivery systems to achieve effectiveness comparable to that of AG.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Jonathan Leckenby

Title: Imaging peripheral nerve regeneration using serial section electron microscopy: thinking like an axon.

Introduction: Peripheral nerve assessment has traditionally been studied through histological and immunological staining techniques in a limited cross-sectional modality. The introduction of transgenic species, such as YFP-H mice, has greatly increased our ability to observe axonal regeneration. However, detailed analysis is still difficult to assess with either of these methods. A new application of serial section electron microscopy (SSEM) is presented to overcome these limitations.    Methods: Direct nerve repairs (DNR) were performed on the posterior auricular nerve of YFP-H mice. Six weeks post-operatively the nerves were imaged using confocal fluorescent microscopy then excised and embedded in resin. Resin blocks were sequentially sectioned at 100nm and sections were serially imaged with an electron microscope (Magellan 400L, FEI). Images were aligned and auto-segmented to allow for 3D reconstruction.    Results: Basic morphometry and axonal counts were fully automated. Using full 3D reconstructions, the relationships between the axons, the Nodes of Ranvier, and Schwann cells could be fully appreciated. The interactions of individual axons with their surrounding environment could be visualised and explored in a virtual three dimensional space.    Conclusions: SSEM allows the detailed pathway of the regenerating axon to be visualised in a 3D virtual space. Fully automated histo-morphometry can now give accurate axonal counts and provide information regarding the quality of nerve regeneration. It is possible to fully visualise and ‘fly-through’ the regenerating nerve to help understand the behaviour of a regenerating axon within its environment


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Shin-Ichi Haginomori

Title: Varicella-Zoster Virus (VZV)-specific Cell-mediated Immunity in Ramsay Hunt Syndrome

Introduction: The etiology of Ramsay Hunt syndrome (Hunt syndrome) characterized by facial palsy, herpes zoster auricularis, hearing impairment and balance disorder is reactivation of latent varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve, leading to neuritis. The mechanism by which VZV is reactivated is unclear, however, one possibility is that the reactivation involves a low level of VZV-specific cell-mediated immunity (CMI).   Objectives: The aim of this study was to clarify the characteristics of the VZV-specific CMI in Hunt syndrome compared to that in Bell's palsy (idiopathic facial palsy), and to obtain clues to its role in the development of Hunt syndrome.    Study design: We examined VZV-specific CMI in 20 Hunt syndrome and 57 Bell's palsy patients using IFN-γ enzyme-linked immunospot (ELISPOT) assays. We analyzed the relationship between the value of VZV-specific CMI and days from disease onset.   Results: The median spot number in Hunt syndrome was higher than that in Bell's palsy. In Hunt syndrome, there was a strong relationship between the ELISPOT count and days from onset. Within the first 5 days from onset, no ELISPOT counts higher than 80 SFCs/4×105 PBMCs were observed. On the other hand, no correlation was observed between the ELISPOT count and days from onset in patients with Bell's palsy. Conclusions: These results suggest that VZV-specific CMI in Hunt syndrome is low at disease onset and increases rapidly thereafter. Consequently, reduced VZV-specific CMI may play an important role in the reactivation of VZV in the facial nerve, leading to Hunt syndrome.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Gabriela Bobarnac Dogaru

Title: The Role of Hedgehog-Responsive Cells in Facial Nerve Regeneration

Introduction:   Facial nerve paralysis is a significant cause of morbidity, affecting speech, oral competence, vision, and emotional expression. Extensive efforts have been undertaken to determine the cellular events that occur during nerve regeneration, in hopes of finding molecular therapeutic targets to improve this process. Increasingly, non-neural cell lineages are recognized as having critical roles in the process of nerve regeneration, but the signaling pathways that drive these cellular responses are not fully understood. The Hedgehog signaling pathway has been shown to mediate complex multicellular responses to tissue injury in multiple tissue types. We therefore sought to characterize the behavior of hedgehog-responsive cells following transection of the facial nerve.     Objectives:   To explore the role of hedgehog-responsive cells (Gli1+) in a mouse model of facial nerve transection and subsequent regeneration.   Methods:   We used a transgenic mouse line with an inducible reporter for lineage tracing of Gli1+ cells (Gli1-CRE;Tdt), and induced a unilateral facial nerve cut injury, using the contralateral side as a control. We analyzed the nerve via immunohistochemistry at 1 day, 1 week, 2 weeks, and 4 weeks after injury.   Results:   There was a significant increase in Gli1+ cells both at the site of injury and within the distal nerve segment. Preliminary results show a subpopulation of these cells to be NG2+ fibroblasts that contribute to the regeneration process via production of the pro-angiogenesis factor VEGF-A.   Conclusions:   This finding describes a key signaling pathway by which fibroblasts participate in motor nerve regeneration. Intraneural fibroblasts may represent a previously overlooked therapeutic target.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Róbert Késmárszky

Title: An Ex-vivo Biomechanical Study of the Human Marginal Mandibular Nerve, the Answers of the Nerve to Tensile Forces

Introduction:    Mechanical trauma to the human facial nerve may cause paralysis, representing a functional, aesthetic and psychosocial problem. Our ex-vivo study exposing the marginal mandibular nerve was achieved to better understand and objectively measure the consequences of mechanical forces.    Objective:    To establish a protocol allowing an objective measurement of the nerve’s answer to axial mechanical forces and collect data to analyze the occurring biomechanical and morphological phenomena.   Methods:    Five pairs of human marginal mandibular nerves were prepared from five adult cadavers. None of the deceased had pathologies or local findings that could have modified their answer to standardized mechanical forces during the tensile test, using specially designed holders. Stereomicroscopy before and after the tensile tests of the marginal mandibular nerves provided information about the structure, diameter and morphology of the specimens. The elongation and maximal load were determined, followed by a statistical analysis.   Results:    The nerves were dissected in their integrity. During the tensile test proportionally important elongations happened at the maximal tolerable load, causing disruption. A mean maximal load value was established. The diameter of the nerves and the age, weight and height of the patients did not show correlation with the value of the maximal load.   Conclusion:    The elasticity and resistance show differences to biomechanical forces. Factors like the number and structure of the constructing fibers, the amount of the protective connective tissue, the collagen content and the related vascular network are supposed to explain this heterogeneity. The observations may help to understand surgical activity, trauma and tumoral displacement related transformations and the mechanism of functional impairment of the nerve. This knowledge may help to reduce the incidence of mechanical  trauma related facial paralysis and to promote the efficacy of nerve reconstruction.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Timothy Eviston

Title: Human evidence of sodium channel conductance changes in acute Bell's Palsy: an emerging therapeutic target.

Introduction - The pathophysiology of Bell’s palsy (BP) has traditionally been attributed to compression of an inflamed facial nerve in the fixed confines of its intratemporal course. Neurobiology evidence, in-vitro and animal models have raised contrarian data suggestive of a more diffuse process. Acute exposure of in-vitro axons to herpes simplex results in profound sodium channel conductance changes, a known stimulus of axonal degradation. This study examines the in-situ properties of the human facial nerve during the acute phase of Bell's palsy by applying the technique of computerized axonal threshold tracking.    Methods - Patients with moderate to severe facial weakness due to Bell's Palsy of less than 10 days duration were consecutively recruited. In eight patients (aged 31-60 years), a full set of nerve excitability recordings was obtained from the extracranial facial nerve using a an established methodology to apply TROND protocol based axonal threshold techniques. Results were compared to healthy controls (n=27) and to a non-Bell's disease control group (n=9).    Results – Bell's Palsy demonstrated idiosyncratic changes consistent with acute sodium (Na+) channel dysfunction. Strength-duration time constant, a marker of persistent Na+ conductances, was decreased (p<0.05) as was refractoriness, a marker of recovery from inactivation of transient Na+ conductances (p<0.05), and subexcitability (p<0.05). The observed findings did not correlate with Wallerian degeneration as seen in the non-Bell's cohort.     Conclusions - The data is characteristic of reduced inward Na+ conductances, as previously demonstrated in the setting of tetrodotoxin ingestion and in agreement with the in-vitro evidence of sodium channel conductance changes post herpes simplex exposure. This is the first human evidence to implicate sodium channel involvement in the early pathogenesis of Bell's Palsy and may represent an important therapeutic target in the early course of the disease prior to axonal degeneration.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Miyuki Uehara

Title: The Electrophysiological and Histopathological Evaluation of the fascicular turnover method in the Reconstruction of Facial Nerve Defects in Rats

Objectives: Fascicular turn over flap for reconstruction of nerve gaps was introduced by Isao Koshima in 2010. He used this method for digital nerves and facial nerve reconstruction, and could have good results. Its advantages are less invasive and accurate nerve regeneration even in cases with longer nerve deficit and scarred recipient bed. The purpose of the present study was to assess the utility of fascicular turn over method and to investigate its possible application in the field of facial nerve reconstruction.   Methods: Wister rats were used in this study. In the operation, a peri-auricular incision was made to expose the buccal and marginal branches of the facial nerve. Eight millimeter gaps were produced into the marginal branches and the buccal branch of the left facial nerve. The left marginal branch gap was bridged with 8-mm fascicular turn over flap or autograft. At 12 weeks after the operation, nerve regeneration was assessed based on clinical, histopathological and electrophysiological evaluations.   Results: The functional result of the fascicular turn over flap models were almost same as the autograft models. Histopathological and electrephysiological results were similar to the outcomes of the autograft models.   Conclusion: The fascicular turn over method can be applied in facial nerve reconstruction even it has longer nerve deficit. However, further evaluation will be necessary to elucidate its indication and mechanism.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Timothy Eviston

Title: Axonal abnormalities in the contralateral face in the setting of facial palsy

Introduction: Abnormal hyperkinesis in the contralateral face in the setting of facial palsy has been commonly observed. Frequently this is treated with physiotherapy and botulinum toxin to improve cosmesis and facial function. In this study we profile the axonal function of the contralateral facial nerve in the setting of facial palsy.   Methods: 22 patients with longstanding facial palsy were studied using axonal excitability techniques, an established non-invasive method for determining axonal properties including ion channel function and membrane conductances. Patients were analysed in two groups: mild/moderate facial palsy, and severe facial palsy. The results were compared with a cohort of normal control facial nerve studies.   Results: Distinct changes in underlying axonal function were noted in the contralateral face recordings. Findings in the mild/mod group and the severe group were markedly different with the mild/moderate group demonstrating changes consistent with underlying axonal depolarization including “fanned in “ threshold electrotonus, decreased magnitude of superexcitability and an increase in resting I/V slope. Contrary to this, the severe group demonstrated changes consistent with axonal hyperpolarization. These included “fanning out” of threshold electrotonus, an increase in the magnitude.    Discussion: the study demonstrates fundamental axonal changes in the contralateral facial nerve of patients with unilateral facial palsy. This explains the hyperkinesis and physical changes observed clinically in patients with facial palsy and may help guide treatment decisions in this group in the future. These findings demonstrate that the “unaffected side” is not a true normal control.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Manzhi Wong

Title: Facial nerve synkinesis in a rabbit model

Introduction: Facial nerve synkinesis is characterized by troubling co-contractions and spasms.     Methods: We describe the production of a rabbit facial nerve synkinesis model by performing facial nerve axotomy in 17 rabbits.  Facial nerve repair was performed at different time points,  immediately,  at two weeks and at 2 months post axotomy.     Results: Facial nerve synkinesis was reliable reproduced in all rabbits. The pattern differed to a some degree depending on the time course of repair. None of the rabbits recovered full muscle power.    Conclusions: The rabbit is a good model for facial synkinesis.  Its larger size compared to the rodent allows for clinical grading of the facial synkinesis


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Olaf Michel

Title: Reactive Oxygen Species and facial nerve palsy: are there NO news?

Edema of the nerve sheath and the resulting ischemia of the facial nerve are believed to be the main pathologic conditions for Bell’s palsy and Ramsay Hunt syndrome. These is strong evidence that the disease results from a viral geniculate ganglionitis by reactivation of HSV-1. Viral triggered inflammatory reactions of the tissue and the vessels may involve regulating mediators and cause endoneurinal blood flow deficits.   In particular the inducible isoform of NO synthase (NOS II) is expressed in viral diseases via induction of proinflammatory cytokines such as interferon-gamma. NOS II produces an excessive amount of NO for a long time compared with other constitutive isoforms of NOS (i.e., NOS I and NOS III). Recent studies indicate that NO and O2- are produced in excess during the host's defense responses against various intruding microbes. Reactive nitrogen oxide species (ROx) such as peroxynitrite (ONOO-) and NOx (NO2 and N2O3) are originated through the reaction of NO with either O2- or O2. Many other infectious diseases are linked to free radical damage arising from imbalance between radical-generating and radical-scavenging systems - a condition called oxidative stress. Metabolites derived from superoxide (O2-) and nitric oxide (NO) play an important role in antimicrobial and antitumoral defense, but may also harm the host -particularly nerve structures. It is also known from other tissues that NO controls the vascular tone and blood flow in many different tissues.    To elucidate the potential role of inducible nitric oxide synthase (NOS II) in facial nerve palsy, we investigated the distribution of the NOS-isoforms - particularly NOS II - and the signaling pathway of NO histomorphologically in the peripheral intratemporal facial nerve and the geniculate ganglion.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Sam Marzo, MD

Title: Location of facial nerve injury and motoneuron cell loss and treatment

Objectives/Hypothesis: The purpose of this study was to assess (1) the degree of motoneuron cell loss following injuries all along the facial nerve including extratemporally, intratemporally, and intracranially and (2) to determine whether the combinatorial therapies of electrical stimulation (ES) and testosterone propionate (TP) can improve cell survival following these facial nerve crush injuries.   Study Design: Prospective, randomized, controlled animal study.   Methods: Male sprague-Dawley rats were randomly divided into groups: extratemporal, intratemporal, intracranial crush injury group as well as sham surgeries.  Animals were further divided into groups with or without ES and TP treatments. The extratemporal crush group underwent a crush injury of the facial nerve as it exits the stylomastoid foramen.  The crush injury in the intratemporal crush group  occurred at the facial nerve tympanic segment.  The intracranial crush groups underwent a crush of the meatal segment. Treatment with or without ES and TP treatment occurred immediately following the injury. Brain sections were thionin- stained and facial motor nuclei (FMN) were counted using light microscopy.    Results: When the facial nerve was injured extratemporally, no significant cell loss is observed .  An intratemporal crush injury resulted in approximately 15% facial motoneuron cell loss, while an intracranial crush injury resulted in approximately 35% facial motoneuron cell loss.  Treatment with electrical stimulation and testosterone significantly improved facial motoneuron cell survival in all injury groups.   Conclusions: Facial nerve injury more proximal to the facial motor nucleus results in facial motoneuron cell death. This has implications for patients with facial nerve injury due to parotid, mastoid, and intracranial neoplasms or lesions. Combinatorial therapies may significantly improve cell survival and therefore facial nerve function. Key Words: Motoneuron cell survival, facial nerve crush injury, electrical stimulation, testosterone propionate


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Alison Snyder-Warwick

Title: In search of a terminal Schwann cell marker... does a tool exist?

Introduction: Reconstruction after nerve injury is limited by the temporal window during which muscle reinnervation may occur. Specialized structures at the neuromuscular junction (NMJ) facilitate the interface between nerve and muscle. Terminal Schwann cells (tSCs) are glial cells present at the NMJ that may contribute to this temporal restriction. While these non-myelinating Schwann cells have been implicated in multiple functional roles, there is no known marker specific to tSCs, making isolation and investigation of this cell type challenging. We sought to identify genetic markers unique to tSCs.      Methods: A novel component dissection technique was utilized to isolate the tSC-containing endplate band from the sternomastoid muscles of young adult S100-GFP mice. RNA was isolated from samples containing: 1) Endplate bands (tSCs + nerve + muscle), 2) Nerve, and 3) Muscle and prepared for microarray analysis. Rank-order analysis was performed to identify genes specific to tSCs. Candidate genes were validated with PCR and immunostaining.   Results: Microarray data generated a total of 11 genes unique to the NMJ. Our short list of candidate genes specific to tSCs includes D-2-hydroxyglutarate dehydrogenase (D2hgdh), Collagen Q (ColQ), and T-bet 21 (Tbx21). These genes were upregulated at the NMJ by 4- to 11-fold compared to muscle or nerve parts alone (p<0.05). Tbx21 expression was elevated by 9-fold at the NMJ on qPCR. D2hgdh protein expression co-localizes with tSCs and is not noted in myelinating SCs from sciatic nerve. Validation studies of these candidate genes are ongoing.     Conclusions: Given their unique functional roles, tSCs likely have a unique transcriptome that differentiates them from other Schwann cell types. Identification of genetic specificity for tSCs facilitates improved methods to investigate these unique cells and allows for translational studies that ultimately may modify the temporal window during which reinnervation can occur.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Nate Jowett

Title: A neuroprosthetic device for reanimation of the hemi-paralyzed face

Introduction: Contralateral facial movements represent an ideal control system for functional electrical stimulation of symmetric expressions in hemi-facial paralysis. Herein, we present initial results on  a neuroprosthetic device for hemi-facial reanimation in a rat model.    Methods: A neuroprosthetic device, consisting of healthy-side implanted sensing epimysial conductive polymer electrodes, signal acquisition and analysis, and diseased-side proximal neural blockade and output stimulation through implanted nerve cuff electrodes is described.   Results: EMG activity was modelled to whisker displacement by means of an impulse response function, with a variance accounted for exceeding 96%.   Conclusions: This is the first study to demonstrate the efficacy and safety of an implantable neuroprosthetic device for FES reanimation of the hemi-paralyzed face, including the ability to use healthy-side EMG activity as control inputs.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Jacqueline Greene

Title: Electrophysiological Assessment of a Peptide Amphiphile Nanofiber Neurograft for Facial Nerve Repair

Facial nerve injury can cause severe long-term physical and psychological morbidity.  Following an acute facial nerve transection that is not amenable to primary neurorrhaphy, repair options are limited and may require multiple reconstructive surgeries, incur morbidity at a donor nerve site for autografting, injure adjacent structures, or cause unnatural facial movements while chewing.  We hypothesize a peptide amphiphile nanofiber neurograft may serve as an off-the shelf option for primary facial nerve repair, and provide the nanostructure necessary to guide organized neural regeneration.  The goal of this study was to compare a novel bioengineered peptide amphiphile nanofiber neurograft with autografting using direct neural stimulation. The buccal branch of the rat facial nerve was electrically stimulated 1) intact, 2) following resection (7.5 mm segment), and following resection and immediate repair with either a 3) autograft (using the resected nerve segment), 4) neurograft, or 5) empty conduit.  After 8 weeks, the proximal buccal branch was surgically re-exposed and the evoked compound nerve action potentials were again recorded for groups 1-5.  As expected, the intact nerves had significantly lower threshold current to compound nerve action potential than those repaired with the neurograft and autograft nerves, but for other electrophysiologic parameters such as latency, conduction velocity and maximum nerve action potential, there was no significant difference between the intact, autograft and neurograft groups.  The resected group had variable responses to electrical stimulation, and the empty tube group was electrically silent.  Immunohistochemistry and TEM confirmed myelinated, organized neural regeneration through the neurograft.  This study demonstrates that the neuroregenerative capability of peptide amphiphile nanofiber neurografts is similar to autografting and holds potential as an off-the-shelf solution for facial reanimation and potentially peripheral nerve repair.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Daniel J Kedar

Title: Nerve regeneration following Hyperbaric treatment in a Rat Sciatic nerve autograft model.

Introduction:    Paralysis of the facial muscles is a devastating condition with a profound functional, aesthetic, and psychological consequences. Reanimation of the paralyzed face focuses on restoration of form and function. In most cases, the Reconstruction procedure relies on a long nerve graft to relay nerve input across the face from the normal side to the paralyzed one. The disadvantage with cross-facial nerve grafting are first that the results are inconsistent and second is the long recovery time, since the Axons regenerate through the average 12cm sheath of nerve graft at a pace of 1mm/day.   The leading cause of failure is suspected to be poor traversing of motor axons into, across, and out of the nerve graft.   Prolonged denervation and poor vascularization render the local environment unreceptive for axonal regeneration.    Hyperbaric oxygen treatment has been used for peripheral nerve injuries since the 1970s; the rationale for its use is to provide optimal tissue oxygen tension to maintain the neural aerobic metabolism and viability of the tissue, reduce edema, enhance perfusion of the injured tissue, restore axonal transport, enable delivery of nutrients at the site of injury, accelerate healing, and promote neovascularization.   Objectives:    Our goal is to evaluate whether hyperbaric oxygen therapy can promote faster regeneration as well as more effective regeneration     Methods:    In our model we use the Rat sciatic nerve. A 10 mm segment is transected and inverted so that it may act as a nerve graft.    The rats are divided into two groups of 21 animals- The control receives the surgery alone and the treatment group, following surgery will be treated with hyperbaric oxygen.   Preop evaluation and postop follow-up will consist of functional motor assessment (SFI), EMG, histology and morphometric assessment.   The results will be reported at the conference.


 

TOPIC: Basic Science/Molecular Studies

Submitting Author: Ryo Sasaki

Title: Surgical anatomy of the miniature swine in facial nerve research: facial, hypoglossal and sural nerves

Objective: In order to develop facial nerve research, the surgical anatomy of facial, hypoglossal and sural nerves of cadavers and anesthetized miniature pigs were investigated. Methods: Facial nerve, hypoglossal nerve and sural nerve were dissected in miniature pig. The dissected nerves were stimulated by nerve stimulator. These nerves were harvested, and the numbers of myelinated fibers were counted. Results: The marginal mandibular branch (MMB) of the facial nerve had an upper and lower division. Stimulation of the facial nerve and its branches showed that the upper division of MMB and buccal branch of the facial nerve innervated muscles and tissues in the upper lip and nose region, and the lower division of MMB innervated muscles and tissues in the lower lip region. The hypoglossal nerve was observed to run parallel to the back side of the posterior belly of the digastric muscle. The nerve stimulation indicated that the hypoglossal nerve innervated muscles and tissues in the tongue. The sural nerve was found to branch from the sciatic nerve under the biceps femoris muscle and run along the dorsal saphenous vein. The sural nerve innervated no muscles and tissues in the leg. The sural nerve (14.5 ± 0.5 cm) was obtained from between the sciatic nerve and peripheral branches in anesthetized miniature pigs. The numbers of myelinated fibers of facial, hypoglossal and sural nerves were 3467 ± 370, 8889 ± 211 and 2639 ± 622, respectively. Conclusion: The gross anatomy of the pigs was found to be similar to that of humans. Although the distributions of the marginal mandibular branch of the facial nerve is different from that of humans, we concluded that miniature pigs are suitable experimental model for the facial nerve study. Moreover, the sural nerve could be donor of autorogus nerve grafts in facial nerve reconstruction study.


 

TOPIC: Botulinum Toxin

Submitting Author: Catriona Neville

Title: Treatment of synkinesis in facial palsy with Botulinum Toxin - outcome of a therapy led chemodenervation clinic.

The aim of this study is to provide reliable and valid evidence that Botulinum toxin (BTX-A) is a successful treatment for facial synkinesis in facial palsy using the synkinesis assessment questionnaire tool (SAQ). Patients routinely attending the facial palsy clinic for BTX-A injections were asked to complete the SAQ over an eighteen-month period. The SAQ was first filled in immediately pre-treatment and two weeks after treatment when BTX-A had reached its full effect. 51 patients completed questionnaires pre and post BTX-A treatment over 103 cycles of treatment. Each patient was individually assessed and then treated according to their presenting symptoms with a dosage in each injection site of between 0.5 to 5 U of BTX-A. BTX-A was administered by therapists, specially trained in administering Botox for facial palsy. A two-tailed, paired samples t-test was used to compare the scores for each question before and after treatment. A significant difference was found between all scores before and after treatment at the level of p < 0.05. As well as an improvement in mean score in the post treatment group there was also a smaller spread of scores in the post-treatment group compared to the pre-treatment group. The study showed that SAQ scores decreased significantly for every question on the SAQ after treatment. This indicates that BTX-A is an effective treatment for synkinesis adding further weight to current evidence. The study also indicated that BTX-A continues to be effective even after three rounds of treatment, with a significant decrease in overall scores after each treatment cycle.


 

TOPIC: Botulinum Toxin

Submitting Author: Catriona Neville

Title: Paradoxical frontalis activation: an under-recognised consequence of facial palsy.

Introduction and Aims   Aberrant reinnervation and synkinesis is common and debilitating after facial palsy. Paradoxical frontalis activation can antagonise eye closure and increase the risk of corneal damage. If recognised, judicious botulinum toxin injection to the affected side may reduce this risk.     Material and Methods    100 consecutive patients with synkinesis were identified from a prospective database. Routine facial view photographs were converted to a standardised scale using iris diameter. The vertical distance from the midpoint of the inter-canthal line to the inferior border of the eyebrow (MCE distance) was measured bilaterally. p<.05 was taken as significant.    Results   82 patients were included, with a median age of 44 years (IQR 33-59) and 59 female. The commonest aetiology was idiopathic (n=55). The median time since onset of palsy was 13 months (IQR 6.5-27 months). There was less MCE excursion on the synkinetic side of the face (2 tailed, unpaired t test; p<.001). 22 patients (27%) displayed paradoxical frontalis movement on the affected side of their face, with increased MCE distance (eyebrow raise) when attempting eye closure compared to attempted eyebrow raise (Friedman test, p=.027).    Conclusion   Frontalis overactivity may have functional and cosmetic implications for patients. Appropriate assessment and intervention with botulinum toxin may provide symptomatic relief, and enhance rehabilitation and recovery. A treatment algorithm is presented and discussed.


 

TOPIC: Botulinum Toxin

Submitting Author: Celia Santini

Title: Maximizing the Effectiveness of Facial Retraining with Botox©

This paper will enumerate our experiences working with patients who have developed synkinesis secondary to facial nerve palsy.   Data is based on patients seen for facial muscle retraining combined with Botox© injections in an attempt to reduce the sometimes debilitating effects of Synkinesis.   The primary goal of the introduced Botox© injections was to maximize facial muscle retraining. Secondarily, the injections provide a more balanced facial appearance during the retraining cycle as well as minimize the actual physical symptoms of synkinesis.   This presentations’ purpose is to primarily share information. We hope to increase the knowledge base of other professionals working in this area. Through our to-date completed research we will provide what we believe is an effective treatment modality for all patients.               Synkinesis treatment is complex. Research data concerning effective treatment processes is scarce. Treating clinicians are faced with patients who are dealing with both physical and emotional distress.   It has been our experience that Botox© has been shown to provide short term relief of cosmetic and functional Synkinesis. This short term respite has proved extremely beneficial with the facial muscle retraining process.   Our practice provides individualized care. While some of the resulting affectations are similar, such as ptosis and speech difficulties, we acknowledge that synkinesis affects everyone differently both emotionally and physically.   Our recommendations are as follows;   1.    Botox© should be administered in combination with facial retraining therapies not only to maximize the results, but also to extend the benefits of both treatment processes.   2.    Additional research is mandatory regarding dosage and best injection placements for patients with this affliction.


 

TOPIC: Botulinum Toxin

Submitting Author: Mihail Akulov

Title: INCOBOTULINUMTOXINA TREATMENT OF FACIAL NERVE PALSY AFTER NEUROSURGERY

Introduction: Facial nerve injury (FNI) is a common complication of surgical intervention for posterior cranial fossa (PCF) and ponto-cerebellar angle (PCA) tumours.   Objective: To evaluate the effect of botulinum toxin type А injections into mimic muscles of the unaffected side during the acute and chronic phases of FNI after neurosurgery. Methods: Patients with acute paresis of mimic muscles due to FNI during surgery in the PCF and PCA areas were included. Patients in group I (active treatment) received incobotulinumtoxinA injections into the mimic muscles of the unaffected side 24–48 hours after FNI. Patients in group II (control group) received conventional rehabilitative treatment. Treatment efficacy was assessed using House-Brackmann and Sunnybrook Facial Grading Scales.   Results: Of 86 patients evaluated, 57 (45.6% male) were included in group I and 29 (51.7% male) in group II. All patients had severe facial nerve dysfunction according to the House-Brackmann scale at baseline (mean [standard deviation] scores 3.18 [0.85] in group I and 3.24 [0.79] in group II). Patients in group I experienced a significant improvement in facial nerve function 1 month after initiation of incobotulinumtoxinA treatment, while an improvement in group II was observed only after 3 months of rehabilitative treatment (p<0.05). One year after surgery, synkinesis was observed in 32.7% of patients in group I and 68.2% in group II (р<0.05). After two years, synkinesis was observed in 16.7% and 75.0% of patients in groups I and II, respectively (p<0.001). Adverse events were observed in 6 (10.5%) patients in group I and regressed during 3-4 weeks with no need for special interventions: lip ptosis (3; 5,3%), negligeable ptosis (3; 5,3%), difficulty speaking (4; 7,0%) and dry eye (4; 7,0%). Conclusions: IncobotulinumtoxinA treatment in FNI was effective in the acute phase and long term


 

TOPIC: Botulinum Toxin

Submitting Author: Susana Moraleda

Title: Descriptive study of patients with facial paralysis treated with botulinum toxin

INTRODUCTION   Since 2004 we have been using botulinum toxin injection in facial paralysis (FP) patients. Those patients were treated at the Physical Medicine and Rehabilitation Department in our Facial Paralysis Unit.   OBJECTIVE   To obtain a global perspective of all FP patients who have received botulinum toxin (BTX) treatment.   METHOD   Performing a descriptive study of 300 patients treated since 2004 up to the present. Demographic data, PFP ethiology, time since the diagnosis, muscles injected, as well as dosage and type of BTX applied have been collected.   RESULTS   Most of our patients (76% of them) were women. The most frequent cause was Bell’s palsy, followed by acoustic neurinoma and other ear surgeries, Hespes zoster, parotid gland surgery,  posterior fossa surgery, among other causes.   Left affectation presented in 159, while billateral in 11.   Great variability found in the time elapsed between the diagnosis and the beginning of the BTX treatment: from a few months to more tan 20 years.   We applied OnabotulinumtoxinA in 207 patients and IncobotulinumtoxinA in the remaining patients.   50% of the patients have received, in total, less than 10 sessions of infiltration, while 25% have received between 10 and 20. The remaining 25% have received more than 20 sessions.   The dosage per session may vary from 7.5 U (3 patients with affected marginal branch) to 72.5 U (2 patients).   Between 7.5 and 25 U: 55 patients. Between 27.5 and 45 U: 75 patients. Between 47.5 U and 72.5 U: 170 patients.   The most infiltrated muscled in the healthy side are Frontalis, Zygomaticus, Risorius, Mentalis and Depressor labii inferioris.   In the paretic side: Coarrugator, Orbicularis oculi, Mentalis, Platysma, Frontalis and Buccinator.   CONCLUSION   -          Our patients are mostly women with right Bell's PFP, receiving BTX infiltration in both sides of the face with dosages over 45 U per session


 

TOPIC: Botulinum Toxin

Submitting Author: Susana Moraleda

Title: Botulinum toxin A injection in facial  paralysis: patient satisfaction

INTRODUCTION   Even though there is much experience in Peripheral Facial Paralysis (PFP) treatment with botulinum toxin A (BTXA), there is not enough awareness about the subjective perspective that the patients experience when the  outcomes are shown.   OBJECTIVE   To know the results of the treatment from the effects of PFP through BTXA injection, focusing only in the patient’s opinion.   METHOD   Prospective study. A simple survey was created so that patients would easily complete it, as well as seeking for quantifiable answers.    A random sample of 70 patients was chosen out of the current 275 patients receiving the treatment.   RESULTS   Every respondent patient presented a high level of satisfaction after receiving therapy, regardless of the paralysis’ ethiology and degree of affectation. Most of the patients feel an improvement especially in rest and synkinesis control.   A significant feature is that all patients –except for one– would repeat the treatment, and 100% of the patients would recommend it to others suffering from PFP.   CONCLUSION   Treatment with botulinum toxin A in patients suffering the effects of peripheral facial paralysis provides a high level of satisfaction related to the patient’s subjective perspective in improvement.


 

TOPIC: Botulinum Toxin

Submitting Author: Susana Moraleda

Title: Botulinum toxin A injection in facial paralysis: is there a different perception between patients and doctors?

INTRODUCTION   Normally, practitioners use scales in order to quantify their treatments’ outcomes. However, little clinical research is being performed to determine treatment outcomes from the patient’s perspective.   OBJECTIVE   To verify whether the objective results after Botulinum Toxin A (BTXA) injection measured from a quantitative scale, match the patient’s subjective perspective.   METHOD   Prospective study. The Sunnybrook Facial Grading System (SFGS) scale was established as the objective assessment scale system from a random sample of 70 patients  before and after BTXA treatment. Those same 70 patients were applied a simple survey, where they were asked about their impressions based on their treatment outcomes after the BTXA injections.   RESULTS   Every patient responded in a high level of satisfaction after receiving BTXA treatment. Most of the patients felt an improvement in both symmetry and rest, as well as in range of movement and a reduction in the intensity of synkinesis.    However, the outcomes did not present a direct relationship to the ones presented in the SFGS scale. For instance, although the scale does not reflect improvement when there is flaccid paralysis,  there is an improvement in the symmetry when the healthy side is injected, which is a very important fact for the patient.    Another discordance found is that the scale does not present improvement in the range of movement even though the patient does feel so.   CONCLUSION   -          After botulinum toxin treatment, the level of satisfaction in facial palsy patients is high   -          The Sunnybrook Facial Grading System is a good scale to measure objectively the improvement after the BTXA injection, but it does not always match the patient’s subjective perspective


 

TOPIC: Botulinum Toxin

Submitting Author: Jin Kim

Title: Half-mirror biofeedback exercise in combination with three botulinum toxin A injections for long-lasting treatment of facial sequelae after facial paralysis

Objectives/hypothesis: The present study was conducted to develop a new method for maintaining the effect of botulinum toxin treatment for facial sequelae. We used a combination strategy including the administration of botulinum toxin three times at 6e8- month intervals followed by daily newly developed half-mirror biofeedback rehabilitation for about 2 years from the first injection.    Study design: This was a prospective study.    Methods: Seventeen patients with unilateral facial palsy for >1 year were included in the study. The amount injected per site varied from 1.5 to 3 U. The purpose of the first injection was to reduce the most inconvenient facial problem such as facial synkinesis or hyperkinetic movement at the points of the periocular area and the zygomaticus major and minor muscles with an average dosage of 17.4   13.9 U. The second injection was to enhance facial symmetry at prominent hypertrophic areas on the contralateral side with 36.5   15.4 U, and the third injection was to add cosmetic configuration at the points of deep furrows and creases caused by facial muscular hyperkinesis or atrophy with 15.6   8.4 U.    Result: After three injections of botulinum toxin A and 2 years of half-mirror biofeedback exercises, all patients showed marked relief of facial synkinesis and facial asymmetry. Before treatment, the mean   standard deviation (SD) Sunnybrook (SB) score was 36.8   8.76. After the first injection, the score increased by 11.4. After the second injection, the score increased by 14.6; it further increased by 15.6 after the third injection.


 

TOPIC: Botulinum Toxin and Other Chemodenervation

Submitting Author: Jin Kim

Title: The minimal invasive treatment for acute and chronic facial palsy

In cases in which medical or surgical treatment options are limited due to patient’s existing medical problems or advanced age, most patients with acute facial palsy are advised to await spontaneous recovery or are informed that no effective intervention exists. To- date, there has been little focus on the treatment of acute facial palsy in patients with conditions that cannot be resolved. So, how about an application of botulinum toxin to healthy side for treatment with facial asymmetry who cannot be optimally treated? Although there has been little evidence, contralateral weakening by botulinum toxin induced face on paralyzed side gaining strength and enhanced the quality of life during recovery of facial function by improving symmetry as a useful alternative.    On the other hand, after severe facial palsy, some problems can occur in the face after several months. Over all, there are 4 types of facial changes. Loss of strength, loss of isolate motor control, contralateral muscular hypertrophy, and synkinesis.     An attempt has been made to produce a new 'balance' in facial dynamics between a paralysed and a non-paralysed face with reduction of synkinesis, by concomitant injection of botulinum toxin A (BTX-A) on both sides in patients with long-lasting facial sequelae. And also develop a new method for maintaining the effect of botulinum toxin treatment for facial sequelae by daily newly developed half-mirror biofeedback rehabilitation for about 2 years from the first injection.   However, for a drooping face after facial palsy which could not be easily resolved by other treatment, various thread can be used for lifting as a minimal invasive treatment. Remarkable control of drooping face especially for old age can be observed with elevated quality of life and personal appearance


 

TOPIC: Diagnostic Imaging

Submitting Author: Nicholas Deep

Title: MRI Assessment of Vascular Contact of the Facial Nerve in the Asymptomatic Patient

Introduction:  Vascular contact of the facial nerve is widely believed to be the most common cause of hemifacial spasm (HFS).  Microvascular decompression has been established as an effective and potentially curable treatment for HFS.  While investigators have studied the accuracy of different types of MRI sequences for identifying vascular loop compression preoperatively as compared to the gold standard of intra-operative findings during microvascular decompression for HFS, there is much less data to address the frequency with which a vessel is contacting or compressing the facial nerve as an incidental finding in the absence of a history of HFS.    Objective: To determine the prevalence of facial nerve vascular contact on MRI in patients without hemifacial spasm (HFS).   Methods: Our radiology database was queried to identify consecutive adult patients without a history of HFS, intracranial tumor, brain radiation therapy, intracranial surgery, traumatic brain injury, or trigeminal nerve vascular compression. One-hundred high-resolution MRI’s of the posterior fossa were independently reviewed by two neuroradiologists for facial nerve vascular contact (200 sides).  Main outcome measures included the prevalence of vascular nerve contact in the non-HFS patient, the location of contact along the facial nerve, the culprit vessel, and severity of compression.   Results: The presence of vascular contact in the non-HFS patient may be as high as 53%. It is typically mild to moderate in severity, most commonly involves the cisternal portion, and usually caused by the anterior inferior cerebellar artery (AICA).   Conclusion: Vascular contact of the facial nerve is frequently identified in asymptomatic individuals but tends to be more peripheral and mild compared with previous descriptions of neurovascular contact in HFS patients. These results should be considered in assessing the candidacy of HFS patients for microvascular decompression.


 

TOPIC: Diagnostic Imaging

Submitting Author: Maurizio Barbara

Title: DOES FACIAL NERVE INVOLVEMENT/DEHISCENCE PLAY A ROLE IN CHOLESTEATOMA RECURRENCE ?

Introduction, Recurrence of cholesteatoma (CHO) may be ascribed to several factors that include extension, age of the subject, surgical skill and procedure. One may also assume that the presence of coexisting complications could play a role in this regard.    Objective. Aim of the present study was to get evidence of the role played by coexisting complications for increasing the risk of CHO recurrence.   Methods. A combined retrospective and prospective study has been performed on a consecutive series of subjects operated on CHO during the last 5 years and in whom a routine non-EPI DW MRI has been planned, with different timing. The retrospective sample was used as control, while for the prospective sample it was applied a new imaging protocol at 1 month, and 6 and 12 months postoperatively, aiming at getting early evidence of eventual residual disease. The study sample was further divided in petrous (PB) and non-petrous bone CHO according to the presence of a concomitant complication, namely facial nerve involvement/exposure, fistula of the semicircular canals and large dural exposure/involvement.    Results   PB CHO with involvement of the facial nerve showed to give the highest rate of residual disease at the 1-month imaging control. In non-PB CHO with facial nerve exposure/involvement, a low rate of residual pathology was found. Negative imaging at 1-month in all the study sample remained as such at 1-year control.    Conclusion   Involvement of the facial nerve is not strictly related to CHO recurrence, apart from those cases of PB CHO in whom an anatomical saving was preliminarily negotiated with each subject for esthetic purposes.


 

TOPIC: Diagnostic Imaging

Submitting Author: Aaron Smith

Title: Imaging Practices in the United States Emergency Department for Primary Bell’s Palsy

Introduction: Bell’s palsy and stroke are the two most common causes of acute, unilateral, facial paresis or paralysis. These patients oftentimes present to the emergency department (ED) for initial evaluation. The 2013 Otolaryngology Clinical Practice Guideline recommends history and physical and against imaging for Bell’s palsy, yet practice patterns prior to its publication are unknown.   Objective: To study patients presenting to the ED with diagnosis of Bell’s palsy, and determine the rate and predictive factors leading to imaging.   Methods: We identified patients from 2006-2010 within the National Emergency Department Sample with a primary diagnosis of Bell’s palsy (ICD-9-CM code 351.0). Co-diagnosis codes were evaluated for alternate diagnoses for facial paralysis. National estimates were calculated from weights within the database. Within SAS Software, patient demographics were examined utilizing Chi-squared test and logistic regression to identify predictors of imaging.   Results:  In the 5-year cohort, 420,650 patients (27.68/100,000 population) were identified with a primary diagnosis of Bell’s palsy.  Only 4.2% had inappropriate co-diagnosis coding of alternate causes, most commonly stroke. Following restriction to reliable CPT coding facilities, 47.4% underwent imaging, usually CT Head. Patients with imaging were more likely discharged home (96.24% vs. 82.68%). Predictors of imaging included increasing age (OR 1.32[1.28, 1.35](10 year increment)), presence of top ten co-morbidity (OR 1.72[1.57, 1.89]) and transfer to short term hospital versus discharge (OR 4.16[1.60, 10.82]). Predictors that decreased imaging were self-pay or no-charge versus private insurance (OR 0.77[0.69, 0.86] and 0.55[0.36, 0.83]), and living outside the South (Northeast OR 0.68[0.57, 0.81], Midwest 0.53[0.43, 0.64], and West 0.40[0.31, 0.51] versus South).   Conclusion: 47% of patients with Bell’s palsy received imaging in the ED, predictors including older age, transfers, living in the South and with insurance. This information provides a benchmark for the American Academy of Otolaryngology guidelines with current misalignment of recommendation and practice.


 

TOPIC: Diagnostic Imaging

Submitting Author: Jong Woo Chung

Title: Prognostic value of temporal bone MR in the recovery of Bell's palsy

Objectives: In facial palsy patient, temporal bone MR (TBMR) image is useful to detect the lesion of damage of the long course of facial nerve. However, there has been reported that TBMR was not related to the prognosis of the Bell's palsy. In this study, we aimed to find the prognostic factors of TBMR for the recovery of facial function of Bell's palsy.   Methods: One hundred forty-nine patients with facial palsy were included. All patients underwent temporal bone MR (TBMR). These patients were divided into two groups according to enhancement region of facial nerve in TBMR. Facial nerve course was divided into regions: intracranial, meatal, labyrinthine, tympanic, and mastoid. 3.0-Tesla MR unit was used and enhancement was done with gadolinium. Grade of facial palsy was evaluated with House-Brackmann (HB) grading system. Severity of initial facial palsy and prognosis were compared between enhancement regions.   Results: No enhancement of facial nerve course was found in 15 patients. Multiple enhancements in more than 2 regions of facial nerve course were observed in 17 patients, 2 regions in 75, and 1 region in 42 patients. Patients of initial H-B grade IV and V were 47% in patients with meatal and/or labyrinthine segment enhancement. In other patients, 60% had initial H-B grade IV and V. Initial ENoG was not clinically different in between two groups. When all enhancements were analyzed separately in relation to the recovery of HB grade, labyrinthine enhancement was the least.    Conclusions: Our findings suggest that facial palsy patient with TBMR enhancement of other than meatal and/or labyrinthine segment had more severe initial facial palsy clinically. Enhancement including labyrinthine region showed worst prognosis.


 

TOPIC: Diagnostic Imaging

Submitting Author: Tamsin Gwynn

Title: Neurovascular compression syndromes in facial paralysis

Introduction:               Vascular loops are a significant etiological factor in hemifacial spasm but in the majority of the populations (65%), cause no symptoms. In this study, we look at its causative role in facial palsy as well as management options.   Patients & Methods:               In a retrospective case review of over 300 new facial palsy referrals seen at our centre in 2016, 44 cases were deemed to have presented atypically with facial paralysis as per our protocol. All of these patients were then subjected to baseline serological and radiological investigations (contrast-enhanced MRI Head and Internal Acoustic Meatus) as per Hadlock et al. Patients presenting with hemi-facial spasm, facial pain and motor tics were excluded from this study.   Results:                We found ten cases of vascular loops causing neurovascular compression (n = 10), accounting for 23 % of those with atypical facial palsies in our centre. There was no male:female preponderance with a mean age of 43 years (range: 18 to 70 years) versus 51.6 years for all atypical facial palsies. The majority of the compression occurred at the root exit zone of VII (40%) and the cisternal segment; between the VII and VIII nerves (40%). One case presented following neurosurgical decompression, which resulted in total VII and VIII nerve palsies.   Discussion:               Neurovascular compression syndromes, although more commonly associated with hemifacial spasms, also do cause facial paralysis in a significant number of atypically-presenting facial palsies. It is hence imperative to specifically look for this radiologically when reporting. Those with return of facial function and residual synkinesis were treated with Botox while persistent flaccidity was managed with smile reanimation procedures.


 

TOPIC: Diagnostic Imaging

Submitting Author: Ho Yun Lee

Title: Varicella Zoster Virus DNA from the Acute Peripheral Facial Palsy Patients’ Saliva

Objective: We aimed to confirm the feasibility of detecting varicella zoster virus from the saliva in patients with acute peripheral facial palsy (APFP).    Method: 27 patients diagnosed as Bell’s palsy or Hunt syndrome were enrolled in this study. On admission day and the third day, patients’ saliva was collected and analyzed to detect varicella zoster virus (VZV) DNA. House-Brackmann (HB) scale was used to evaluate the degree of facial palsy on the admission day, the week two, and week 10 to 12 after the onset of treatment. In addition, the relationship between the presence of VZV DNA and the accompanying symptoms including pain, hearing level, tinnitus, and dizziness as well as the enzyme-linked immunosorbent assay (ELISA) result was evaluated.   Results: VZV DNA was detected in 8 (29.6%) patients. VZV DNA was not detected in the all of saliva specimens collected on the admission day and all found from the third day specimens. Among the 19 patients without vesicular eruptions, VZV DNA was detected in 2 (10.5%) and 6 (75.0%) of 8 patients with vesicular eruptions in the ear or the oropharynx had VZV DNA in the saliva (p = 0.002). In contrast, the presence of anti-VZV IgM antibody was not different regardless of rash (p = 0.065). Patients with VZV DNA had worse hearing in the affected side at most frequencies (p < 0.05). Aside from hearing, none of the accompanying symptoms were different according to presence of VZV DNA (p > 0.05). Patients with VZV DNA tended to have higher HB grade but it was not significant except the HB grade in the week two.     Conclusion: Detecting VZV DNA from the saliva in peripheral facial palsy is one of the considerable options for more accurate differential diagnosis of APFP.


 

TOPIC: Diagnostic Imaging

Submitting Author: Vera Hurler

Title: Sonoanatomy of the facial nerve from the exit out of the temporal bone to the orbicularis oculi and zygomaticus musculature

Introduction:    The course of the facial nerve is well researched and described in detail in many anatomical atlases. Nevertheless, detailed data on the extratemporal portion of the facial nerve and its depth and variability when innervating facial muscles is still deficient. Furthermore, a method to track the individual peripheral facial nerve branches in vivo still is lacking.   Object:    By combining high resolution ultrasound with classical anatomical preparation, we will add the missing third dimension to our anatomic knowledge of the peripheral facial nerve.    Material and Methods:    The exact depth of the facial nerve, the muscles, fat, glands, and bones was measured by ultrasound in 10 hemifaces before preparation. During preparation, every step was photodocumented. For ultrasound, the face was examined in strip-wise scanning at a distance of 1 cm both in the transversal and sagittal plane with a 3-12 MHz linear transducer for vascular presentation.   Results:   The depth of the muscular and connective tissue as well as the nerve branches could be traced from the exit at the temporal bone to the musculature which it is innervating. Immediately after exiting from the stylomastoid foramen the facial nerve could be seen at a depth of about 25 mm perpendicular to skin surface and 10 mm laterocaudal of mastoid process. In the periphery, the nerve entered the orbicularis oculi and the zygomatici muscles at an average depth of 4 to 10 mm.    Conclusion:   High resolution ultrasound can be a useful supplement to the classical preparation to add the third dimension and reconstruct the depth course of anatomic structure. Despite the relatively low number of cases, the data obtained helps to better understand the threedimensional facial nerve tract. The method seems to have the potential to track the individual facial nerve in vivo. This will be the aim of succeeding investigations.


 

TOPIC: Diagnostic Imaging

Submitting Author: Eun Jin Son

Title: Identification of facial nerve by 3D PD TSE with DRIVE in patients with intracanalicular tumors: case series

Background: Diagnosis of small intracanalicular tumors has become more feasible with with improved imaging techniques. While acoustic schwannomas comprise most of intracanalicular tumors, tumors may arise from the facial nerve. Radiologic identification of the facial nerve and its relation to the tumorous lesion would provide valuable information for therapeutic planning. In this study, we aimed to identify the facial nerve in patients with intracanalicular tumors.    Methods:The study included 11 patients with lesions confined to the internal auditory canals. Gadolinium (Gd)-enhanced 3D proton density (3D) turbo spin echo (TSE) images were obtained. The neural components of the internal auditory canal (IAC) were identified. The radiologic findings and clinical feastures were compared.    Results: Facial nerve and the other neural components could be traced from the brainstem to the fundus of IAC in all patients, although the clinical characteristics were not definite. Either the facial nerve or vestibulocochlear nerve origin of the intracanalicular tumors could be inferred from the 3D PD images, and the relation between the tumor and the course of the facial nerve could be described due to increased contrast in the tumor lesion than conventional MR images. The facial nerve origin was detected in one patient who presented with dizziness.   Conclusion: In addition to conventional MR images, 3D PD TSE with DRIVE technique provides important information concerning the facial nerve and other structures in the IAC in patients with intracanalicular tumors.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Johnny Chuieng - Yi Lu

Title: Simultaneous reconstruction of the lower lip during functioning free muscle transplantation for smile reanimation in facial paralysis: objective and subjective evaluation comparing different surgical methods.

Introduction and Objective:   Lower lip reanimation is often a neglected field in smile reanimation. This aim of this study is to compare the different lower lip reconstructive methods combined with FFMT for facial paralysis.   Methods:   53 patients operated during 2006-2015 were included in the study and divided into 3 groups. The method of lower lip repair for group 1 was suturing a free plantaris tendon graft onto the FFMT and then passing the graft through the entire lower lip in a loop fashion. In group 2, the proximal gracilis aponeurosis was lengthened and then repaired to the lower lip. The lower lip was not repaired in group 3 patients. Subjective evaluations emphasized on the discrepancy of the vermillion exposure between the two halves, midline deviation and horizontal tilt of the lower lip. Objectively, the preoperative and postoperative volume dimension and movement excursion of the lower lip were measured and compared between the two halves. Statistical analysis of the final results was performed by using chi-square and one-way ANOVA tests.   Results:   Groups 1 and 2 showed significant improvement in vermillion exposure dynamically and midline deviation statically. Both these groups also had a significantly higher overall score than group 3. Group 2 had the least discrepancy in vermillion exposure postoperatively. Objectively, the discrepancy of the lower lip volume between the paralyzed and healthy halves all decreased after surgery in the 3 groups, with no significant difference. However, groups 1 and 2 both showed significantly larger increase in postoperative volume of the paralyzed side.     Conclusions:   Both groups 1 and 2 showed significant improvement in vermillion exposure and volume increase subjectively and objectively, with the group 2 having the least discrepancy in the vermillion exposure.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: James Wokes

Title: Primary Lengthening Temporalis Myoplasty in Cancer Patients

Primary lengthening temporalis myoplasty in cancer patients   Introduction   Of over 120 lengthening temporalis myoplasty procedure performed in the Newcastle upon Tyne NHS trust, 18 have been for primary facial reanimation following cancer resection sacrificing the facial nerve. These patients are in many ways more complex, with multiple co-morbidities and the potential need for adjuvant treatment modalities   Methods   We performed a retrospective review of medical and physiotherapy case notes. Patient demographics, tumour histology and surgical resection margins, reconstructive procedure, adjuvant or previous chemo- or radiotherapy, physiotherapy input and overall results were recorded including tendon excursion.    Results   We present our experience of the 18 cases performed to date. Photographs and videos demonstrate our immediate and long term results.   Discussion   This patient cohort presents a more complicated challenge in terms of reanimation than non-cancer facial palsy patients. We will discuss some of the differences and some of the difficulties we have encountered in this group of patients.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Irina Domantovsky

Title: Long Term Outcomes of Young Adults with Moebius Syndrome Following Facial Reanimation Surgery

Introduction:   Segmental gracilis muscle transplant is the standard of care for smile reanimation in children with Moebius syndrome. However, the long-term clinical efficacy and psychosocial impact of the transplant is unknown.   Objectives:   1) To determine the oral commissure excursion of gracilis transplant 10-20 years after surgery in patients with Moebius syndrome   2) To determine the long-term psychosocial impact of facial reanimation surgery   Methods:   Patients with Moebius syndrome who underwent gracilis muscle transfer between 1985-2005 were included in the study. Oral commissure excursion, the FaCE scale, and semi-structured interviews were used to assess function.   Results:    Thirteen patients completed the study, 69.2% female. The mean age at surgery was 12.5 years (5 - 34) and the mean follow-up was 19.6 years (7.5 - 31.5) after surgery. Twenty-two gracilis muscle transplants were performed, all single-stage and powered by the nerve to the masseter. The mean oral commissure excursion during animation was 13.8 mm (± 2.8) at last follow-up. The mean difference in oral commissure excursion was 1.7 mm (± 1.2) in 9 bilateral cases and 4 mm (± 3.3) in 4 unilateral cases. The overall mean FaCE score from the cohort was 63.1 (± 3.2). The mean score from facial comfort subdomain was 84.7 (± 21.0) and social function subdomain was 70.8 (± 17.9). Although facial movement subdomain score was 35.4 (± 11.8), the score related to smiling alone was 85.4 (± 19.8). Interview responses indicated high satisfaction with surgery, fulfilled expectations of social acceptance, improved communication, enhanced self-confidence, and a sense of increased facial symmetry, spontaneity, and smile excursion.   Conclusion:   Segmental gracilis muscle transplantation provides long-lasting improvements in objective and patient-reported measures of facial function.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Martinus van Veen

Title: A higher quality of life with cross-face-nerve-grafting as an adjunct to a hypoglossal-facial jump graft in facial palsy treatment

Introduction: Nerve reconstructions are the preferred technique for short standing facial paralysis, most commonly using the contralateral facial nerve or ipsilateral hypoglossal nerve. The hypoglossal nerve gives a strong motor signal. The signal of a cross-face nerve graft (CFNG) is weaker, but spontaneous. Spontaneity in facial expression is believed to be of importance for psychological wellbeing. Therefore combination of the two procedures combines the best of both: a strong motor signal and a spontaneous smile.    Objective: Aim of this study was to objectify whether combining these two procedures is of benefit.   Methods: Of the 19 patients who received a hypoglossal-facial nerve anastomosis in the period from 1995 to 2015 in our institutions, 12 patients were included in this study, five with and seven without a cross-face nerve graft. The outcomes were compared using photographs, the disease-specific quality of life (Facial Clinimetric Evaluation scale (FaCE)), a self-reported synkinesis scale (Synkinesis Assessment Questionnaire), and presence of a spontaneous smile.   Results: Median Total FaCE scores were considerably larger (18.3 points) for patients who underwent the combined procedure. Symmetry of the face in repose and during smile, quality of life, synkinesis and spontaneity did not differ significantly between the two groups. A spontaneous smile was observed both with a cross-face nerve graft (n=2) and without (n=1).    Conclusions: The addition of a cross-face nerve graft to a hypoglossal-facial nerve anastomosis resulted in a positive trend in disease-specific quality of life.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Martinus van Veen

Title: Cross-face nerve grafting; a comparison of outcomes within indications for use

Introduction: A cross-face nerve graft (CFNG) is one of the most commonly used procedures in facial reanimation either  as a solitary procedure or combined with a muscle transplantation or cranial to facial nerve anastomosis. The postoperative outcome of cross-face nerve grafting has thoroughly been studied in animal models. These studies determined the weight of the connected muscle, amongst others, to be of influence on the outcome. In a rabbit model, a nerve transfer was able to control a muscle double or triple the native size.    Objective: The aim of this study was to objectify if the same phenomenon takes place in human subjects depending on the type of operation.   Methods: All patients from the University Medical Center Groningen and Isala Clinics treated with a CFNG between 1995 and 2015 were invited to participate. Patient photographs were analyzed with the FACE-gram software and graded according to the May classification. Longitudinal analysis was performed using three moments in time: preoperative, postoperative and long term. Comparison of the clinical outcomes was performed cross-sectionally on recent photographs.   Results: Thirty-three patients were included, from an initial inclusion of fifty-seven patients. All patients (n=24) were excluded due to a lack of pre- and postoperative data. The photographs showed an increase in excursion of the corner of the mouth and an improvement of symmetry of the mouth in repose and during smile. At the same time, an improvement of May classification scores was found. Divided by type of reanimation procedure, the gracilis muscle transplantation demonstrated a trend towards better results. Conclusions: This is the first study that demonstrates a trend towards better results after gracilis muscle transplantation compared to a solitary CFNG or a CFNG in combination with a hypoglossal-facial nerve anastomosis. These results are in line with earlier animal model studies.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Adriaan Grobbelaar

Title: Dynamic restoration of eye closure in unilateral facial paralysis; an early experience of 12 cases using platysma functional muscle transfers

Introduction: Epiphora, lagophthalmos and the inability to spontaneously blink are the main problems facial palsy patients describe and if left untreated can compromise the cornea and vision.  Free functional muscle (FFM) transfers remain the gold-standard for smile restoration however, spontaneous eye closure remains a difficult problem to correct. Although satisfactory eye closure is achievable with traditional surgical and supportive modalities, patients continue to report photosensitivity and can develop exposure keratitis. The aim of this study is to review the outcomes of patients receiving a two-stage free platysma transfer to restore spontaneous protective eye closure.   Methods: All patients being considered for pan-facial reanimation were selected as candidates for dual restoration of both smile and eye closure. Patients were treated using a two-stage approach: at the first stage two sural nerve grafts were harvested and coapted to an isolated buccal and zygomatic branches of the functioning facial nerve. At the second stage a FFM was transferred to restore the smile and a free platysma was used to restore spontaneous eye closure. Patients with no eye symptoms were not offered this treatment modality and those not fulfilling the criteria for FFM transfers were excluded. After six months, all patients were evaluated by the senior surgeon, an ophthalmologist and an independent blinded panel rated video analysis.   Results: Twelve dual two-stage FFM transfers were performed between 2011 and 2016. Four females and eight male patients fulfilled the inclusion criteria. The median age at the second stage was 9.7 years (SD 4.9 years) and all had a minimum follow-up of six months post second stage. All patients reported improvement of their pre-operative eye symptoms and 80% had a restored blink reflex at six months follow-up.   Conclusions: Although free platysma transfers are technically early outcomes appear to offer excellent functional restoration of the paralysed eye.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Akram Rahal

Title: Long term results of lengthening temporalis myoplasty in facial paralysis reanimation

Objectives   The objective of this study was to review all the cases of lengthening temporalis myoplasty for facial paralysis reanimation done at our institution from 2011 to today that had a minimum follow-up of one year to look at aesthetical and functional outcomes and complications.   Methods   We reviewed the charts of 20 patients as well as preoperative and postoperative videos. We recorded pertinent demographic data, cause of paralysis, delay between paralysis and surgery, duration of surgery, length of hospital stay, length of follow up, associated procedures done and complications. Preoperative and postoperative videos were reviewed in order to assess symmetry at rest, restoration of voluntary smile and spontaneous smile at minimum one year follow up.   Results   The main pathologies responsible for permanent facial palsy leading to reanimation surgery were acoustic neuromas and parotid cancer. Surgery lasted in average 4,3 hours and hospital stay was on average 3,7 days. The most common associated procedure was botulinum toxin injection on the non-affected side. The most common complication in 2 patients was early detachment of the tendon that had to be re-operated in the following days. At minimum one year follow up, symmetry at rest and voluntary smile was restored in all patients. Spontaneous smile was restored in 30% of our patients. Preoperative  and postoperative videos will be presented to illustrate our results.   Conclusion   Lengthening temporalis myoplasty is a one-step dynamic facial reanimation operation aimed at restoring symmetry of the mid-face and smile. At one year follow up, all patients achieved a voluntary smile and 30% of them recovered the ability to smile spontaneously.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Gerardo Muñoz-Jiménez

Title: Inferior belly omohyoid muscle as free functional flap, cadaveric anatomical study

Introduction: Infrahyoid muscular and musculocutaneous pediculated flaps has been described before, even like functional flap, but the most of authors don’t use the inferior belly omohyoid muscle, the variability of vascular pedicle and the distance from the surgical site are the reasons. The morphology of this muscle it’s so peculiar that can be useful for specialized reconstruction goals.   Objective: Anatomical description of the inferior belly omohyoid muscle as free functional flap.   Methods: The findings of 5 anatomic cadaveric models are described. Two flaps were discarded for previous surgical access. 8 flaps included. The dissection was made through a supraclavicular incision.    Results: A great variability in the vascular anatomy and muscular morphology was found. The mean dimensions of the omohyoid inferior belly was length: 93mm, wide: 12mm, thick: 7.5mm. two flaps (same model) has no intermediate tendon. Vascular pedicle of two flaps (same model) came from cervical transversus vessels, the rest from subclavian vessels (two flaps receive, extra minor vascular pedicle), all vascular pedicles were less than 1mm diameter and the mean length: 22.3mm. The nervous pedicle came from ansa cervicalis in all flaps and the mean length: 27.8mm.   Conclusions: There is no previous anatomical description focused in this muscle as free functional flap. Although the small diameter and anatomical variability can difficult dissection and anastomosis of the pedicles, with supermicrosurgery techniques (allowing vascular anastomosis ≤0.8mm diameter) could be feasible to use this muscle as a free functional flap in cases where functional flaps of small dimensions are required, such as facial reanimation, blink restoration, vocal chords reconstruction, and others. Description of innovative flaps and techniques expand the possibilities and improve the results of the reconstructive microsurgery.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Laura Hetzler

Title: Facial Nerve Translocation for Low Tension Neurorrhaphy between the Masseteric Motor Branch to the Tympanic Segment of the Facial Nerve in Facial Reanimation

Introduction: The techniques of facial reanimation are continually evolving in search of the ideal method for rehabilitating the paralyzed face.  In the past, alternative cranial nerve motor nuclei have been used to power facial musculature.  The trigeminal nerve is gaining popularity as a promising nerve to drive facial motion, particularly in the lower face.     Objectives: This article describes a low-tension technique of using the transposed facial nerve to the trigeminal nerve (masseteric branch) for facial reanimation.      Methods: Six patients over 3 years were treated with facial nerve translocation with division at the 2nd genu and direct neurorrhaphy to the motor nerve branch of the masseter.  Four of the six had previous transmastoid skull base surgery with fat and cement mastoid obliteration.  Patients were evaluated by physical exam, measurement of oral commissure excursion and video assessment.  Follow-up was between 8 months and 35 months.     Results: In all patients the nerve length was adequate for tension free neurorrhaphy between the tympanic segment of the facial nerve and the motor branch of the trigeminal nerve.  There were no cerebrospinal fluid leaks or intracranial complications associated with reopening the skull base surgery exposure.  Patients demonstrated early motion within 4 months postoperatively and were placed into facial physical therapy.  All demonstrated improvements in oral competence, strong oral commissure excursion with good symmetry, speech improvements and variable results in facial tone.  One patient did suffer with synkinesis requiring chemodenervation for optimal outcomes.  One patient did recover enough upper division tone to warrant consideration of upper eyelid platinum weight removal.     Conclusion: The motor branch of the trigeminal nerve is an effective option for facial reanimation via facial nerve translocation and end to end neurorrhaphy.  Variable results in facial tone were noted.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: callum faris

Title: Application of Free Muscle Transfer For Smile Rehabilitation In Advanced Parotid Malignancy

Introduction   Advanced parotid malignancy requiring the sacrifice of facial nerve is uncommon. Despite initial reconstructive efforts, a number of these reconstructions fail to effectively rehabilitate a meaningful smile. In these instances, further smile reanimation techniques can be considered.  We review our experience of secondary smile rehabilitation with free Gracilis muscle transfer in patients with prior malignant parotid disease.   Objective:   To review the effectiveness of gracilis free muscle transfer for smile reanimation, in patients with a prior diagnosis of radical parotidectomy and adjuvant therapy.   Methods   Retrospective case review. All patients undergoing gracilis free muscle transfer for smile reanimation with a prior diagnosis of radical parotidectomy and adjuvant therapy from 2002 to 2016 were included.   Results   There were 12 patients that underwent gracilis free muscle transfer for smile reanimation (5 males and 7 females). The average duration of facial paralysis before intervention was 1-35 years (8.7 mean). Prior reanimation therapy (cable grafting) had been undertaken in 4 of the 12 cases. Following gracilis free muscle transfer for smile reanimation total eFace and midface static and dynamic scores were all statistically improved. Quality of Life as measured by the FaCE instrument was statistically improved. There were no vascular failures or major complications.    Conclusions   Gracilis free tissue transfer can be a reliable procedure for dynamic reanimation of the smile in patients who have undergone prior radical parotidectomy and adjuvant therapy.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Ayato Hayashi

Title: Modified Lengthening Temporalis Myoplasty through an Intraoral approach

Background: Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves moving the whole temporal muscle anteroinferiorly and inserting its tendon directly into the nasolabial fold (NF). However, to advance temporal muscle tendon toward nasolabial fold, it requires nasolabial fold incision, which is one of the biggest problem of this procedure especially for young or female patients.    In this presentation, we report our experience of performing modified LTM under intraoral approach to manipulate temporal muscle tendon toward NF and avoiding incision on the face.    Method: We performed modified LTM under intraoral approach in 4 female patients with permanent facial paralysis. To put key-sutures creating NF at proper points, we used propeller needle for epidural anesthesia. To avoid infection to the advanced tendon, we switched the thread to fix tendon from polyfilament to monofilament, and tried to reduce time of intraoral exposure of the tendon as less as possible.  We also performed several additional static reconstructions for other remaining deformities with our original modifications.    Results: We were successful at achieving considerable static improvement at rest, immediately after the surgery, and we could achieve smile reconstruction without obvious scar on the face. There was no infection or other major complications after the surgery; however, one patient developed slight dimple which required revision subsequently. All the patient could get good facial movement within 3 months.    Discussion:  We could perform modified LTM under intraoral incision and obtained fairly good results. Understanding detail anatomy toward coronoid process, we could advance temporal tendon toward nasolabial fold firmly; however, obtaining good traction points at NF was more difficult than conventional method.       Establishing modified LTM without NF incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reconstruction in all generation.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Ruben Yap Kannan

Title: Super-selective Neurotisation of the Zygomaticus major and Levator labii superioris muscles for the Weak Smile

Objective:               To evaluate the efficacy of selectively neurotising the zygomaticus major (ZM) and levator labii superioris (LLS) muscles directly for smile reanimation, in patients with residual resting tone.      Methods:               In a prospective study over eighteen months, we selected seven patients (n = 7) for this procedure wherein either the masseteric nerve or cross-facial nerve graft (CFNG) was used to directly neurotise the distal ZM and the LLS depending on the pre-operative smile vector analysis of the patient. All patients had a pre-operative HADS and Sunnybrook facial grading scale assessment as well as needle EMG studies to identify the target muscle group. Patients were followed up at six weeks, three months and six months following surgery using the Sunnybrook scale and House-Brackmann scores alongside surface EMG tests over this period to measure clinical improvement.   Results:               The mean in-hospital stay was one day, with no complications reported. The masseteric nerve (n = 6) and the CFNG (n = 1) were used to neurotise the ZM and LLS while the fascia lata sling was used to improve the resting symmetry of the face in one patient. Patients reported having improved tone within three months while increased smile excursion was observed by six months post-op. This translated to Sunnybrook score improvements of up to 58% clinically.   Conclusion:               Super-selective neurotisation of the ZM and LLS muscles can strengthen the smile cascade and provides a more natural-looking alternative to muscle transfers for smile augmentation. Masseteric nerve innervation was noted to provide mass action movement while the CFNG-neurotised ZM had good control of tone and spontaneity.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Kyeong-Tae Lee

Title: Evaluation of Donor Morbidity Following Single-Stage Latissimus Dorsi Neuromuscular Transfer for Facial Reanimation

Introduction   Single-stage latissimus dorsi (LD) neuromuscular transfer is one of the main reconstruction methods for facial reanimation. In this procedure, segmental LD muscle block and long length of thoracodorsal nerve were harvested, which might affect donor site morbidity.    Objective   The present study aimed to provide a comprehensive analysis for donor morbidity following LD neuromuscular transfer in patients with established facial paralysis.    Methods   A retrospective analysis was performed for all cases of facial reanimation with LD neuromuscular transfer between January 2002 and November 2016. Donor morbidity was analyzed in two aspects: postoperative complications and functional impairment. The Quick-Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was surveyed for assessing postoperative donor-site function.   Results   A total of 60 patients with a mean age of 37 years were analyzed. Size of harvested LD muscle was 37.2 cm2 on average. Descending branch of thoracodorsal nerve with a mean length of 14.9 cm (range, 10.0 to 20.0) was harvested. An adjacent nerve branch was harvested in addition to descending branch of the nerve in 10 patients for dual innervation. In six cases, skin paddle based on thoracodorsal artery perforators was harvested together to correct facial contour deformity. Donor site complication developed in 7 cases, all of which were seroma formation and resolved by outpatient clinic-based aspiration.  Of 60 patients, 42 completed Quick-DASH questionnaire at median follow-up period of 51 months (range, 2 to 169). The mean score was 2.49 (range, 0 to 31.8). All but two patients scored less than 10, showing minimal functional impairment developed. No variables including age, muscle size, inclusion of skin paddle and co-harvesting an adjacent nerve branch showed significant association with the Quick-DASH score.    Conclusions   Our results suggest that LD neuromuscular transfer is associated with a low rate of complications and minimal functional morbidity in the donor site.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Hak Chang

Title: Facial reanimation using interfascicular nerve splitting of innervated partial latissimus dorsi muscle flap: anatomical study and clinical application

Introduction: Although vascularized functional latissimus dorsi transfer is frequently used for dynamic reconstruction of paralyzed face, there are few reports on the residual muscle function of the donor site. We focused on how to minimize the sacrifice of the latissimus dorsi muscle and investigated whether the thoracodorsal nerve can be divided.    Objectives: To study the anatomic basis for the interfascicular nerve-splitting technique   applied to the innervated latissimus dorsi muscle flap to preserve the remnant muscle   function.    Methods: A total of 42 latissimus dorsi muscles from 21 preserved cadavers were dissected,   and the distribution of the nerves and arteries were studied. The thoracodorsal neurovascular bundles were identified entering the muscle, and the distance from the upper margin and lateral margin of the muscle were measured. This surgical procedure was adapted to six patients with facial nerve palsy. The function of the residual latissimus muscle was evaluated by EMG   Results: The thoracodorsal neurovascular bundle entered the muscle at a distance of   39.1 +/- 8.8 mm from the upper margin, and 23.8 +/- 10.3 mm from the lateral margin. The thoracodorsal nerve always branched before the artery, and the distance from the first branching of the nerve to the first branching of the artery was 20.4 +/- 8.9 mm. Interfascicular dissection of the nerve was performed under operating microscope, by opening the epineurium and splitting the nerve. Four of six cases were able to preserve the branch toward the residual muscle by splitting the thoracodorsal nerve under a microscope. The free transplant succeeded in all cases and postoperative muscle contraction began in 4-8 months.     Conclusion: We simulated and confirmed that the preservation of the remnant muscle function was possible by using the nerve-splitting technique in the innervated latissimus dorsi muscle flap.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Malou Hultcrantz

Title: Bell’s palsy: Effect of prednisolone treatment and early cross facial surgery

Introduction:  Earlier very little help was provided to patients suffering from Bells palsy, but recently it was shown that prednisolone given within 72 hour after onset augments healing in those patients. A modified Cross-facial transplant surgery has been introduced and also this method seems to increase outcome.     Objectives: To assess if prednisolone treatment in combination with cross facial surgery enhances recovery of Bells palsy, when performed within 6 months after start. To register quality of life scoring during 1 year.     Methods: 15 patients with Bell’s palsy treated with prednisolone within 72 hours after start was pilot-operated and thereafter 10 patients were included in a prospective, surgical study and were randomized to have surgery or no surgery. Both groups had follow ups and physiotherapy. Sunnybrook grading scale was used to assess facial function and photos and films were organized. Patients were tested within 72 hours before treatment start, and at 1, 2, 3 and 12 months. Inclusion criteria were, age < 60, non smokers, Sunnybrook score <50 at 1 month, EMG and ENeG performed with bad outcome. The test group had a transposition of  n. Suralis  performed to both sides Facial nerve and connected to n. Hypoglossus on 1 side (cross facial surgery (i.e. baby sitter surgery). Two validated Quality of Life scales were filled out.     Results:  At baseline, treatment with prednisolone and the Sunnybrook score were significant factors for predicting non-recovery. Cross facial surgery enhanced cosmetically outcome and movement of the face. Quality of life documentation will be discussed.     Conclusions: Cross facial surgery can be a good model for helping Bells palsy patients with a primary bad scoring. Even though the surgery is major, outcome makes it worth performing due to better dynamic results concerning the mimic facial muscles.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: David Jensson

Title: Platysma Motor Nerve Transfer for Restoring Marginal Mandibular Nerve Function

Introduction: Injuries of the marginal mandibular nerve (MMN) of the facial nerve result in paralysis of the lower lip muscle depressors and an asymmetrical smile. Herein, we investigate the anatomical technical feasibility of transfer of the platysma motor nerve (PMN) to the MMN for restoration of lower lip function, and we present a clinical case where this nerve transfer was successfully performed.   Methods: Ten adult fresh cadavers were dissected. Measurements included the number of MMN and PMN branches, the maximal length of dissection of the PMN from the parotid, and the distance from the anterior border of the parotid to the facial artery. The PMN reach for direct coaptation to the MMN at the level of the crossing with the facial artery was assessed. We performed histomorphometric analysis of the MMN and PMN branches.   Results: The anatomy of the MMN and PMN was consistent in all dissections, with an average number of subbranches of 1.5 for the MMN and 1.2 for the PMN. The average maximal length of dissection of the PMN was 46.5 mm, and in every case, tension-free coaptation with the MMN was possible. Histomorphometric analysis demonstrated that the MMN contained an average of 3,866 myelinated fiber counts per millimeter, and the PMN contained 5,025. After a 3-year follow-up of the clinical case, complete recovery of MMN function was observed, without the need of central relearning and without functional or aesthetic impairment resulting from denervation of the platysma muscle.   Conclusions: PMN to MMN transfer is an anatomically feasible procedure for reconstruction of isolated MMN injuries. In our patient, by direct nerve coaptation, a faster and full recovery of lower lip muscle depressors was achieved without the need of central relearning because of the synergistic functions of the PMN and MMN functions and minimal donor-site morbidity.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Phuong Nguyen

Title: Comparison of muscle activity and facial symmetry in lengthening temporalis myoplasty vs. two-stage free gracilis muscle transfer in children

Introduction   Two facial reanimation procedures currently being used – lengthening temporalis myoplasty (LTM) and cross face nerve graft with gracilis free flap transfer (CFNG-FGMT) – have become popular methods to improve facial symmetry and dynamic facial reanimation.  In this study we seek to compare onset of muscle activity and facial symmetry after these dynamic reanimation procedures.   Methods   A retrospective review of patients from 2008-2016 at a children’s hospital who underwent LTM or CFNG-FGMT for facial palsy was performed. Surface EMG (sEMG) measurements were recorded at maximum open smile along with complete Sunnybrook scores at postoperative evaluations. Statistical analysis included Wilcoxon rank sum, Fisher exact test, and multi-level mixed-effects regression.   Results   Five patients with LTM and 14 with CFNG-FGMT were identified. The average age at time of surgery was 14.3±5.7 years for LTM and 12.4±5.4 years for CFNG-FGMT (p=0.41).  There was no difference in number of treatment sessions between LTM and CFNG-FGMT patients (9.0±4.9 vs. 10.3±11.8, p=0.661).  Significant muscle activity was first identified in LTM patients after 3 months (44.4±12.2mV, p<0.001) and CFNG-FGMT patients after 2 months (38.3±17.4mV, p=0.028). Beta-coefficient regression revealed a steeper slope of increase in sEMG in LTM compared to CFNG-FGMT patients (9.2mV/month versus 2.3mV/month, respectively). CFNG-FGMT patients exhibited a 17.0±5.9 Sunnybrook score increase at the 6-9 month interval relative to the first three months after surgery (p=0.004). Sunnybrook scores were no different between LTM and CFNG-FGMT patients when assessed for interval increase (p=0.905)   Conclusion Facial reanimation outcomes can be reliably assessed with sEMG and Sunnybrook scores.  LTM demonstrates a faster rate of muscle recruitment compared to CFNG.  Both LTM and CFNG-FGMT demonstrate muscle activity at 2-3 months.  Facial symmetry by Sunnybrook score improves at 6-9 months postoperatively


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Henri Marres

Title: Hypoglossal-facial nerve jump graft in dynamic reanimation of the paralyzed face: up or out?

Background: The hypoglossal–facial nerve jump graft (HFNJG) is a commonly used nerve transfer procedure for dynamic reanimation of the paralyzed face. We aim to evaluate the functional results and the quality of life after this procedure in our department.    Methods: Fifty-nine patients underwent HFNJG between November 1992 and March 2013. Patient charts were retrospectively reviewed. Patients received a set of questionnaires pre-operatively: Facial Disability Index, and post-operatively: SF-36, EQ-VAS, Facial Disability Index, Facial Clinical Evaluation instrument and some surgery specific questions.   Results: House-Brackmann grade improved from a 6 to a mean of 3.7 (SD 1.1) (P<.001; t-test) and Sunnybrook score improved from a mean of 3.5 (SD 2.5) to a mean of 40 (SD 13.1) (P<.001;t-test). Movements returned after an average of 8 months and a stable and automatic state were reached after a median of 28 and 24 months respectively. After surgery patients needed less protection of their eye on the affected side. No cases of dysarthria and dysphagia were reported. The Facial Disability Index for physical function and social/well-being function improved from a 44.5 (SD 15.5) to a 72.1 (SD 16.9) (P<.001;t-test) and from a 44.6 (SD 23.1) to a 76.8 (SD 18.6) (P<.001;t-test) respectively. Total score on Facial Clinical Evaluation instrument postoperatively was 52.2 (SD 16.6).   Conclusions: The HFNJG is a safe and effective technique to restore facial function. Most patients achieved symmetry at rest and with eye closure and improved quality of life, with no side effects. It can form a fundament for additional refining procedures.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Ichiro Tanaka

Title: Functional multi-vector facial reanimation with the superficial subslips transfer of the serratus anterior muscle innervated by both the masseter nerve and the contra-lateral facial nerve

Introduction:   We have reported multi-vector facial reanimation with multiple superficial subslips transfer of the serratus anterior muscle by implanting in the cheek at different angles to create multi- vector movements, using the masseter nerve for nerve anastomosis.  Sufficient elevation of the lips and modiolus with a proper 3-directional movement were achieved from the early postoperative period. However, it was difficult to acquire spontaneous smile. To resolve the problem, we improved the muscle transfer to be innervated by both the masseter nerve and the contra-lateral facial nerve via a sural graft.   Methods:   Free muscle transfer by double innervation was performed in 8 cases (3 cases in two stage and 5 cases in one stage) with longstanding complete facial paralysis. The masseter nerve was anstomosed to the proximal end of the longthoracic nerve. Cross facial nerve graft (CFNG) was performed between the buccal branch of the contra-lateral facial nerve and the longthoracic nerve. CFNG was anastomosed end to side to the longthoracic nerve in 5 cases, and end to end to the proximal end of the longthoracic nerve in 1 case and to the distal end in 2 cases. The follow up periods was 5-32 months. Voluntary and spontaneous smile in intensity, symmetry and shape were assessed.   Results:   The recovery time to voluntary contraction was 3 to 6 months (Average 3.5 months) in both one and two stage, and spontaneous contraction was 4 to 7 months in two stage and 7.5 to 11 months in one stage. Almost symmetrical or adequate smile in shape and intensity were achieved in most of the cases. Spontaneous smile tended to be smaller than voluntary smile in intensity.   Conclusions:    Multiple superficial subslips transfer of the serratus anterior muscle by double innervation seems to have possibility of creating more natural smile not only voluntarily but also spontaneously.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Manzhi Wong

Title: Immediate Lengthening Temporalis Myoplasty after Radical Parotidectomy

Aggressive parotid malignancies may necessitate facial nerve resection during extirpation.  The results despite nerve grafting tend to be poor and unpredictable due to the need for postop radiation. We present two patients who underwent immediate lengthening temporalis myoplasty at the time of surgical rejection.  Good results were obtained in a single stage without significant prolongation of operation time.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: Yorikatsu Watanabe

Title: One-stage facial reanimation of established facial paralysis using free latissimus dorci-serratus anterior combined muscle transfer with dual innervation for improving the quality of smile

Introduction:Microneurovascular free muscle transfer is a gold-standard surgical procedure for re-animation of established facial paralysis. However, innervation of the transferred muscle by the single motor source; contralateral facial nerve, is usually insufficient and unstable to smile. In addition, the corner of the mouth moves like to be pulled up rather than smile expression after the conventional single muscle transfer because of the movement in single direction.    Objective:To overcome these drawbacks, we report facial reanimation using one-stage free latissimus dorci (LD)-serratus anterior (SA) combined muscle transfer with dual innervation for improving the quality of smile.   Methods:The LD-SA combined muscle flap intended to move the corner of the mouse bidirectionally for natural smiling is harvested with thoracodorsal artery and vein as common vessels. The LD muscle is located the same direction as the zygomaticus major muscle and re-innervated by the dual innervation concept (Watanabe, 2009). The contralateral facial nerve is coapted with thoracodorsal nerve and ipsilateral masseter motor nerve is inserted into the LD muscle by intramuscular neurotization fashion. The 6th or 7th SA muscle is located the same direction as the risorius muscle and re-innervated by the neurorrhaphy of the long thoracic nerve and the ipsilateral masseter motor nerve.     Results:Four patients has been treated with this method since 2015 without any complications. On average, SA muscle movement was recognized on voluntary biting at 3 months and on spontaneous expression of smiling at 7 months after surgery. The patients developed a spontaneous natural smile with minimum synkinesis after postoperative mirror rehabilitation.   Conclusions:This one-stage method, requiring high-tech procedures, has potential to improve the unstable results of conventional facial reanimation surgery.


 

TOPIC: Dynamic Facial Reconstruction

Submitting Author: quan ngo

Title: MEEI FACE-gram analysis of 7 consecutive temporalis myoplasties

Introduction:   Lengthening temporalis myoplasty technique was described by Daniel Labbe in 1997 as a modification of the original technique described by Gillies. Here the entire muscle is detached from temporal fossa, transposed downwards and inserted into the perioral region. Activation of the temporalis results in a smile. No publication has been done to accurately document the degree of excursion of the technique.   Goal:   To measure the degree of perioral excursion in patients after temporalis myoplasty.   Method:   Nine consecutive cases of temporalis myoplasties done for complete unilateral facial nerve palsy after tumour resection were followed. Photos and videos were recorded at 6 and 12 months postop.   Nasolabial excursion and elevation were calculated using the Massachusetts Eye & Ear Infirmary software (MEEI FACE-gram). To minimise measurement errors inherent in photography variations and constraints of 2D measurements, absolute distances were avoided in favour of ratios.  Distance between midline lower lip and most lateral point of nasolabial fold (M-NL) was measured at rest and maximal smile. Difference in M-NL distance between L/R sides was divided by the M-NL of normal side to give percentage asymmetry. The angle of nasolabial elevation was also measured for affected/ unaffected sides at rest and maximal smile.    Result:   One patient was lost to follow-up and one patient developed early postop infection, resulting in technique failure. Seven patients were followed through. The average % asymmetry of M-NL was 9% at rest (median 5.3) and -2.1% (median -0.2%) on attempted maximal smile. Mean angles of nasolabial elevation on the affected vs unaffected sides were 121.70 vs 120. 50 at rest, and 122.70 vs 121.60 on maximal smile.   Conclusion:   Temporalis myoplasty helps to restore dynamic smiles and reduce perioral asymmetry. The vector of pull by temporalis muscle is slightly steeper than is the case for normal smile.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Matthew Carlson

Title: Facial Nerve Schwannomas: A review of 80 cases

OBJECTIVES: To describe the clinical behavior, treatment, and outcomes of sporadic facial nerve schwannoma (FNS) in a large cohort of patients managed in the post-MRI era.   PATIENTS & METHODS: Retrospective review at a single tertiary health care system (1990-2015)   RESULTS: Ninety-eight patients with FNS were identified; 10 with incomplete data and 8 with neurofibromatosis type 2 were excluded. The remaining 80 patients (median age 47 years; 58% women) were analyzed. Fifty-four percent of patients presented with asymmetrical hearing loss, 41% facial paresis, and 26% reported facial spasm. Twenty-one percent exhibited radiologic features mimicking vestibular schwannoma, 18% presented as a parotid mass, and 6% were discovered incidentally. Factors predictive of facial nerve paresis or spasm prior to treatment were female sex and tumor involvement of the labyrinthine/geniculate and tympanic facial nerve segments. The median growth rate among growing FNS was 2.0mm/year. Details regarding clinical outcome according to treatment modality are described.   CONCLUSION: In patients with FNS, female sex and involvement of the labyrinthine/geniculate and tympanic segments of the facial nerve predict a higher probability of facial paresis or spasm. When isolated to the posterior fossa or parotid gland, establishing a preoperative diagnosis of FNS is challenging. Treatment should be tailored according to tumor location and size, existing facial nerve function, patient priorities and age. A management algorithm is presented, prioritizing long-term facial function.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Kareem Tawfik

Title: Facial palsy following embolization of juvenile nasopharyngeal angiofibroma

Introduction   Preoperative embolization is a common treatment strategy to minimize intraoperative blood loss and facilitate complete resection of large, vascular juvenile nasopharyngeal angiofibromas (JNA). We report a case of an acute facial palsy occurring after preoperative, particle embolization of a large ipsilateral JNA.     Objectives   1)   To increase awareness of this extremely rare complication of transarterial embolization of head and neck tumors.    2)   To describe the clinical course of a facial nerve palsy related to transarterial embolization and review similar cases in the literature.   Methods   Clinical case report.    Results   A 13 year-old male was diagnosed with a large left JNA. He underwent preoperative, transarterial embolization of his tumor with polyvinyl alcohol particles followed by subtotal tumor resection via combined transoral and endoscopic-endonasal routes. His postoperative exam was notable for significant facial swelling, which subsided to reveal a House-Brackmann 5/6 left facial nerve (FN) palsy approximately 3 days after surgery. Contrasted magnetic resonance imaging showed left FN enhancement at the labyrinthine and tympanic segments. On subsequent cine-fluoroscopy review of the embolization procedure, the interventional radiologist identified errant embolization of polyvinyl alcohol particles to the left middle meningeal artery with associated ischemic compromise of blood supply to the perigeniculate region of the FN. Particles were seen to have traversed collateral vasculature following embolization of the pterygopalatine segment of the internal maxillary artery. By 2 months post-embolization, the patient’s facial function had fully recovered and no further neurologic deficits have occurred.   Conclusion    This is the first known report of facial palsy complicating JNA embolization in the Neurotology literature. Surgeons should be aware of the potential for errant embolization of neurovascular structures when managing vascular head and neck tumors and counsel patients accordingly.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Matteo Alicandri-Ciufelli

Title: Critical literature review on the management of intraparotid facial nerve schwannoma and proposed decision-making algorithm

Management of intraparotid facial nerve schwannomas (IFNS) is very challenging because the diagnosis is often made intra-operatively and in most cases, resection could lead to severe facial nerve (FN) paralysis, with important aesthetic consequences. Articles in the English language focused on the management of FN schwannoma have been selected and critically reviewed. A decision-making algorithm is proposed. In the case of type A or B neoplasms, or in case of a pre-operative FN House-Brackmann (HB) grade IV or worse, the authors would favor a resection of the IFNS and (where necessary) a reconstruction of the nerve. In the case of pre-operative HB grade III or better and type C or D neoplasms, patients would undergo an intra-operative biopsy to rule out malignancy, and a possible conservative management could be adopted. Localization and adherences of IFNS, as well as pre-operative FN function are important factors that must be considered in the decision-making process for IFNS to optimize the functional outcomes.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Nicholas Deep

Title: Facial Nerve Meningioma: A Cause of Pediatric Facial Weakness

Introduction:  Meningiomas of the temporal bone are rare, particularly in children.  Meningiomas most commonly involve the temporal bone by direct extension of an intracranial meningioma via the tegmen tympani, posterior fossa plate, or internal auditory canal. Uncommonly, they may develop due to extracranial growth from cranial nerve sheath arachnoid cells.    Objective:  To present an unusual case of a temporal bone meningioma with intrafascicular spread throughout the temporal facial nerve from cerebellopontine angle (CPA) to stylomastoid foramen.     Methods:  Case study and comprehensive review of the English-language literature (PUBMED, EMBASE, MEDLINE, Web of Science) on temporal bone meningiomas.  The clinical, radiological, and histopathological findings of temporal bone meningiomas are discussed.   Results:  A four-year-old female presented with progressive facial weakness to a House-Brackmann V and normal hearing. Imaging demonstrated a mass within the left internal auditory canal (IAC) and asymmetric enlargement with enhancement of the left facial nerve from CPA to the stylomastoid foramen consistent with a facial schwannoma.  She underwent left translabyrinthine craniotomy.  Gross tumor was noted in the IAC and the fallopian canal appeared expanded and the facial nerve was enlarged and had an irregular contour. Resection of the facial nerve from the CPA to just proximal to its exit at the stylomastoid foramen was necessary to achieve negative margins.  Cable grafting was performed.  The histopathologic diagnosis was transitional meningioma with intraneural growth throughout the length of the resected facial nerve segment.   Conclusion:  Meningiomas involving the temporal bone are exceedingly rare.  We report a rare case of a child presenting with progressive facial weakness due to a presumed facial schwannoma spreading along the facial nerve throughout its intratemporal course that at surgery was found to be an intrafascicular CN VII meningioma.  To the authors’ knowledge, this presentation of a meningioma has never been reported in the English literature.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Michael Mooney

Title: Long-Term Facial Nerve Outcomes following Microsurgical Resection of Vestibular Schwannomas in Patients with Preoperative Facial Nerve Palsy

Introduction: Preoperative facial nerve palsy is a relatively rare presentation of vestibular schwannoma (VS) that often occurs in the setting of large, compressive tumors. Decompression of the facial nerve and surrounding neurovascular structures is one potential benefit of microsurgical resection, however, long-term facial nerve outcomes in these patients is lacking in the literature.   Methods: Review of 368 consecutive patients who underwent vestibular schwannoma resection was performed. Patients that underwent a prior operation or radiosurgery treatment were excluded. Preoperative imaging studies and clinical follow-up were examined to determine radiographic characteristics and outcomes, respectively.   Results: Of the 368 patients eligible for review, 9 patients were confirmed to have documented preoperative facial nerve dysfunction not due to prior treatment, for an estimated incidence of 2.5% in the surgical population at our institution. Eight out of nine patients had Koos grade 3 or 4 tumors, with a mean tumor diameter of 2.9 cm (range: 2.0-4.4), and seven tumors were subtotally resected.Of the patients with preoperative HB 2/6, two patients improved to HB 1/6 , three patients were stable, and two patients worsened to HB 3/6. Of the patients with HB 3/6 or worse, both remained stable at their preoperative HB grade at 1.1 and 3.9 years of follow-up.   Conclusions: Preoperative facial nerve palsy is a rare occurrence in patients with vestibular schwannoma and tends to occur in relatively large lesions. Long-term outcomes of facial nerve function after microsurgical resection are lacking, however, our series suggests that good outcomes can be achieved. 75% of patients had either stable or improved facial nerve outcomes, however, GTR rates were relatively low in these patients. These outcomes are important to consider when counseling patients on surgery for vestibular schwannoma and facial nerve dysfunction. Future authors are encouraged to distinguish facial nerve outcomes for this unique group of patients.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: BEOMCHO JUN

Title: Uncommon clinical features of facial weakness in two cases of intratemporal facial nerve schwannomas

Facial nerve schwannomas (FNSs) are rare benign tumors which derive from the myelin-producing Schwann cell sheath FNS is more often revealed by a progressive facial weakness followed by hearing loss. However, in case of a sudden onset of the facial impairment it can be wrongly diagnosed as idiopathic facial paralysis or in case of no facial symptom it could be misdiagnosis as other tumorous condition by its size and site. The most important concern regarding surgical treatment of facial nerve schwannoma is the inevitable facial palsy caused by nerve injury during the misdiagnosed tumor removal. Therefore preoperative diagnosis and appropriate facial nerve monitoring is essential to appropriate treatment. We introduce 2 cases of intratemporal facial nerve schwannomas, The clinical feature of first case was sudden facial palsy. The other one was no facial weakness. Both were diagnosed as tumorous condition preoperatively and confirmed by frozen section biopsy intraoperatively by proximity to facial nerve during mastoid surgery.  We also discuss the otoscopic finding and CT finding of temporal bone which increase the possibility of facial nerve schwannomas.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: John Leonetti, MD

Title: Neoplastic Causes of Non-Acute Facial Paralysis: A review of 221 cases

Objectives:   1.      To assess the clinical presentation of patients with tumor-related, non-acute facial paralysis.   2.      To review our series of 221 such patients.   3.      To provide an algorithm for the evaluation and management of these cases.   Study Design:   A retrospective chart review of patients with tumor-related non-acute facial paralysis treated at our tertiary care, academic medical center.   Methods:   Patients were included with neoplastic related facial paralysis treated at our institution between July of 1988 and July of 2011.  The clinical signs and symptoms along with the radiographic findings were assessed.   Results:   Gradual-onset facial weakness or facial twitching occurred in all 221 patients.  The tumor location according to MRI and/or CT scanning was extratemporal in 128 patients (58%), intratemporal in 55 patients (25%), and intradural in 38 individuals (17%).  The majority of the extratemporal tumors were malignant (99%), while (91%) of the remaining patients had benign lesions.  Associated clinical manifestations such as hearing loss, tinnitus, other cranial nerve deficits, and the presence of a mass helped identify the tumor site. A transtemporal approach was utilized for the intratemporal and intradural tumor resections while the extratemporal lesions required parotidectomy with partial temporal bone dissection.   Facial nerve grafting was performed in 110 of 221 patients (50%).   Conclusion:   Gradual onset facial paralysis or twitching may be due to neoplastic invasion of the facial nerve in its course from the cerebellopontine angle to the parotid gland. Beware of the diagnosis of “atypical Bell’s Palsy”.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Kurt Grahnke

Title: Prognostic indices for predicting facial nerve outcome following the resection of large acoustic neuromas

Introduction   Facial nerve (FN) injury is still a primary concern when resecting acoustic neuromas (AN) despite decreased rates of FN injury in the last few decades. Tumor size is commonly reported to predict FN outcome, but when considering large AN only, the relationship between tumor size and FN injury is less clear. Anatomical position and degree of anterior extension may be more direct indicators of FN injury in these cases.    Objectives   We present a prognostic index, which can be readily measured on standard MRI to predict FN outcome following AN resection.   Methods   A retrospective chart review was performed on large (>2.5cm largest extracanicular diameter) AN operated on by one neurosurgery-otolaryngology team (DA and JL) since 2005. 105 patients were included. Pre-operative MRIs were reviewed and FN function was assessed according to the House-Brackmann (HB) scale. The prognostic index is defined as the ratio of tumor extending anterior to the internal auditory canal (IAC) relative to posterior to the IAC, measured parallel to the petrous ridge (A/P index).   Results   Good FN function rates (HB I-II) were 72% at one month and improved to 89% at one year or last follow-up. Average tumor size was 3.4cm. For every one standard deviation increase in A/P index, a patient was 3.57 (95 CI: 2.02 – 6.29) times more likely have a higher post-operative HB score (p < .0001). After controlling for tumor size, a patient was still 3.47 (95 CI: 1.96 – 6.16) times more likely to have a higher post-operative HB score for every one standard deviation increase in A/P index (p < .0001).This relationship also held true at one year or last follow-up (p<.001).   Conclusion Our prognostic index may be useful to assess the risk of FN injury pre-operatively for large AN, while also providing information about the tumor-nerve relationship.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Matthew Bartindale

Title: The Natural History of Facial Schwannomas: A Meta-Analysis of Case Series

Introduction: Facial nerve schwannomas generate a clinical dilemma because the morbidity of intervention can be comparable to its natural course. The factors leading to morbidities associated with this neoplasm are poorly understood.   Objective: To establish predictors of facial paralysis and auditory morbidity secondary to facial nerve schwannomas by assimilating individualized patient data from the literature.   Methods: A systematic review of the English literature was conducted for studies regarding facial schwannomas. Studies were only included if they presented patient-level data and reported House-Brackmann scores. Odds ratios were estimated using generalized linear mixed models with case series as a random effect.   Results: Data from 505 patients were collected from 32 studies. The mean age was 42.8 years (SD=16.0, N=387), 46.7% were males (N=351), and 50.6% were left-sided (N=89) in studies where those factors were recorded. The most common presenting symptom was facial palsy for intratemporal tumors and hearing loss for intradural tumors.   Patient age, sex, and tumor size were not associated with facial nerve or hearing function. The odds of higher grades of facial weakness were greater for left-sided tumors (OR=3.05, p=.01), intratemporal involvement (OR=5.52, p<.001), and a greater number of facial nerve segments involved (OR=1.31, p<0.001). Intradural (OR=0.60, p=.01) and extracranial (p<.001) involvement were associated with lower odds of facial weakness. Positive predictors of hearing loss were intradural involvement (OR=2.97, p<.001) and number of facial nerve segments involved (OR=1.37, p=.02). Extracranial involvement was a negative predictor of hearing loss (OR=0.28, p=0.02), and intratemporal involvement had a moderate protective effect (OR=0.44, p<.05).    Discussion: The most important factors associated with facial weakness and hearing loss are tumor location and the number of facial nerve segments involved. An understanding of the factors that contribute most heavily to the natural morbidity can help guide the appropriate timing and type of intervention in future cases.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Ashkan Monfared

Title: Preliminary Analysis of Facial Nerve Outcomes in a Multi Center Prospective study of Large Acoustic Neuromas (Acoustic Neuromas Receiving Subtotal Resection Study (A.N.S.R.S))

Excellent facial nerve outcome has remained historically poor for patients with large tumors undergoing complete resection.  Many centers have gravitated to near-total or subtotal resection of these tumors which carry a much higher chance of tumor regrowth.  In this prospective multicenter trial we have followed patients with large acoustic neurmoas (2.5cm or greater in the largest dimension in the cerebellopotine angle) after they have received gross total (GTR), near total (NTR), or subtotal resection (STR).  Patients received stereotactic radiation therapy in case the tumor residual demonstrated signs of growth on follow up MRIs.     Out of 143 patients enrolled, 66 had at least 1-year follow up (mean 38 months).  Mean tumor diameter was 3.33 ± 0.7 cm.  Eight patients had GTR, 18 NTR, and 40 STR.  There were 14 recurrences (21%), one had received GTR, 2 NTR, and 11 STR with average of 34.6 months to recurrence (4-74mo).  All recurrences were treated with SRT except two due to size of recurrence.  Three of these remnants (25%) continued to grow and required surgical salvage.  Tumor recurrence was related to longer followup, and larger residual tumor.  Recurrence was twice as likely in STR (27.5%) compared to GTR and NTR groups but did not achieve statistical significance.       Good facial nerve function was achieved in 68% immediately and 85% at 1-year from surgery.  Better immediate nerve function was associated with smaller tumor diameter (r=.43, p=.0003) and larger tumor residual (r=1.28, p=.023) but not in long term follow up.  Immediate outcome was better in STR groups but not statistically significant.  There was no difference in long term outcome among three groups


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Takatoshi Furukawa

Title: Benefits of High-Dose Steroid Administration in the Treatment of Bell’s Palsy

Objective: The efficacy of high-dose steroid administration of prednisolone (PSL) has not been examined for Bell’s palsy in a large-scale investigation in recent years. We thus compared treatment results between the administration of a normal-dose steroid (PSL 60 mg/day) and high-dose steroid (PSL 200 mg/day) + Hespander + Mannitol administration as well as the concomitant administration of an antiviral agent.   Study design: Retrospective case review.   Setting: Tertiary referral center.   Patients: A total of 706 patients with Bell’s palsy classified as grade V or grade VI on the House-Brackmann (HB) scale were treated in our department between 1995 and 2015. These patients were divided into a normal-dose group and high-dose group.   Methods: We separately assessed treatment outcomes for HB grade V patients and HB grade VI patients. Logistic regression analysis was also performed to investigate factors which can impact treatment outcomes, i.e. gender, age, days to start of treatment, PSL dosage and antiviral drug administration.    Results: Recovery rates were significantly better in the high-dose steroid + Hespander + Mannitol group in comparison with the normal-dose steroid group for HB grade V (100% vs 77.7%) and HB grade VI (92.6% vs 66.7%). Antiviral agents were only found to have an additional beneficial effect in the normal-dose group. Significant factors in treatment outcomes were PSL 200 mg/day administration and early initiation of treatment. Insignificant factors were gender, age and antiviral drug administration.   Conclusion: We showed that high-dose steroid + Hespander + Mannitol administration produced significantly better outcomes than normal-dose steroid administration in the treatment of patients with Bell’s palsy.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Yang-Sun Cho

Title: Functional Outcome of the Facial Nerve After Surgery for Vestibular Schwannoma: Prediction of Acceptable Long-Term Facial Nerve Function Based on Immediate Postoperative Facial Palsy

Facial palsy (FP) is one of the most serious morbidities in treatment of vestibular schwannoma (VS) and reducing the high risk of FP after surgery has become a major issue. This investigation was performed to examine the relationship between immediate postoperative and long-term FP, and identify a treatment strategy for VS regarding long-term outcomes of facial nerve function and tumor control.   A total of 385 patients who underwent surgery in a single institution were retrospectively reviewed; 12 patients with neurofibromatosis, 6 with preoperative radiosurgery, and 14 with multiple surgeries were excluded. The generalized estimating equation method was used to show the correlation between immediate and later postoperative FP and to identify the cutoff grade of immediate postoperative FP.   The tumor control rates for 1 year, 3 years, and 5 years were 88.7%, 83.9%, and 80.0%, respectively. Preservation of facial function above House-Brackmann (H-B) grades I and II was achieved in 47.9% of patients immediately postoperatively, in 50.1% after 1 month, and in 74.5% after >2 years. The immediate postoperative H-B grade showed a statistically significant relationship with the severity of FP on long-term follow-up (P < 0.001). Immediate postoperative H-B grade III was identified as the cutoff grade that showed the most significant relationship between immediate postoperative H-B grade and better outcome than the cutoff (H-B grade I-III) on long-term follow-up (P < 0.001).   In summary, immediate postoperative H-B grade can predict facial palsy at long-term follow-up. H-B grade III at immediate postoperative point is the lowest tolerable grade that guarantees functional improvement on long-term follow-up. Planned facial nerve preservation surgery followed by radiosurgery is thought to be optimal treatment in patients with VS for both tumor control and facial nerve function.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Yang-Sun Cho

Title: The prognostic factors of facial palsy after translabyrinthine approach

As facial nerve (FN) outcome is one of the crucial indicators of postoperative quality of life, preservation of FN function is still a major concern of lateral skull base surgery. The aim of this study was to analyze the possible prognostic factors of postoperative facial nerve (FN) outcomes after translabyrinthine (TL) approach for vestibular schwannoma (VS).    Medical records of a total of 96 patients who were undertaken TL approach for VS from March 1997 to June 2014 in a single tertiary center were retrospectively reviewed. Demographic, tumor-related and FN-associated factors were analyzed for possible prognostic significance. FN status was evaluated using House-Brackmann (H-B) grading system preoperatively, immediate postoperatively and at each follow-up visits at 1, 3, 6, and 12 months.   The mean age of patients was 49.7 (24-68) years old, and male to female ratio was 41:55. Age, gender of patient, origin of the tumor and recurrence didn’t show correlation with FN outcome. Size of the tumor, resection extent, recovery point of facial palsy, preoperative FN status showed correlation with postoperative FN outcome in a univariable analysis. Among them, size of tumor (p=0.04) and recovery point of FN palsy (p<0.01) showed a significant correlation by multivariable logistic regression analysis. Delayed facial paralysis did not result in a better outcome than immediate postoperative paralysis.   In summary, size of the tumor and recovery point of facial palsy are significant prognostic factors of facial nerve outcome in patients with VS operated by TL approach.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Gi Sung Nam

Title: The best candidates for nerve-sparing stripping surgery for facial nerve schwannoma

Objectives: Clinical decision making for facial nerve schwannoma is particularly complicated in patients with good facial nerve function; however, an early nerve-sparing tumor enucleation technique minimizes facial deficits associated with treatment. This study characterized the optimal candidate for this nerve-sparing surgical strategy in patients with good facial function.   METHODS: Nerve-sparing stripping surgery was performed on 28 patients with facial nerve schwannoma. The House-Brackmann grading system was used to assess pre- and postoperative facial function. We retrospectively analyzed pre- and postoperative facial function, duration of facial palsy, tumor size, and location and number of involved segments. The data were analyzed using Fisher exact test and independent t tests.   RESULTS: Of the 28 patients, 18 successfully underwent stripping surgery and 16 had a favorable outcome. Favorable postoperative facial function was associated with good preoperative facial function (House-Brackmann grade [HBG] ≤II); small, localized tumors; and tumors located in the geniculate ganglion and/or its proximal portion.   CONCLUSIONS: Patients with facial nerve schwannoma who have good preoperative facial function (HBG ≤2), tumor located in the proximal portion of the geniculate ganglion, and small tumors (<2 cm) involving one or two facial nerve segments can be the best candidates for nerve-sparing stripping surgery.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Petr Vachata

Title: Metastasis of the intratemporal portion of the facial nerve mimicking a facial nerve schwannoma

Introduction:   The most common tumor originating in the facial nerve canal is a schwannoma slowly remodeling the canal and its bony margins.   Case report:    A 68-year-old woman with anamnesis of complex breast cancer treatment 21 years ago was admitted to our hospital with complete right-sided facial nerve paralysis (House-Brackmann grade VI) slowly deteriorating during the last eight months. Furthermore, she suffered a complete sensorineural hearing loss on the ipsilateral side. An high resolution CT revealed smooth enlargement of the ganglion geniculi area and the labyrinthine part of the facial nerve canal with opening of the basal turn of the cochlea. A contrast MR confirmed the presence of a tumor in the intratemporal portion of the facial nerve. The tumor was resected via  translabyrinthine approach with subsequent reconstruction of the nerve by autologous nerve graft. The histology revealed an intraneural metastasis of breast cancer excluding the expected diagnosis of schwannoma.   Conclusion:    Distant hematogenous metastasis to the intratemporal portion of the facial nerve is an extremely rare case of facial nerve tumor mimicking the most common schwannoma.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: SANDRO BORDIN

Title: CASE REPORT: Intra and extracranial facial nerve neuroma.

The authors describe a rare case of  facial nerve neuroma developed near the geniculate ganglion.   It happened to an 18 years old patient who displayed a facial nerve paralysis diagnosed as Bell’s palsy.   The patient was treated with antiviral drugs and corticosteroids.   The RMN performed after the paralysis proved to be negative.   In the following months, the patient presented conductive hearing loss with a “flat” tympanogram.   The hearing loss was interpreted as a "glue ear" and treated with the insertion of a Ventilation Tube.   Since the deafness was worsening, the patient underwent an exploratory mastoidectomy surgery, where the surgeon met a heavily bleeding mass inside of the attic and the tympanic cavity.   The doctor then performed a biopsy, that diagnosed a facial nerve schwannoma.   The patient was then subjected to further tests and MRI scan showed presence of a tumor that had an intracranial portion at the middle cranial fossa level and an esocranial portion at the attic and the tympanic cavity level.   Given its size, a resection of the tumor limited to esocranial part through an open tympanoplasty was performed.   The portion of intracranial neuroma was then treated with a "Cyber Knife" session.   The paralysis of the facial nerve was treated with a hypoglossal-facial nerve anastomosis.   The paralysis improved from a IV grade in the House-Brackmann grading system to a II grade: the static facial expression muscles were preserved, the mobility of the eyelid was restored, and only a deficit of the orbicularis oris still remained .   After 5 years, the intracranial portion, treated with the "Cyber Knife", reduced in volume, the attic-mastoid cavity is perfectly re-epithelized, the neotympanum is preserved, but there remains a  severe mixed hearing loss, since the neuroma had practically destroyed the ear bones.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Vladimir Poshataev

Title: Techincal evaluation of cranial nerve tractography in Koos 3-4 vestibular schwannomas

Objective   Diffusion tensor tractography (DTT) is an effective imaging technique for visualization of cranial nerves, and can be particularly useful in patients with vestibular schwannomas (VSs). There is however limited data concerning the effectiveness of DTT for reconstruction of facial nerve (CN VII) and its relationship with 3D tumor reconstruction. This is particularly true in Koos 3 and 4 tumors where there is greater difficulty in visualization of the cranial nerves.   Methods               DTT and anatomical images obtained on 3T-MRI were used to build individual tumor-cranial nerve models. Preprocessing of the images is necessary, which included motion correction. Tumor model reconstruction and tractography were performed using 3D-Slicer software platform. Regions of interest (ROIs) were placed on anteriosuperior, anteromedial anteroinferior and posterior of the tumor model and visualization of the tracts was done with the help of fiducial markers.   CN VII tracts were reconstructed in cases of Koos grade 3-4 VSs (tumors filling the cerebello-pontine cistern). The cut-off point for building the tracts was diameter of the tumor exceeding 4 cm due to distortion of the facial nerve and it’s thinning.   Conclusion   DTT is a powerful tool for reconstructing of CN VII fibers in patients VS. The best results are obtained in tumors less than 4 cm. Giant VS result in extensive distortion which adversely affects reconstruction. Instead, small (Koos 1-2) tumors the visualization of CN VII is also complicated due to the short, straight course of the nerve, Good anatomical preservation of CN VII and presence of a cleavage plane between the nerve and a tumor in Koos 1-2 VSs surgery, makes necessity of DTT implementation in these cases qestionable.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Sarah Grigg

Title: Jumping to conclusions: A rare case of intrapetrosal facial nerve squamous cell carcinoma

Squamous cell carcinoma (SCC) is responsible for approximately one- third of all non-melanoma skin cancers in Australia and accounts for over 90% of all head and neck primary malignancies. Temporal bone malignancies are relatively rare accounting for around 0.2% of all head and neck malignancies and are commonly described as arising from external acoustic canal metastatic SCC. 1 Our case describes an instance of jump metastasis from a facial cutaneous lesion to intrapetrosal facial nerve in a patient with a metachronous pituitary adenoma.   A 78-year-old man had a cutaneous SCC removed from his left malar region in 2014 by a plastic and reconstructive surgeon. On review by his ophthalmologist for glaucoma in 2015 he was noted to have a dense seventh cranial nerve palsy. In the context of known left sided sensorineural hearing loss, an MRI brain was arranged which reported an “incidental” pituitary macroadenoma but no cerebellopontine angle lesion or intracerebral lesion to correlate his symptoms. He underwent subsequent resection of his pituitary lesion but with persistence of his palsy. On review of his skin cancer history a metastatic SCC palsy was then considered and he proceeded to a temporal bone exploration and frozen section of his left facial nerve. Histopathology reported invasive SCC within his sacrificed left intrapetrosal facial nerve, with clear proximal and distal margins and he was referred for radiotherapy.   A review of the literature demonstrates an increased risk of loco-regional metastasis with SCC that exhibits perineural invasion in the primary lesion. The concept of “jump” lesions is described along with the prognostic significance and management options.    [1]       Zanoletti E, Lovato A, Stritoni P, Martini A, Mazzoni A, Marioni G. A critical look at persistent problems in the diagnosis, staging and treatment of temporal bone carcinoma. Cancer Treatment Reviews. 2015; 41:821-6.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Djemil Odamanov

Title: Facial nerve outcomes following the surgery for vestibular schwannomas previously treated with radiation.

Introduction     Despite the effectiveness of the stereotactic radiosurgery and radiotherapy for vestibular schwannoma, in 2% -12% of patients a radioresistant tumors are found. Surgical removal of the previously irradiated vestibular schwannoma is the only reasonable treatment option.     Objective     The aim of our study was to assess outcomes of facial nerve function following the surgery (total and subtotal resection) for vestibular schwannomas previously treated with radiation.     Methods     We reviewed a series of 34 patients with vestibular schwannomas that were previously treated with radiation. All of these patients underwent surgery in Burdenko Neurosurgery Institute during the 10-year period from 2006 to 2016. Surgery after the combined operative and radiation treatment was performed in 21 patients (I group), and surgery after stereotactic radiation treatment only was performed in 13 patients (II group). Time between radiation treatment and the surgery was 9-77 months. Size of the tumor varied from 22 to 55 mm.     Results     In group I when total removal of the tumor was performed normal function of the facial nerve (House–Brackmann grade I-II) was detected in 11,1% of patients. When subtotal resection was performed normal facial nerve function was seen in 44,4% of patients.      In group II no one patient had normal facial nerve function in total removal of the tumor. 33,3% of patients with subtotal resection had grade I-II House–Brackmann scale.      Thus overall assessment of both groups detected normal facial nerve function in 11,1% in total removal, and in 77,7% in subtotal resection.     Conclusion     Subtotal resection increases the preservation of facial nerve function in 7 times comparing with total resection.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Hadi Kasbkar

Title: Avoidance of facial nerve dysfunction in surgical resection of vestibular schwannoma, preservation associated factors and surgical outcomes.

Despite development of surgical techniques, anatomic and functional preservation of facial nerve is still challenging in neurosurgery. Since it is a psychologically and physically debilitating complication for patients, avoidance of facial nerve injury is one of the main goals in surgeries in cerebellopontine (CP) angle. Vestibular schwannoma is responsible for about 85% of all cerebellopontine angle tumors in adults. Surgical removal of the tumor is the main part of treatment in vestibular schwannomas at least in large or complex ones. There are three main surgical approaches to resect schwannomas, the translabyrinthine, the retrosigmoid, and the middle cranial fossa approaches. Herein, we present a series of 32 consecutive patients with tumors measuring 30 mm or larger in diameter underwent microsurgical resection of schwannomas via retrosigmiod approach and intra-operative neuromonitoring. The evaluation of post-operative facial nerve function was performed for patients in follow-up intervals. Also, we reviewed the previously published series of vestibular schwannoma surgeries to compare their outcomes regarding facial nerve preservation with ours and to identify variables which have effect on post-operative facial nerve function. In all of our cases we achieved anatomical preservation of facial nerve. Our post-operative outcomes show that the rate of functional preservation of facial nerve immediately after surgery is 64% (House–Brackmann grade I and II) and 6 months after that it rose to 86%. 12 months after surgery rate of functional preservation was 89%. Review of literature reveals some variables that have association with post-operative function of facial nerve such as tumor size, surgical approach, intra-operative neuromonitoring and a mastery of the microsurgical anatomy of CP angle.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Takanari Goto

Title: Examination of treatment options for facial nerve palsy caused by zoster sine herpete

Introduction: Facial nerve palsy (FNP) with a viral etiology is overwhelming diagnosed as either Bell’s palsy or Ramsey-Hunt syndrome. However, FNP can also be caused by zoster sine herpete (ZSH) attributed to reactivation of the varicella-zoster virus. ZSH is distinguished from zoster herpete by no zosteriform rash (unlike Ramsey-Hunt syndrome) or severe pain. However, FNP caused by ZSH is initially indistinguishable from Bell’s palsy, thus we test all apparent Bell’s palsy patients for ZSH. Since test results take approximately a week, treatment is generally started immediately, particularly for severe FNP. Ultimately less than 5% of viral FNP patients are found to have ZSH, usually with severe FNP. The question thus becomes what is the best initial treatment to ensure the best outcome for both Bell’s palsy and ZSH patients.    Objective: To retrospectively examine treatment results for patients with FNP caused by ZSH.    Methods: We examined the records of 1,656 patients with what initially appeared to be Bell’s palsy in our department between 1995 and 2015. Data was collected on ultimate diagnosis, age, gender, severity, treatment methods and recovery rates. The House–Brackman grading scale was used to classify patients as mild-to-moderate FNP (Grades I to IV) or severe FNP (Grades V to VI) with treatment subgroups of 60-mg prednisolone, 60-mg prednisolone/antiviral agent, 200-mg prednisolone or 200-mg prednisolone/antiviral agent.    Results: Fifty-three patients had ZSH with 47 graded as severe. Recovery rates for the severe FNP patients were 60-mg prednisolone/4 out of 9 patients recovered/44.4% recovery rate; 60-mg prednisolone/antiviral agent/9 out of 12 recovered/75% recovery rate; 200-mg prednisolone/9 out of 9 recovered/100% recovery rate; and 200-mg prednisolone/antiviral agent/13 out of 17 recovered/76.5% recovery rate with the best outcome obtained in the 200-mg prednisolone group.  Conclusion: Severe ZSH initially disguised as Bell’s palsy is best treated with a high 200-mg dose of prednisolone.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Olaf Michel

Title: Get the best results: Surgical approach to the facial nerve in parotid gland surgery

Parotid gland tumors requiring surgery implicate dissection of the facial nerve. The experience of parotid gland surgery in more than 1000 cases has shown that second to complete tumor removal the preservation of the facial nerve in patients without preoperative facial paralysis should be always the ultimate goal followed by a cosmetic acceptable result.  The risk of major complications can be lowered by preoperative diagnostic procedures such as FNAC, CT/MR and ultrasound. To achieve good functional outcome the use of microscope and adequate microsurgical instruments and an adequate technique by dissecting all branches of the facial nerve are essential. Over the years an spare incision and the use of fat filling is essential for a good cosmetic result. Sequels such as Frey-Syndrome can be treated by botulinum injections.   In consequence, mastering facial nerve preservation in parotid gland surgery professionally bases on standardized procedures to obtain stable and predictable good results.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Sergey Tanyashin

Title: The outcomes of facial nerve function after large and giant vestibular schwannomas surgery.

Introduction: Surgical removal of vestibular schwannomas larger than 3 cm remains the difficult situation for surgeon, especially when their radical removal, because of the involvement of neurovascular structures can lead to poor results and lower quality of life of patients. Facial nerve loses its normal structure and becomes invisible to the surgeon. The border of dissection of the tumor from the facial nerve is usually not clear or absent.    Purpose: The aim of study was to assess outcomes of facial nerve function after removal of large and giant vestibular schwannoma, to identify the localization of the tumor’s rests in non-total removal cases.   Materials and methods: We operated on 500 patients with vestibular schwannomas more than 3 cm. The aim of each surgery was radical removal of the tumor. All patients were divided into two groups: total and non-total removal. All surgeries were performed with neurophysiological monitoring of the cranial nerves functions. In the absence of a border of dissection piece of tumor is left. The localization of the residual tumor was recorded in the surgeries protocol.   Results: Facial nerve function was evaluated 7 days and 1 year after surgery. The outcome function of the facial nerve in the group of total removal on House-Brackmann scale I-III consist of 42% and 64,48%  in the early period and 1 year respectively. In group non-total removal it was 62.4% and 82,5% respectively. The common places of localization of residual tumor are the facial nerve (63%), brain stem (30,2%), only internal auditory canal (22%).   Conclusions: Non-total removal of large and giant acoustic neuroma and possibility of following radiological treatment allow to reduce frequency of severe dysfunction of the facial nerve and to preserve the quality of life of patients.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Kirill Shevchenko

Title: Outcomes of facial nerve function after total removal of acoustic neuromas depended on topography of the tumor.

Introduction: Acoustic neuromas are benign tumors that usually occur in the internal auditory canal or the cerebellopontine angle cistern. Despite the improvement in microsurgical techniques and the use of neurophysiological monitoring to identify the facial nerve during the surgery, the occurrence of facial nerve paresis in the postoperative period remains a big challenge for neurosurgeon.    Objective: The aim of our study was to assess the relations between the topographic and anatomical features of neuromas and the functional status of the facial nerve in the postoperative period.   Methods: We reviewed a series of 186 patients with acoustic neuromas who underwent total surgical removal of the tumor in our institute from January 2012 to January 2017. All operations were performed with neuromonitoring of cranial nerves. We assessed topography of the tumors with MRI: its expansion in the internal acoustic canal, oral or caudal growth in relation to normal position of facial nerve and the tumor size.    Results: Outcomes of facial nerve function don’t depend on the depth of the tumor expansion in the internal acoustic canal but depend on growth of the tumor in relation to internal acoustic canal (r = 0,19, p = 0,0007). Normal function of facial nerve in the postoperative period was seen in 16,4% in tumors with oral growth and in 36,1% in tumors with caudal growth.    Conclusion: The results of this study allow predicting better outcomes in function of facial nerve in patients with acoustic neuroma with preferential caudal growth in relation to internal acoustic canal.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Moises Arriaga

Title: Conduits and Onlay Grafts in Temporal Bone and Cerebellopontine Angle Facial Nerve Repair

Introduction: Conduits and onlay grafts rather than suture neurorrhaphy may offer advantages in peripheral, intratemporal and cerebellopontine angle facial nerve repair.    Methods: A retrospective review of facial nerve repairs in our department between July 2006 and December 2016. The patient demographics, location of facial nerve lesion, facial pathology, technique of  repair and facial nerve outcomes were recorded.   Results: Ten cases of non-neurorrhaphy repair of the peripheral, intratemporal and CPA facial nerve. Clinical outcomes ranged from H-B grade 3 to grade 6.   Discussion/Conclusion: Factors predictive of success/failure include the status of the distal stump, distance of the graft, and potential shearing of the anastomosis by CSF pulsations. In specific situations, non-suture neurorrhaphy offer good outcomes in facial nerve repair.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Thomas Mawby

Title: The Toronto Experience of Facial Nerve Schwannomas: Timing is Everything

Introduction:   Primary facial nerve tumours are rare. Facial nerve schwannoma’s are the most common form of facial nerve tumours and make up to 64% of tumours others types include haemangiomas, perineuriomas and malignant schwannomas. Facial nerve schwannomas typically present with facial weakness, hearing loss, tinnitus, balance disturbance or may be incidental findings. They can be classified by the location as arising in the cerebellar pontine angle, intra-temporal or extra-temporal.    Objective:    The management of vestibular schwannomas is controversial. Management options include conservative management, surgical decompression, surgical resection or stereotactic radiotherapy. We propose a treatment based on the location of tumour and facial nerve function.   Methods:    A retrospective review over thirty years in a tertiary referral centre.    Results:    For tumours arising in the cerebellar pontine angle or extra-temporal regions confirming the diagnosis can be challenging. In these areas the tumour is often able to grow considerably without compressive symptoms and therefore often maintains facial function. In intra-temporal tumours a conservative approach is still advocated where possible but facial nerve decompression should be considered but if the facial nerve function is compromised, if this is not possible then resection can be considered with appropriate reconstruction with direct anastomosis for small tumours, interposition cable graft or facial hypoglossal anastomosis depending on the size and location of the defect.   Conclusion:   A management strategy is presented aiming to preserve and maximise facial nerve function.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: yuechen han

Title: Facial nerve granuloma:two cases report

Abstact   Objective: To report two cases of facial nerve granuloma in clinical practice and the clinical characters of these cases were investigated.    Methods: Two patients who suffered from peripheral facial paralysis were involved in this retrospective research. The routine blood tests, biochemical blood tests, blood clotting tests, X-ray film of the chest, electrocardiogram (ECG),audiometry, electromyogram of face, facial nerve electrogram, temporal bone CT, leprosy bacillus test were done preoperation.    Results: The temporal bone HRCT revealed that the bony canal of the right facial nerve was involved, the perigeniculate area, tympanic segment and mastoid segment were more coarser than the normal side, however the edges of them was smooth, the bony canal was unclear. In the operations, we found that the diameter of facial nerves were bigger than normal, and the tunica vaginalis of the tumors were intact. The postoperative pathological report suggested that facial nerve granulomatous inflammation had been found in the lumps.   Conclusion: we suggested that facial nerve granuloma may be a new disease of facial nerve, and this was the first report of this kind of disease in facial nerve.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Daniele Bernardeschi

Title: Facial Nerve Schwannoma: clinical presentation, management and outcomes in a large monocentric series

Introduction: Facial nerve schwannoma (FNS) is a rare tumor and its management is still debated.   Objective: To analyse the clinical presentation, the management and the outcomes in a large series of FNS.    Methods: Medical charts of 74 patients with solitary FNS were reviewed in this retrospective study. Clinical presentation was assessed on both facial impairment and otological symptoms; patients were divided following the management in surgically treated patients, wait-and-scan patients and gamma-knife patients.   Results: Facial palsy was the main symptom in 53% of cases (n= 39). The tumor was mostly located in the geniculate ganglion (31%). Wait-and-scan management was chosen for 21 patients (28%). Three patients (4%) underwent gamma-knife radiosurgery and 50 patients (68%) underwent microsurgical resection. A complete excision was performed in 41 cases (82%), a partial removal in 8 cases (16%), and a decompression in one case (2%). In case of complete excision, the facial nerve was anatomically preserved in 2 cases. All other cases had facial nerve rehabilitation: facial nerve graft in 23 cases, XII-VII anastomosis 12 cases, and temporal myoplasty in 4 cases. A HB grade III was achieved in 70% of cases after facial nerve graft and in 36% of cases after XII VII anastomosis, with no significant difference. Only duration of preoperative facial palsy was found to be significant for postoperative facial outcomes (p=0 .05 – Spearman test). Conclusion: Management of FNS should be tailored to each patient: Surgery is the treatment of choice when the FN function is worse than a grade III HB. The wait-and-scan strategy is the preferred option in case of good facial nerve function, and stable tumor while the gamma knife radiosurgery is usually reserved to patient with FN function less than III HB with growing tumor.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Francesca Romana Fiorini

Title: Facial nerve palsy following Vestibular Schwannoma surgery: outcomes and treatment options at a single UK Institution

Introduction   Facial nerve palsy (FNP) frequently complicates surgery for Vestibular Schwannoma (VS). There is no circumscribed management of post-surgical FNP.  Instead, different options are offered to improve facial neuromusculoskeletal function based on individual needs.  There is limited data as to the selection or personalisation of the multifaceted treatment approach.     Objectives   To describe our population and the degree of FNP after surgical or radiosurgical treatment for VS, and to outline the type and frequency of rehabilitative treatments offered.     Methods   A retrospective study was carried out of patients who attended the multidisciplinary facial nerve clinic (FNC) at our UK institution since 2014, having had facial nerve compromise following surgical intervention for VS.  The degree of FNP was evaluated by collating this cohort’s scores on the Sunnybrook Facial Grading System (SFGS).  The types of post-surgical treatments offered to the patients was also collated.   Results   16 patients attended the FNC, having developed FNP following previous treatment for a sporadic unilateral VS with exclusive surgery (n=13), gamma knife (n=1) or surgery followed by gamma knife to the remnant (n=2).  The extent of FNP ranged from 33 to 89 on the SFGS. Botulinum toxin (BoNT) injections were administered to 9 patients (56%) for synkinesis treatment. Physiotherapy was offered to all patients. Dynamic surgical procedures offered to 3 patients included hypoglossal to facial nerve transfer (n=2), cross facial nerve graft (n=1) and platysma resection (n=1).   Conclusion   The treatment of FNP after VS surgery remains challenging. In our experience, however, only a small proportion of patients have persistent flaccidity requiring dynamic surgical procedures. So far, only one patient has had compromising synkinesis requiring myectomy.  Physiotherapy then BoNT are the most routine therapies offered to patients.  The next phase of this research is to look at patient reported outcomes to see if they corroborate these encouraging findings.


 

TOPIC: Facial Nerve and Tumors

Submitting Author: Elliott Kozin

Title: Sensorineural Hearing Loss in Patients with Facial Nerve Schwannomas

Introduction: Facial nerve schwannomas (FNS) and vestibular nerve schwannomas (VNS) often occupy similar locations in the internal auditory canal (IAC). Prior studies of VNS have shown that size and location of tumors do not necessarily correlate with severity of hearing loss. We hypothesize that the size and location of FNS do not correlate with hearing loss.    Methods: A single institution retrospective review of all patients diagnosed with FNS was performed. Demographic data, tumor size and location, severity and type of hearing loss as well as facial nerve function were analyzed. Otopathologic review of a case of FNS was also performed.    Results: Patients with FNS were identified. Nine patients had tumors involving the IAC facial nerve, while 24 had distal tumors without IAC involvement. Eleven patients (33%) had hearing loss, and 55% of patients with SNHL had tympanic segment tumors without IAC involvement. The presence of SNHL was not associated with IAC tumor location. Maximal dimensions of FNSs did not correlate with incidence or SNHL severity. Otopathologic review of an example case of untreated IAC FNS demonstrated disproportionate spiral ganglion and hair cell loss within the ipsilateral cochlea compared to the contralateral ear.     Conclusions: Tympanic segment FNS without IAC involvement may result in SNHL. Tumor size is not associated with presence or severity of SNHL. Mechanisms for SNHL in schwannomas are likely multifactorial and may be unrelated to cochlear nerve compression.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Shin-Ichi Haginomori

Title: A new electroneurography as a prognostic tool for marginal mandibular nerve paralysis after parotid gland surgery: a preliminary study

Introduction: Marginal mandibular nerve paralysis is the most frequent complication of benign parotid tumor surgery and results in cosmetic deformity. The purpose of this study was to develop a new electroneurography method for marginal mandibular nerve paralysis using electroneurography (ENoG) and judge its usefulness for clinical practice.   Methods: Twenty-seven patients who underwent surgery for benign parotid tumor were enrolled. We proposed and use the mandibular angle method, in which the recording electrode was placed on the skin above the depressor anguli oris muscle while the reference electrode was placed on the skin of the parietal region, and percutaneous electrical stimulation was applied to enclose the mandibular angle that could measure the function of the marginal mandibular nerve solely. Preoperative and postoperative ENoG values were compared in paralytic and non-paralytic patients.   Results: The mean postoperative ENoG value (35.0%) was lower than the preoperative value (90.5%) in paralytic patients, whereas no difference was observed between preoperative (79.3%) and postoperative (69.5%) ENoG values in non-paralytic patients.   Conclusion: A new ENoG method (mandibular angle method) was thought to reflect marginal mandibular nerve injury and might be useful for determining the likelihood of paralysis.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Timothy Eviston

Title: Axonal threshold tracking for the determination of axonal function

Introduction: Computer tracked axonal excitability methods have an established role in determining the biophysical properties of human axons in the setting of health and disease. These methods use the rapid, automated application of conditioning and paired pulse stimuli and the tracking to submaximal threshold changes to evaluate axonal membrane and ion-channel properties. The translation of these techniques to the facial nerve setting is an important advancement towards the in-situ determination of axonal function in realtime.    Methods: Using anatomical and surgical landmarks for two facial nerve branches, a reproducible methodology was developed to allow facial nerve assessment using the TROND protocol for axonal threshold tracking. Zygomatic branch stimulation with nasalis recording and marginal mandibular branch stimulation with depressor angularis oris (DAO) recording were applied to a cohort of 27 normal controls. Comparisons were made between the two branches and with the median nerve. The relationship between gender, age and nerve properties was explored through subgroup analysis.   Results: A full set of recordings were obtained in all participants across a wide age range. In total 27 zygomatic-nasalis recordings and 19 marginal-DAO recordings were completed and analyzed. The studies were well tolerated by all participants. Excitability parameters were found to be similar for both branches of the facial nerve.   Conclusions: This study establishes the feasibility of using axonal threshold tracking techniques for the facial nerve and lays the foundation for the translation of the technique into diseased cohorts and the operating room. Full recordings were found to be possible in all participants and normative data is established. The biophysical properties of the facial nerve demonstrate distinct differences when compared to median nerve recordings in line with morphological and functional differences.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Seung Geun Yeo

Title: Prognostic value of the blink reflex test in Bell’s palsy and Ramsay-Hunt syndrome

Poster    This study was designed to evaluate the prognostic value of the blink reflex (BR) test in patients with Bell’s palsy (BP) or Ramsay-Hunt syndrome.     The House-Brackmann (HB) grade of patients diagnosed with BR and RHS was determined at first visit and 3 months later. Final HB grade III–VI was defined as an incomplete recovery. Factors evaluated as prognostic of poor recovery included axonal loss (AL) >95% on electromyography (EMG), electroneurography (ENoG) degeneration rate (DR) >90%, and absence of BR. Rates of complete and incomplete recovery were calculated and the associations between prognostic factors and recovery were determined.    Of the 129 included patients, 98 (76%) had BP and 31 (24%) had RHS. Absence of BR and low mean ENoG value were significantly associated with incomplete recovery in both the BP and RHS groups (p<0.05 each). Initial HB grade V–VI and EMG AL >95% were significantly associated with rate of incomplete recovery in patients with RHS (p<0.05 each). Severe residual palsy (final HB grade V–VI) in the absence of BR was significantly more frequent in patients with RHS than with BP (p<0.05).    BR test results were a good prognostic indicator in patients with BP and RHS, as were ENoG and EMG. Absence of BR and/or EMG AL > 95% were more frequently associated with severe residual palsy in RHS than in BP.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Aaron Remenschneider

Title: Is Serial Electroneuronography Indicated Following Temporal Bone Trauma?

Introduction: Current guidelines advise facial nerve (FN) decompression within two weeks of temporal bone trauma if a single electroneuronography (ENoG) demonstrates >90% degeneration of the FN. Utility of serial ENoG in traumatic facial paralysis, however, is unknown. Herein, we describe cases where serial ENoG was employed following temporal bone trauma.  Methods: Cases of adult patients with traumatic temporal bone fractures and resultant ipsilateral FN paresis were reviewed. Serial ENoG followed by observation or decompression of the FN was performed. Outcomes were assessed using House-Brackmann (HB) graded FN function.  Results: Nine cases of blunt temporal bone trauma resulting in ispilateral FN paralysis were identified and reviewed. Immediate paralysis occurred in four cases, while five were delayed. A single ENoG was performed in seven patients and was predictive of final function in six, while one patient had an initially reassuring ENoG but did not obtain full recovery of FN function (HB 4). Two patients underwent serial ENoG on a weekly basis which, while initially reassuring, demonstrated declining FN function on subsequent testing. Decompression was performed in both patients with excellent long-term recovery of FN function (HB1 and HB2).    Conclusions: The majority of ENoGs performed within two weeks of temporal bone trauma provide sufficient prognostic data for treatment decisions. A single ENoG, however, may not always predict long-term FN outcomes. For patients with an initially reassuring ENoG, who fail to improve with observation alone, serial ENoG may capture declining FN function. A new diagnostic algorithm is proposed to better identify a subset of patients that may benefit from late decompression of the FN.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Lieber Li

Title: Standardization of Procedure for Intra-Operative Facial Nerve Monitoring in Cochlear Implantation

Introduction: Facial nerve monitoring (FNM) has been widely performed in the surgical process of cochlear implantation (CI). However, the procedure of intro-operative FNM was never standardized.   Objective: The aim of this study was to propose the standardization of intra-operative FNM for the surgical process of CI on the basis of our experiences.   Methods: Different amount of electrical current (EC) were used for FNM in various stages of the operation. When incus was identified during posterior tympanotomy and mastoidectomy, EC of 2.0 mA was used to locate possible route of facial nerve. After air cells in mastoid were removed and compact bone was encountered, EC of 1.0 mA was used to reveal whether there was evidence of nerve aberrance. While facial recess was being approached, EC of 0.5 mA was used to confirm the course of facial nerve until the nerve was visible.   Results: Eighty-six patients receiving CI surgery were recruited. There was not any type of injury to facial nerve in all patients. The average evoked strength for monitored electromyogram (EMG) by the stimulus of 2.0; 1.0; and 0.5 mA was 1370.7 μV (labeled V2), 1625.4 μV (labeled V1), and 1942.0 μV (labeled V0.5), respectively. V0.5 could furthermore be predicted by the following formula: V0.5 = 0.3 x V2 + 0.7 x V1 + 443.1.  Conclusion: The standardization of intra-operative FNM for the surgical process of CI was suggested for the first time. By using the proposed procedure of FNM, no facial nerve injury was noted in our patients. Besides, V0.5 could be predicted by a formula with the measured V2 and V1. A longitudinal study with a larger sample size was needed to verify the standardized procedure and the use of the formula in a translational setting.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Vittorio Colletti

Title: An Update of Facial Nerve Antidromic Potentials during Vestibular Schwannoma Surgery

Introduction. For many years, EMG monitoring of facial muscles has been the gold standard for monitoring the facial nerve (FN) during vestibular schwannoma (VS) surgery despite a series of drawbacks: unreliable with the use of endplate blockers, no quantification of the degree of damage.    Objective. To provide an update on direct monopolar recording of FN antidromic potentials (FNAP) during VS surgery and demonstrate that this procedure is more effective than EMG.   Methods. A prospective single center study from 1990 to 2013 recruited two hundred and fifty-five patients (mean age: 46 years; 123 males and 132 females) with VS (maximum diameter, ranging from 29 to 48mm) that had retrosigmoid transmeatal approach. Preoperatively all subjects presented House-Brackmann (HB) grade 1 facial function. All subjects underwent intraoperative monitoring alternatively with direct (monopolar and/or bipolar) recording of FNAPs (140 patients) or EMG monitoring (115 subjects).    Results. HB evaluation of postoperative facial nerve function revealed excellent results: Grade I-II in 96% of small tumors (<2cm), 74% of medium tumors (2.0-3.9cm), and 38% of large tumors (4³cm). A postoperative function (Grade III or IV) was achieved in 4% of small tumors, 26% of medium tumors, and 58% of large tumors. Near-total resection (>95% removal) was achieved in 191 (74%) cases and subtotal removal (>90% removal) in 24 cases (9%) At 6 month follow-up, HB grades I–III were observed in 212 cases (83%), HB grade IV in 15 cases (6%) and HB grade was V in 22 cases (9%).    The group of subjects who performed FNAP monitoring showed a statistically significant percentage of HB grades I-III (93%) in respect to subjects who underwent EMG monitoring (71%; p<0.001).   Conclusions. FNAP monitoring is a valid tool for FN identification, quantification and prevention of damage. This technique demonstrated significant advantages versus EMG monitoring.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Jack Wazen

Title: Intraoperative facial nerve monitoring, benefits and pitfalls

Intraoperative facial nerve monitoring is a valuable tool in otological and skull base surgery, helping with early identification and preservation of the facial nerve. It does not however replace a solid knowledge of the surgical anatomy, and proper surgical technique.   The purpose of this paper is the review the experience of a well-established 34 years old fellowship program in facial nerve monitoring and preservation.   A questionnaire was sent to 45 fellows who successfully completed our fellowship focusing on their indications for monitoring, the type of monitoring techniques, the incidence of iatrogenic facial paralysis, and the causes of such complications.   The results of the questionnaire will be presented with a discussion of cases where paralysis occurred despite the monitoring. The causes of such breakdown are discussed, and appropriate steps to prevent such events are described.    Intraoperative facial nerve monitoring remains an integral part of our otological and skull base procedures, particularly in a training program where experiences vary greatly and microscopic surgical deviations can cause devastating complications.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: WooYeon Han

Title: Fluorescence-assisted direct visualization of facial nerve using near-infrared camera

Background   Facial nerve injury during deep tissue dissection on the face should be avoided. But it is hard to distinguish the facial nerve from surrounding tissue in some cases. Many indirect techniques have been made to identify facial nerve using intraoperative devices such as nerve stimulator. In this study the facial nerve could been directly identified with an intraoperative fluorescence-assisted near-infrared camera during the operation.   Methods   From November 2014 to October 2016, there were 34 cases with intraoperative indocyaninegreen-assisted direct visualiization. The cases consist of 3 groups which were Neurofibromatosis (n=14), Aging face (n=12), Facial palsy (n=8). Intravenously injected ICG is distributed systemically along the blood flow and fills the lumen of the epineural vessels around the nerves (vaso nervorum) in a minute.    Results   The trajectories of the facial nerve could been directly visualized using fluorescence detecting near infrared camera. Deep tissue dissection to remove deeply set mass or sub SMAS face lift using this camera was possible. Facial nerves were distinguishable from surrounding tissues such as ligaments and were safely secured without any injuries in all cases. Postoperative facial nerve function was preserved in all cases.   Conclusion Injuries to the facial nerve could be effectively avoided via direct visualization of the nerve using intravenous ICG injection. Portable near-infrared camera enabled this direct and real-time visualization of the nerve and prevented the injuries. This novel technique can prevent disastrous complication of facial palsy with simple and efficient method.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Zane Upate

Title: Neurophysiological Evaluation as a Prognostic Indicator for Non-recovery after Bell’s Palsy.

Neurophysiological evaluation of facial nerve function is well known as a prognostic indicator mainly in early stages of Bell’s palsy. Patients with axonal nerve damage (axonotmesis, neurotmesis) recover slowly and usually incomplete. The aim of our study was to assess the healing process in later stages (1-6 month) after facial nerve damage and to evaluate risk for almost complete non-recovery.    In this prospective study we selected patients with Bell’s palsy with slower improvement than expected. They were neurophysiologically examined 1-6 month respectively 2-3 year after palsy onset. Clinical evaluation were done using the Sunnybrook Facial Grading System 1-2 day, 1-2 month, 8-12 month and 2-3 year after onset. We used different parameters of electroneurography (CMAP), Blink reflex (latency and persistence) and electromyography (spontaneous activity, MUP-analysis, interference pattern, jiggle, synkinesis) and evaluated risk for non-recovery by using a recently developed 8-parameters scale. Each parameter was graded with 1, 2 or 3 points depends on whether values corresponded to the theoretically expected one with respect to the time. Patients with high scores (20-23 points) according to 8-parameters scale by first investigation had relatively god reinnervation and function of facial muscles at later investigation. Patients with low scores by 8-parameters scale (lower than 19 points) had higher risk for poor reinnervation and non-recovered function of facial muscles.


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Daniele Bernardeschi

Title: ROLE OF ELECTROPHYSIOLOGY TO GUIDE NEAR-TOTAL RESECTION FOR FACIAL NERVE FUNCTION PRESERVATION IN LARGE VESTIBULAR SCHWANNOMA SURGERY

Object: In large vestibular schwannoma surgery, the facial nerve is at high risk of injury. Near-total resection has been advocated in the case of difficult facial nerve dissection, but the amount of residual tumor and when dissection should be stopped remain controversial factors. The objective of this study is to report facial nerve outcome and radiological results in patients undergoing near-total resection guided by electromyographic proximal supramaximal stimulation of the facial nerve.   Methods: Twenty-five patients were included in this retrospective analysis of a prospectively mainteined database. Inclusion criteria were an incomplete resection due to the strong adherence of the tumor to the facial nerve and the loss of around 50% of the response of supramaximal stimulation of the proximal facial nerve at 2 mA. Facial nerve function and the amount and evolution of the residual tumor were evaluated by clinical examination and by MRI at a mean of 5 days postoperatively and at 1 year postoperatively.   Results: Good facial nerve function (grades I/II) was observed in 16 (64%) and 21 cases (84%) at day 8 and at 1 year postoperatively, respectively. At 1 year postoperatively (n=23), 15 patients (65%) did not show growth of the residual tumor, six patients (26%) had regression of the residual tumor and only two patients (9%) presented of the tumor progression.  Conclusions: Near-total resection guided by electrophysiology represents a safe option in the case of difficult dissection of the facial nerve from the tumor. This seems to be a good compromise between facial nerve function and the amount of residual tumor


 

TOPIC: Facial Nerve Monitoring

Submitting Author: Lolade Giwa

Title: The Facial Paralysis Evaluation Profile- a new scale with promising results.

Introduction: Facial palsy lesions can have significant but variable physical, functional and emotional effects on patients. There are a number of scales which are used in combination to objectify and standardise outcomes- both clinician and patient reported. These include House Brackmann, Sunnybrook scores and Facial Disability Index (FDI). Our senior author has developed a new scale- the Facial Paralysis Evaluation Profile (FPEP). In this study, we aim to show the strength and reliability of this new scale.   Methods: 250 patients presenting to the Facial Nerve combined clinic over a 42-month period were retrospectively reviewed. All patients completed a Patient Reported assessment tool formed of the Hospital Anxiety and Depression Scale, the Synkinesis Assessment Questionnaire, The FDI and the FPEP.    Results: Aetiologies of facial palsy included Bell’s Palsy, Vestibular schwannoma, trauma and Ramsay Hunt Syndrome. Correlation between FPEP and the other 3 factions of the PROM was assessed using Pearson’s Correlation Coefficient. A high correlation was found between FPEP and FDI (r= -0.67, p<0.01) and moderate correlation with HADs and SAQ (r= 0.45 p<0.01, r= 0.44 p<0.01). A low correlation was found between the Sunnybrook Score and the FPEP (n= 73 r=-0.19 p<0.10)   Discussion: The large correlation of the FPEP with FDI- a highly validated assessment scale shows it as also being a good assessor of patient reported facial nerve outcomes. The small correlation of the FPEP with the Sunnybrook further serves to highlight the difference between clinician observed and patient observed outcomes. In order to develop a universal, comparable scale, one may need a scale with both patient and clinician reported factions.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Gaye Cronin

Title: Physical and Mental Treatment Interventions for Synkinesis

Synkinesis, aberrant regeneration, mass muscle movements, cross-wiring, and associated abnormal movements are all terms that are disturbing to patients suffering from, and clinicians treating, these problems. Synkinesis refers to cross wiring of the facial nerve branches as the nerve regenerates following facial paralysis.  The objective of this paper is to describe a combination of physical and mental treatments for synkinesis and the outcomes. Method: 26 patients that demonstrated synkinesis in 2 or more muscle groups and 6 patients with abnormal gustatory lacrimation following facial paralysis as a result of Bell's palsy, Ramsey Hunt syndrome, axonotomesis, facial nerve grafts, and post surgical removal of acoustic neuromas were treated as part of a neuromuscular facial retraining program. Physical treatments included specific muscle and tissue stretches, facial massage, ultrasound and infrared light modalities, surface electromyography, and small facial exercises with mirror. auditory and tactile feedback. Mental strategies included isolation of facial muscles using facial muscle pictures, visualization utilizing facial muscle and nerve pathway anatomical charts, specific relaxation technicians and mental concentration to isolate muscles.. The average number of treatment sessions was 16.   Five patients had botox neurotoxin injections. Results: The average increase of percentage of facial expression and movement on the May Facial Grading Scale was 29% and the scores increased by as average of 28 points on the Facial Disability Index. 5 of the 6 patients no longer demonstrated gustatory lacrimation. Conclusion: Physical and mental treatment intervention strategies used in combination can promote neuroplasticity and can result in improved facial function and expression, with decreased synkinesis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Takahiro Azuma

Title: Prevention and treatment of facial synkinesis after facial palsy using facial biofeedback rehabilitation with mirror

Objective        In the present study, we examined preventive and therapeutic effects of facial biofeedback rehabilitation with mirror on oral-ocular synkinesis of patients with facial palsy.      Methods   The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry of eye opening width during mouth movements (% eye opening).     Results    In patients with facial palsy, facial synkinesis developed 3-5 months after the onset.  However, there was no relationship between the percentages of ENoG on day 7-10 and the onset time of the synkinseis.   Oral-ocular synkinesis was developed in 88.5% of patients with less than 40% of ENoG, but in 18.8% of patients with 40% or more of ENoG.   Accordingly, there was a significantly correlation between the percentages of ENoG on day 7-10 and % eye opening at 12 months after the onset.           Based on the above findings, we instructed the patients with facial palsy of which ENoG was less than 40% to perform facial biofeedback rehabilitation with a mirror in order to prevent oral-ocular synkinesis.    The % eye opening of oral-ocular synkinesis was significantly higher in rehabilitation patients than that in control patients after 10 months of rehabilitation.   Finally, we instructed the patients with established oral-ocular synkinesis to perform facial biofeedback rehabilitation with a mirror after pre-administration of a single dose of botulinum A toxin in order to treat oral-ocular synkinesis.   The % eye opening of oral-ocular synkinesis was significantly increased after 10 months of rehabilitation when the effects of botulinum toxin had completely disappeared.      Conclusion   The value of less than 40% of ENoG on day 7-10 is a predictive factor of the development of oral-ocular synkinesis in patients with facial palsy.   Mirror biofeedback rehabilitation is effective to prevent the development of oral-ocular synkinesis.  The combined therapy is an effective treatment of the established oral-ocular synkinesis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Catriona Neville

Title: A model for development of a multidisciplinary facial therapy specialist network

The UK is the 1st country in the world to set up a multidisciplinary facial therapy specialist network (FTS-UK, Facial Therapy Specialists UK, www.fts-uk.org)   FTS-UK  was set up in 2009 by 4 UK based therapists; Catriona Neville, Vanessa Venables, Sally Glover and Lorraine Clapham; who met at the 11th international facial nerve symposium in Rome and realised there was a need to;   ·         Set UK standards for best practice in assessment, outcome measurement and therapy management of facial palsy patients.   ·         Collaborate on research and enable multi-centre research trials   ·         Improve peer support, networking and training for all facial therapy specialists working  within the UK   ·         Improve access for patients to quality regional care following facial palsy   FTS-UK now has an established committee and membership base including physiotherapists, speech and language therapists and psychological therapists.   The FTS-UK website incorporates;   ·         advice for therapists on the causes and effects of facial palsy as well as therapy treatments and surgical options    ·         guidelines for acute and later stage management    ·         a newsletter archive including journal reviews and reference lists    ·         downloadable therapy hand-outs   ·         a members network    ·         links to the UK based charity Facial Palsy UK (www.facialpalsy.og.uk)   Members of FTS-UK can also attend our acute and advanced courses and become members of our facial therapy specialists UK Facebook group.   We hope to encourage other countries to develop similar facial therapy specialist networks which can then link to FTS-UK in order to enhance patient care internationally.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Anna Kinsten

Title: Physiotherapy treatment and outcome, one year after Bell's palsy in adults.

INTRODUCTION     Earlier many ideas concerning neuromuscular retraining have been put forward and prospective randomized studies that could be verified statistically are few.      OBJECTIVES     To identify the effectiveness of a neuromuscular retraining program (NRP) that contributes to recovery of Bell’s palsy in a short and long time perspective and give a view of self assessed problems.     MATERIAL AND METHODS     This is an on-going comparative study that includes 20 adult patients diagnosed with Bell’s palsy, at the Karolinska University Hospital in Stockholm, Sweden. Two groups were compared, nine respectively eleven patients in each (A and B), in order to follow short and long time results and the effect of NRP. Group A were diagnosed with Bell’s palsy one year ago. Group B were diagnosed four - ten years ago. A baseline score according to the Sunnybrook facial grading system (SFGS) and House-Brackmann system (HB-FGS) was created. All patients were followed regularly by a physiotherapist and given a NRP for one year, including specific techniques for treating flaccid paralysis as well as synkinesis. A follow-up was made after one year, in group A and after five - eleven years in group B. Tests used for the follow-up were HB-FGS, SFGS, Facial Clinimetric Evaluation Scale (FaCE), Facial Disability Index (FDI) and Synkinesis Assessment Questionnaire (SAQ). Patient perception regarding the most difficult symptoms and characteristics were penetrated.      RESULTS     Both groups were followed equally. Group B was followed over a longer period of time and i.e. the SFGS was not as common then as today, therefore some parameters are lacking. Detailed results concerning scoring of the included scales and outcome of NRP will be discussed.     CONCLUSION      A comparative study has been performed trying to verify the use of NRP at an early time after onset of Bell’s palsy. Instruments and parameters for scoring are given.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Katherine Konosky

Title: Novel Therapeutic Interventions for Facial Nerve Rehabilitation

A major barrier patients/providers encounter that affects recovery of facial nerve function is poor tissue health including:  myofascial tightness, diminished sensation, and altered circulation of the vascular /lymphatic systems.  These changes occur regardless of cause of paralysis or paresis.  The use of negative pressure and photobiomodulation (low level laser therapy) appear to optimize tissue health and promote recovery of nerve function.  This is accomplished by : using negative pressure and vibration  which lifts fascial planes, softens tissue texture, enhances circulation, and provides sensory stimulation; and by using low level lasers to decrease oxidative stress and increase ATP production creating tissue health on a cellular level.  This presentation will provide an overview of these modalities as adjuncts to treatment and case studies showing changes in patients seen at a Facial Reaninmation Clinic.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Carien Beurskens

Title: Mime therapy: Who, when and what

There is limited evidence regarding the effect of non-surgical medical treatment options for patients with facial palsy. Possible non-surgical interventions can include biofeedback therapy, exercise therapy like neuromuscular facial retraining and mime therapy. Rehabilitation of facial expressions, or mime therapy, is developed in The Netherlands and shows evidence in alleviating sequels in facial palsy. Valid and reliable measurements are used during intake and evaluation. Treatment includes auto-massage, relaxation and coordination exercises, inhibition of synkinesis, and emotional expression exercises.     Treatment for patients with sequels after reinnervation of the facial nerve can be organized by categorizing patients into four treatment stages based on the phase of recovery. Phase 1 paralysis: when there is no voluntary movement at all. Phase 1 treatment options consist of   patient information, coaching and instructing auto-massage. Phase 2 first movement: when initial voluntary movement of facial muscle function has started. In this stage, mime therapy focuses on functional exercises based on motor learning theories. Therapy starts with basic and advances to more complex functional coordinative exercises. Phase 3 synkinesis: when patients are confronted with synkineses. In this phase it is important to control and inhibit synkineses as much as possible. In case of very severe synkineses a combination of botulinum-toxin injections and mime therapy is often an alternative. Phase 4 dynamic reconstructive surgery: patients with very limited or no recovery of facial nerve function can undergo dynamic reconstructive surgery. the therapeutic approach and timeframe in post surgical treatment strongly depends upon the type of operation.   This presentation will focus on who is qualified for mime therapy, when and how to begin, details concerning the exercise program, with an accent on emotional expressions.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Susan Rankin

Title: Face to Face: A Method for Teaching Facial Neuromuscular Retraining

The number of therapists doing rehabilitation for facial palsy internationally has increased very slowly over the years. In 1984 there was one facial therapist in attendance at the International Facial Nerve Conference in Bordeaux, France.  In Boston, there were 50 therapists from around the world and a portion of the conference was dedicated to non-surgical rehabilitation of the facial nerve. Although this is not representative of all the facial therapists trained internationally, it is still a very small group.  One of the reasons for the low number of trained facial therapists is the availability and quality of training.  A literature search revealed no articles about teaching facial retraining. Through personal communications, the writer learned that facial therapists are typically trained one-on-one by a combination of didactic education and observational clinical experience.  The objective of this presentation is to explore one method for training more facial therapists with a high degree of educational value. Because most facial therapists work in isolation their training must be good enough that they can operate independently upon returning to their place of work. Dale’s Cone of Experience states that the most effective way to learn is to “do the real thing”. Most Physical Therapy courses use participants as the models for learning about how to treat various body parts. However, using the face on normal models is of limited value. Students must be able to assess and treat real patients in order to leave with the knowledge that Dale’s Cone of Experience suggests.  The facial neuromuscular retraining workshop in this paper fulfills training more than one therapist at a time and involves the highest level of learning.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Vanessa Venables

Title: A descriptive study identifying commonly reported problems with eating, drinking, and other oro-motor functions, in conjunction with an evaluation of the effectiveness of a treatment programme to ameliorate these difficulties.

This study aims to identify and describe eating, drinking and other oro-motor difficulties experienced by people with chronic lower motor neuron facial palsy. Secondly, to measure the effectiveness of a treatment programme to remediate these symptoms. The 26 patients recruited into the study were a minimum of nine months post onset of their facial palsy and presented with pan-facial tightness and synkinesis.  Participants completed the following: questions 1 – 5 and 10 from the Facial Disability Index, (FDI); 11 questions on an Oro-Motor Skills Visual Analogue Scale, (VAS), and 20 questions from an Inventory of Patient Reported Eating and Drinking Difficulties, (IPREDD).  These were completed at their initial appointment and on discharge from therapy.  The questions for the VAS were generated from a focus group about the impact of facial palsy on oro-motor function.  The FDI questions relate to physical and psycho-social problems associated with oro-motor skill dysfunction.  The IPREDD is an inventory of twenty questions designed to identify the frequency of specific eating and drinking difficulties. A two-tailed paired sample t-test was used to compare the results from each assessment pre and post therapy.  Mean scores for each question from the 26 participants was compared.  A significant difference was found between scores before and after treatment as follows: VAS at the level of p < 0.0001 – 0.0038; FDI at the level of p <0.0001 – 0.0003; 16/20 symptoms on the IPREDD at the level of p < 0.0001 – 0.0152.  This study indicates oral stage eating and drinking problems associated with weak lip seal were the most frequently reported problems, (e.g. dribbling, losing food or fluid from the corner of the mouth).  Pharyngeal stage problems, (e.g. coughing after eating and drinking), were reported infrequently.  Furthermore all patients made significant improvements in eating, drinking and oro-motor functions following therapy.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jodi M. Barth

Title: Hydrodissection: Alternate Treatment for Facial Tightness in Slow Recovering Facial Palsy Patients

Introduction   Just as studies of peripheral nerve injuries like carpal and tarsal tunnel syndrome address fibrosis of connective tissue, ultrasound assessment has confirmed that fibrosis also exists in the face following facial palsy, causing the conflation of muscle layers and movement restriction; this could explain mass movements, or compensatory muscle spasms, typical for chronic facial palsy. We hypothesize that ultrasound guided hydrodissection severs connections bound by fibrosis, enabling improved, independent muscle movements which might assist in decreasing synkinetic activity or reinnervation/polyinnervation.    Objective   We conducted a study to assess ultrasound guided hydrodissection on the face as treatment for facial palsy patients exhibiting abnormal, involuntary movement at the eye and experiencing facial tightness.   Methods   Four patients with slow recovering (>6 months), idiopathic facial palsy were scored before and after each procedure by the Sunnybrook Facial Grading System (FGS) at regular intervals. Dr. Chad Zatezalo performed ultrasound guided hydrodissection on the paretic side of the orbicularis oculi region with a 25 Gauge blunt-tipped DermaSculpt® Microcannula needle and 2.5mL lidocaine. Swelling control modalities were utilized afterwards.    Results   All patients had synkinesis prior to intervention that increased, on average, 2.75 points and plateaued at 5/15 points after intervention. Two patients had recovery rates of -0.3 and 0.38 points/month (over ~21 months) prior to intervention and 2.4 and 1 points/month (over ~4 months) after intervention, respectively. The remaining patients had higher initial recovery rates at 2.2 points/month (over ~10 months) and demonstrated no statistical changes after intervention.   Conclusion   Ultrasound guided hydrodissection for treatment of facial tightness caused by fibrosis is more effective for patients with slow-recovering (initial recovery rate <1 point/month), rather than fast-recovering (initial recovery rate >1 point/month) idiopathic facial palsy. Additionally, ultrasound guided hydrodissection of fibrosis appears to control synkinesis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jodi Barth

Title: Ultrasound Scanning for Early Detection of Synkinesis in Patients with Facial Palsy

Introduction   Ultrasonography is advantageous to facial recovery therapy because it allows its practitioners to view below the skin in real time and detect abnormalities like synkinesis, or involuntary movements arising from imperfect recovery from nerve damage.    Object    To assesses ultrasound as a screening tool for detecting emerging synkinesis in facial palsy patients.   Methods   From April to December 2016, 29 patients’ facial muscles were scanned using an ultrasound machine LOGIQ e (GE) and a high frequency linear probe (6.7-18.0 MHz). The orbicularis oculi was observed while the patient voluntarily puckered, rolled their lips, and closed their eyes. The modiolus region was observed while the patient voluntarily blinked and closed their eyes. The same protocol was conducted on the uninvolved side as an control.    Results   In 7 of 29 patients, synkinetic muscle activity was only detectable by ultrasound. This early synkinetic activity, evident in the modiolus region, increased and became visible an average of 26 days later (min. 5, max. 48 days). For one patient, synkinesis was detected by ultrasound during the first assessment, demonstrating that there was synkinesis prior to facial rehabilitation; in that case, synkinetic activity was detected by visual evaluation five days later. On the uninvolved side, no synkinetic activity was detected in any case.    Conclusions   Ultrasound can be used to detect synkinesis prior to visual evaluation and prompt early intervention. In all 7 cases, therapy was adjusted knowing that misguided reinnervation would become a problem for that patient. Consequently, since introducing facial ultrasound in April 2016, the application of facial ultrasound has changed the diagnosis and treatment of 7 of 29 patients (24%).


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: MARCELA BONIN

Title: Peripheral facial paralysis in the puerperium: Physiotherapeutic approach - case report

INTRODUCTION: Peripheral facial paralysis (PFP) is a dysfunction of the facial nerve that affects individuals of all ages, characterized by the temporary interruption of facial muscle movements, causing emotional, social and occupational changes. Idiopathic or Bell´s Palsy (BP) is the most common cause of PFP; it is an acute paralysis of the facial nerve of undefined cause being diagnosed by exclusion. Sir Charles Bell was the first to associate PFP with gestation. It is believed that the reactivation of herpes simplex virus is the main cause of PB. PFP is a situation that deserves specialized attention in cases related to gestation and puerperium and it is necessary to have an appropriate treatment. The physiotherapeutic approach facilitates muscle activity in functional movement patterns. The muscular reeducation associated with elastic bandage is related to better results than only the conventional treatment.   OBJECTIVE: To use the technique of muscular reeducation associated with elastic bandage (sensory feedback) in the treatment of PFP.   MATERIAL AND METHODS: A descriptive case study was conducted in a female patient, 32 years old, with diagnosis of BP and immediate postpartum. In an initial evaluation, House-Brackmann (HB) showed Grade V, asymmetry at rest, muscle tone decreased, muscle strength deficit. The rehabilitation program was carried out for 12 months, with physiotherapy sessions twice a week, being prescribed exercises of muscular reeducation and use of the elastic bandage in inferior orbicular muscles of the eyes and orbicularis of the mouth.   RESULTS: There was a significant improvement in muscle function and resting symmetry, final grade HB I, observed in the photographic protocol and in the HB scale.   CONCLUSION: Elastic bandaging associated with specific muscular reeducation exercises has been beneficial in the treatment of PFP. Further studies are required for method validation.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Damian Palafox

Title: Speech and language disorders in patients with Mobius Syndrome.

Background: Mobius syndrome is characterized by congenital bilateral paralysis of the facial and abducens nerves. Clinical manifestations may include feeding problems, dysphagia, sialorrhea, strabismus, and lack of facial expression.    Objective: The aim of this study was to describe the most common speech, swallowing, and language disorders in individuals with Moebius syndrome.    Methods: 97 patients with Mobius syndrome, aged 18 months to 25 years were studied. All patients belong to the data base from our institution. Clinical observations by a certified speech and language pathologist (SLP) were collected in a previously designed database including articulation placement and manner, intelligibility, and the presence of language disorders.   Results: Sialorrhea was observed in 23% of the patients. 69% percent of the patients presented with (expressive and/or receptive) language disorders. Articulation errors in bilabial sounds were observed in 68% patients and 50% presented errors in other sounds.    Intelligibility was as follows: 17% adequate, 51% mildly affected, 20% moderately affected, 12% severely affected. Also, only 23% reported good performance at school, the rest ranged between regular and poor school performance.    Conclusions: Patients with Mobius syndrome are at risk of presenting speech and / or language disorders. Early intervention by a speech pathologist should be undertaken in order to enhance language and speech development. This could improve communication and reduce the risks of underachieving school performance.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Mika Takahashi

Title: Effect of Mirror biofeedback rehabilitation on oral-ocular synkinesis with chronic  facial palsy in children.

Objective   In adult patients with chronic facial palsy, it is difficult to treat their established facial synkinesis by rehabilitation. In the present study, we examined whether facial biofeedback rehabilitation with a mirror improve established synkinesis after facial palsy in pediatric patients.    Methods   Four pediatric patients who showed oral-ocular synkinesis with chronic facial palsy continued facial biofeedback rehabilitation with a mirror at home every day for 12 months. The patients were instructed to try to keep eyes opening symmetrically during three mouth movements of lip pursing /u:/, teeth baring /i:/ and cheek puffing /pu:/  .    In order to keep their motivation for rehabilitation, they were trained for facial biofeedback rehabilitation with a mirror by pediatric otolaryngologists and practiced together in a group every month. The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry of eye opening width (% eye opening) during mouth movements.    Results   Before the treatment, the mean values of % eye opening during lip pursing /u:/, teeth baring /i:/ and cheek puffing /pu:/ movements were  48.38±8.36 , 58.68 ± 13.66and 44.92±16.85, respectively. After 12 months treatment, they were 76.91±8.71 in /u:/ , 78.80±9.51 in /i:/ and 70.01±14.01 in /pu:/. The percentage of eye opening during mouth movements significantly increased in the pediatric facial palsy patients after 12 months.    Conclusion   These findings demonstrated that daily facial biofeedback rehabilitation with a mirror improved oral-ocular synkinesis after facial palsy in children. It is suggested that mirror biofeedback rehabilitation is a promising treatment of established facial synkinesis with chronic facial palsy in pediatric patients, unlike adult patients.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Ruben Yap Kannan

Title: Residual masseter function following masseteric nerve transfers: A clinical, radiological and EMG-based assessment

Objective:            To assess the degree of masseter muscle atrophy following masseteric nerve transfers and neurotisations from a clinical, radiological and electrophysiological perspective.   Methods:            In a prospective study over eighteen months at our institution, residual masseter bulk and function was studied in patients who had masseteric nerve-based facial reanimation procedures. Pre-operatively, all patients were assessed in a multi-disciplinary setting with the HADS psychological, Sunnybrook facial and CADS grading scales. EMGs were performed to confirm the electrical activity of the masseter muscle. At three months post-op, a repeat assessment alongside facial MRI scans and EMGs were performed to assess masseter function.     Results:            Twelve masseteric-nerve based procedures (n = 12) were performed during the trial period; six super-selective neurotisations, two free functional muscle transfers, two vascularised nerve grafts and two babysitter procedures. Their ages ranged from 14 to 60 years with iatrogenic injury being the causative factor in 92% of cases. Preliminary data suggests that there is no functional debilitation in using the masseteric nerve as the donor nerve in terms of overall function although some degree of masseter atrophy can be expected.   Conclusion:            Masseteric nerve-based transfers and neurotisations do not affect the overall function of mastication and have minimal objectified morbidity.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Susan Coulson

Title: Electrical stimulation as a treatment for facial nerve paralysis: a systematic review

Introduction: The use of electrical stimulation for physiotherapy rehabilitation following facial nerve paralysis (FNP) is still debated in the literature. Although in the 1950’s research found no significant advantage for the use of electrical stimulation after Bell’s palsy,    there have been conflicting findings about facial electrotherapy treatment in human and animal subjects ever since.      Objective:  This review aims to analyse the efficacy of electrical stimulation after peripheral FNP and inform best practice management in this area.   Methods: A systematic review of randomised and quasi-randomised controlled trials was undertaken to evaluate the effects of electrical stimulation after FNP using data from human and animal studies published up until August 2016.     Results: Six studies were included for analysis – five with human subjects (majority with Bell’s palsy), one with animals.  Various outcome measures were used in the studies and a meta-analysis was not possible.  In acute facial nerve paralysis, three studies found no benefit of electrical stimulation and two studies found improvement.  In chronic facial nerve paralysis, one study found improvements after extensive electrical stimulation.   Conclusion: There is no evidence to support the use of electrical stimulation during the acute phase of recovery after Bell’s palsy and there is only low-level evidence for patients with chronic, ongoing symptoms.  There is no evidence available on the use of electrical stimulation for other causes of facial nerve paralysis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Sergio López Pozo Susana Moraleda Pérez

Title: NEUROMUSCULAR RETRAINING IN FACIAL PARALYSIS: Can we quantify the improvements?

INTRODUCTION:   Facial Neuromuscular Retraining (FNR) is, in our field, the non-surgical treatment of choice for patients with peripheral facial paralysis (PFP), independent of the etiology.   Nevertheless, although we may subjectively perceive that our patients improve, we do not always have an objective measure of that improvement.   OBJECTIVES:   To evaluate the effectiveness of FNR as the sole treatment therapy in patients with  sequelae.    METHODS:   Retrospective study in which we reviewed the Clinical Histories of outpatients assessed in the Physical Medicine and Rehabilitation Department of the Facial Paralysis Unit between October 2013 and December 2016.  Only those patients with PFR who had not previously received treatment with botulinum toxin were included.  This was done to evaluate the effectiveness of FNR as a stand-alone treatment intervention.   Each patient was assessed pre and post-treatment using the Sunnybrook Facial Grading Scale (SFGS) by the same person.   RESULTS:   Out of 377 individual patients reviewed, only 82 of these met the inclusion criteria.     The results obtained were varied.  A greater percentage of improvement was found amongst patients who received early treatment with FNR following their first assessment at the Facial Paralysis Unit.  Improvements were more noticeable in the control of synkinesis and in the total SFGS scores.   CONCLUSIONS:      FNR is a useful non-surgical treatment for patients with PFP sequelae, especially if it can be introduced in the early stages of the condition.       Improvements are likely to be more evident if assessed in the longer term, when the patient has a greater control over their movements.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Maria LLuisa Torrent  Bertran

Title: THE USE OF MYOFASCIAL TECHNIQUES (DRY NEEDLE) FOR THE TREATMENT OF MAINTAINED MUSCULE CONTRACTION IN PERIPHERAL FACIAL PALSY

INTRODUCTION   Based on the clinical and neurophysiologic similarities between the palpable taut band of the myofascial pain and the facial palsy’s maintained muscle contraction, we considered treating the latter with dry needling the trigger points found in the physical examination.   OBJECTIVE   To assess the effect of dry needling as a method of treatment for the maintained muscle contraction in patients with peripheral facial palsy, to improve pain and tightness as well as to facilitate movement.   MATERIALS AND METHODS   We performed dry needling techniques in the affected side of the face to 5 random patients with facial palsy with maintained muscle contraction and trigger painful points noticed in physical exam. The dry needling technique was applied one or two months after botulinum toxin injection. Generally, dry needling was done over zygomaticus major, zygomaticus minor, levator labii superioris, mentalis, procerus, buccinator, depressor labii inferioris, using a screw technique.   After one week, the patient answered the Patient Global Impression of Improvement Scale and the Clinical Global Impression of Improvement Scale, through which relief of pain and tightness were assessed and the question ‘Do you have better face movement after the dry needling?’, which was evaluated through a Likert Scale.   RESULTS   The Patient Global Impression Improvement Scale results were “Much improved” in 4/5 patients and “Very much improved” in 1/5 patient. The Clinical Impression of Improvement Scale was “Improved” in all patients.   The assessment of improvement in movement through the Likert Scale was of 5 in all cases.   CONCLUSIONS   Patients refer significant improvement in both pain and movement after the dry needling technique.   We consider that the dry needling technique as a supplemental treatment after botulinum toxin may improve maintained muscle contraction and facilitate movement in the affected side of the face.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Scott Chaiet

Title: A Multidisciplinary Nursing-Surgeon-Therapist Team Approach for the Evaluation of Chronic Facial Paralysis

Introduction   Facial nerve injury is a devastating condition that may lead to chronic paralysis, paresis, and synkinesis. In addition, it often results in significant psychosocial sequelae. This disorder is best evaluated by a multidisciplinary team comprised of nursing, surgeons, therapists.   Objectives   Upon completion of this session, participants will be able to describe the multidisciplinary team approach for evaluating chronic facial paralysis; decide optimal timing for initial evaluation; understand therapeutic approaches regarding the treatment of synkinesis; and understand the process of creating a multidisciplinary facial nerve program with team approach.   Results   Otolaryngology nurse, Kari McConnell, RN, will review the clinic coordination process including patient counselling after acute facial nerve injury, clinic intake and multidisciplinary care management.   Neuromuscular retraining therapist Jackie Diels, OT, will review the initial evaluation of facial movement in the multidisciplinary setting and decision making regarding therapeutic approaches to synkinesis in treatment of chronic facial paralysis.  She will review the current knowledge base and provide case based studies to highlight the strengths of the surgeon-therapist simultaneous initial evaluation.    Otolaryngologist Scott Chaiet, MD, will review evidence supporting a multidisciplinary facial nerve team for evaluating chronic facial paralysis.  He will utilize case based studies to highlight the team approach from the surgeon’s viewpoint, and provide knowledge regarding building a multidisciplinary facial nerve program from experience at the University of Wisconsin in Madison.   Conclusion   This session will provide otolaryngologists and non-physician clinicians with expert opinion and evidence-based approaches for a multidisciplinary, nursing-surgeon-therapist, team evaluation of chronic facial paralysis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Celia Santini

Title: Talking Your Way Out of Facial Paralysis

This presentation will show the importance of using speech and facial expression in the rehabilitation of facial paralysis. Speech in can take place of repetitive exercises as a way to achieve symmetry in a more natural and spontaneous environment.    Facial paralysis is devastating and traumatic mostly because it affects the individual’s communication. When a person is suddenly robed of their ability to easily communicate they need to work harder to express themselves. During the acute stage there is a dense paralysis and a complete lack of movement on the affected side of the face leading to exaggerated movements of the strong side of the face. Therefore, it is very common to see patients talking with a severely distorted speech that is very negative to their recovery at many levels. This presentation will show the importance of incorporating speech exercises and facial expression as a focal component of Facial Neuromuscular Retraining. Using specific speech exercises that can help the patient stimulate the brain in a natural way by tapping on spontaneous speech movements that will help reduce the natural neglect that occurs from favoring the strong side of the face.   Because the nerve is sometimes slow in return, patients lack the perception of the weak response that is present, besides the strong side of the face is pulling the muscles to the opposite side very hard making sensation even more difficult to sense. The excessive participation of the strong side of the face results in not only a greater negative asymmetry, but also greater speech distortion and poor facial expression. Addressing speech articulation and facial expression takes rehabilitation to a level beyond workout and repetitive exercises bringing to a meaningful and practical level.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Diane Picard

Title: Software rehabilitation in peripheral facial palsy

Early management of facial palsy is essential to increase recovery and prevent sequelae. Within the context of e-health, we wondered about the relevance of a virtual rehabilitation for peripheral facial palsy. The main purpose of the present study was to compare classical rehabilitation and software rehabilitation.   First, 391 therapists and 81 patients answered questionnaires about their expectations and needs. This data helped us design a DVD which was provided to ten therapists and ten patients. A survey was then conducted in order to assess its relevance as a rehabilitation tool. Afterward, we led a 1-year-monocentric nonparametric therapeutic study. 2 groups of patients (n=10) were included: 5 patients benefit from a classic rehabilitation, whereas 5 patients followed a virtual rehabilitation with the DVD. Their facial motor skills, severity grades and quality of life were estimated. The range of the smile was measured with the ENS scale and the MEEI face-gram program.   The study reveals that the implementation of a software as a rehabilitation tool is well-appreciated for the visual feedback it delivers as well as for its pedagogic content which meets patients' expectations (9,1/10 ; 0,74ds). Furthermore, it seems to motivate patients by involving them in the rehabilitation process. The findings clearly reveal that this DVD is a promising tool that may improve the treatment of Bell's palsy.    Facial motor skills of patients included in this therapeutic study increase significantly from the third month post-inclusion. One year after, the findings are not significantly different between both groups in term of motor skills, range of smile or quality of life. In common with classical rehabilitation, software rehabilitation could increase functional facial expression recovery.    Considering diagnosis errors and the wandering path of patients to find a specialized therapist, software rehabilitation can be crucial regarding patients' quality of life and professional practices.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Daniela Issa Benítez

Title: CONSENSUS GUIDE FOR THE REHABILITATION TREATMENT IN FACIAL PALSY IN A MULTICENTRIC CLINICAL PRACTICE

INTRODUCTION   The treatment for facial palsy is complex and requires specialized units as well as a multidisciplinary team to assess the patient globally and respond to the problems of each phase.    OBJECTIVES   To unify criteria and define the best treatment for each phase of the facial palsy, to improve facial function and quality of life.    MATERIALS AND METHODS   Both doctors and physical therapists from the Facial Palsy Units from the Rehabilitation Services of two university hospitals in Barcelona, Spain, got together to revise scientific articles, share clinical experiences and introduce new technique for facial palsy management.   Afterwards, a consensus document was created as a protocol for both medical centers.    RESULTS   Consensus on best treatment for each phase was achieved, as follows:   - Hypotonic phase: neurosensory stimulation through Perfetti method, proprioceptive and cognoscitive activities with neurosensory feedback, and movement induction by neuromuscular training (ill side). Treatment with botulinum toxin helps diminish hypercontractility of the sound side.    - Initiation of movement: neuromuscular training and Perfetti’s neuromuscular stimulation.    - Synkinetic Phase: neuromuscular retraining with dissociated movements of the synkinetic muscles. Relaxation treatment of the maintained muscle contractures. Treatment with botulinum toxin helps control aberrant movements and induces facial symmetry.    Myofascial techniques (dry needling and mesotherapy) may help diminish maintained muscular contraction.    After dynamic surgery, treatment must be based on the physiology of the reconstruction implemented, inducing movement according to the given nervous stimuli.    In congenital/obstetric palsies, treatment will be similar to that of adults’ Bell’s palsy, adjusting treatment to patient’s age.    CONCLUSIONS   We believe this consensus will allow for a better clinical practice, to offer the patient the best treatment to improve functionally, mentally and socially, thus improving quality of life.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Maria Lluisa Torrent Bertran

Title: Smile Reanimation Surgery in Patients with Facial Palsy with Gracilis Flap. Descriptive Study and Functional Results

Introduction   Surgery in facial palsy aims to restore the face’s symmetry in rest as well as reanimation of the smile. Gracilis flap is a therapeutic option for patients with long term facial palsy.   Objective   To describe evolution and functional results of patients treated surgically through gracilis transposition.   Material and methods   27 patients with chronic (>12months) unilateral facial palsy were treated with gracilis transposition to reanimate smile. Demographic information such as age, gender and personal history was gathered, as well as onset of facial palsy, affected side, etiology, date and kind of surgery, complications and initiation of movement. Functional results were evaluated with the Facial Disability Index and the smile item on the Sunnybrook Scale.    Results   Mean age was 50 years old and a slight prevalence of women over men and right sided palsy over left was observed. Most prevalent etiology was iatrogenic after acoustic neuroma surgery (33.3%). 59% of palsies were less than 5 years old in evolution.    Donor nerve most frequently used was the masseter (48%), followed by the cross-face nerve graft with masseter babysitter (33.4%) and lastly, cross face sural nerve graft (18.6%). Four patients required a second reanimation surgery. Most common complication was scar retraction at the angle of the mouth.   Majority of patients initiated smile around 2-4 months after surgery, being a complete or almost complete movement in 66.6% of patients. Facial Disability Index Global Score was less than 100/200 in 20% of patients and more than 150/200 in 44% of them.    Conclusions   Functional results were good in more than half the patients, with mild-moderate facial disability. There is a tendency to associate the use of masseter donor with better smile movements and facial disability indexes, even though results are not statistically significant.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Camilla Ekwall

Title: A description of a physiotherapy program on smile for patients after masseter nerve transfer surgery

Introduction   The goal with smile reanimation surgery is to achieve a symmetric, effortless and/or a spontaneous smile. When using nerve transfers in facial reanimation, postoperative training is most probably important to optimize the outcome and to encourage central relearning. We present our experience using an individualized physiotherapeutic program in patients with post facial reanimation using the masseter nerve as neurotizer.     Objective   To describe a physiotherapy program on smile for patients after masseter nerve transfer surgery.   Method   Patients who had had masseter nerve transfer to the facial nerve or connected to a free muscle transfer can be introduced to postoperative physiotherapy in order to improve smiling. Suggested measurement of facial function are the Sunnybrook Facial Grading System, House-Brackmann scaling and photo/video documentation. The physical therapy program consists of four main exercises:   1.     Practice to bite, find the coordination   2.     Try to bite and hold for ten seconds   3.     Try to bite and relax, bite and relax   4.     Practice to bite and then smile with good symmetry   The patient has individual training with physiotherapist and is stimulated to carry out the exercises in front of a mirror at least six times per day. Follow-up sessions are at three months, six months and one year after surgery.   Results   In our experience, patients improve symmetry of smile and smile excursion with the addition of physiotherapy to surgery. The program is easy to understand and carry out, and thereby compliance becomes high.   Conclusion   A structured physiotherapy program might enhance the postoperative result after masseter nerve surgery. In order to confirm positive results of the suggested program, a structured, clinical study needs to be carried out. Such a study has to include both an intervention and a control group.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Mónica Gómez Martínez

Title: Application of kinesiology tape treatment to orbicularis zone in Peripheral Facial Palsy for Hypotonic earlier reinnervation phase.

Introduction:   The kinesiology tape (kinesiotaping) is a therapeutic method based in the use of an elastic cotton bandage heat sensible with elasticity between 140–150%. The properties of the bandage simulate a “second skin” with a special design in order to promote the proprioceptive improvements and somatosensory perception in the sensitive receptors of the skin. In the current evidence few researches have been concluding in evaluating the kinesiotaping treatment for correcting the ectropion and/or lagophthalmos in patients with peripheral facial palsy.   Objectives:   The main objective of this technique is to improve proprioception of patients with diagnosis in ectropion and/or lagophthalmos secondary to facial nerve paresis or paralysis and therefore, improve the functionality of periocular muscles in case of reinervation.   Other important objectives are the neuromuscular facilitation, corneal protection and the subjective comfort of the patient improving eye closure from the early stage of the pathology.   Methods and Provisional Results:   This research consists of a prospective 5 cases study.   The patient received the proper instructions and kinesiology tape was applied.   Up to the date we have compiled data of 3 out of 5 patients, the physical disability index improve 7.71 %.   The social disability index improves 7.9 %. Regarding the subjective perception of the ocular proprioception patients showed an important improvement.    Finally, according to the prekinesiotaping results using picture analysis, the distance between the lower and upper eyelid is decreased by an average of 1.2mm   Conclusion:    With the kinesiotaping treatment patients showed an important improvement in their physical and social disability index as well as heir sensation of ocular movements and their overall wellbeing.   Proven positive outcomes with these patients, future investigations seem indicated to evaluate the kinesiotaping for low functioning facial muscles, insisting on ocular occlusal correction.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jodi Barth

Title: Negative Pressure Therapy as Adjunct Treatment for Patients with Facial Palsy

Introduction   Physical therapists perform 3D manipulation with negative pressure therapy devices to stretch and loosen tissues that have thickened and caused a decrease in circulation and adhesion to surrounding tissues. This technique has been applied to patients with a variety of diagnoses.   Objective   To assess the use of negative therapy devices on patients exhibiting facial palsy.    Methods   Four patients were evaluated for facial tightness and treated using a negative pressure therapy device. Patients were scored according to the Sunnybrook Facial Grading System (FGS) before and after the introduction of negative pressure therapy, on average, every three weeks.    Results   Before negative pressure therapy, when patients underwent standard treatment, including manual therapy and neuromuscular reeducation, on average, voluntary movement increased by 5 points, resting symmetry improved by 1.5 points, synkinesis did not change, and composite score increased to 6.25 points. When negative pressure therapy was introduced, on average, voluntary movement increased by 4 points, resting symmetry improved to 2.5 points, synkinesis did not change, and composite score increased to 6.5 points.    Conclusions    Although there was no statistically significant increase in composite score, all patients reported decreased discomfort and facial tightness, as well as overall progress. Further investigation is recommended to determine the long-term benefits of negative pressure therapy for facial palsy patients.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Ameya Misato

Title: The rehabilitation after hypoglossal-facial nerve anastomosis

Introduction   In Ehime Medical School Hospital, patients are encouraged to practice the rehabilitation after hypoglossal-facial nerve interpositional-jump graft (jump graft) or network like reconstruction. Despites of its importance, few studies have reported the rehabilitation using tongue movements after hypoglossal-facial nerve anastomosis.   Objective   In this study, we report the exact contents of the method we have been using and the situations of patients who followed our instruction.   Methods   Based on the House-Brackmann scale we retrospectively evaluated 5 patients who underwent hypoglossal-facial nerve anastomosis for facial paralysis during the period from 2011 and 2016 and who participated in the rehabilitation after the operation in our institute.   Results   All cases were administered the rehabilitation that included both mimic muscle massage to prevent its atrophy and intraoral tongue movement to facilitate the activity of mimic muscle(protrusion, depression, and retraction).After the rehabilitation we observed clinical improvement in 4 patients. The tongue movements applied to them were not exactly the same: depression was applied to 3 patients; retraction to 1 patient.   Conclusion This results suggest that the rehabilitation after hypoglossal-facial nerve anastomosis is effective. We assumed that intraoral tongue movement to facilitate the activity of mimic muscle differs from patients to patients. Choosing an appropriate intraoral tongue movement which easily connected with mimic muscle is very important in the rehabilitation.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Laura Hetzler

Title: Patterns of Therapy: How a Multidiscipline Approach to Facial Nerve Recovery Can Optimize Outcomes in Facial Reanimation

Introduction: Recovering from facial paralysis can be a slow and arduous process.  Despite our best efforts, facial nerve recovery can be simultaneously incomplete with lack of meaningful motion yet excessive with hypertonicity.  A patient’s perception their own recovery is based on their personal sense of facial harmony.     Objective: This paper discusses how different patterns of recovery must be recognized prior to refining present function.  The authors have used a multidiscipline approach to treat facial nerve disorders for optimal treatment of hypertonicity, synkinesis, and to augment nerve repair and reanimation outcomes.     Methods: Facial paralysis patients were seen in a multidiscipline setting to include a surgeon and specialty trained facial physical therapist.  Patterns of synkinesis and hyperfunction were ultimately defined and used to guide in office treatment methods.  Therapeutic exercises were employed prior to chemodenervation.  Patients were evaluated by physical exam, video assessment and patient surveys.     Results: Seeing patients in a multidiscipline setting was successful in individualizing therapeutic options and creating an algorithm for physical therapy versus procedural intervention. Patients understood their care and were more invested in therapy with multidiscipline care as indicated on quality initiative surveys.         Conclusion: Simultaneous evaluation of facial nerve function by both a surgeon and a therapist offers different perspectives of the same clinical picture.  Facial nerve disorders of all etiologies evaluated in a multidiscipline setting can highlight the subtleties of facial nerve recovery that can be missed in an individual clinic.  This combination of perspectives gives the patient improved understanding of goals and expectations as well as garners them a better understanding of their own facial harmony.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Phuong Nguyen

Title: Mitigating oral opening challenges following lengthening temporalis myoplasty

Introduction: Mouth opening following lengthening temporalis myoplasty (LTM) for facial reanimation may be challenging, leading to decreased oral intake and delayed muscle rehabilitation.  We hypothesize that using a jaw motion rehabilitation device (TheraBite) postoperatively improves facial mobility and interincisal distance.    Methods:  A retrospective review of all patients who underwent LTM for facial reanimation at a single institution was performed.  Postoperative maximal mouth opening was measured from maxillary central incisor to the mandibular central incisor.  Surface EMG (sEMG) assessed muscle activity.  A multilevel mixed-effects regression analysis was performed, controlling for age, sex, surgeon, and postoperative monthly treatment intervals.   Results: Five subjects, 2 unilateral and 3 bilateral facial palsy patients, underwent LTM.  Four of five patients (80%) demonstrated postoperative oral tightness.  Three of five (60%) required use of TheraBite to improve oral excursion after failing traditional massage therapy.  Average age at time of surgery was 14.3 ± 5.7 years.  Patients started TheraBite treatment on average 84.7 days after initial facial reanimation procedure.  Univariate analysis revealed a significant difference with TheraBite use versus no use in sEMG  (90.2 ± 33.6mV vs. 56.4 ± 32.3mV, p=0.0003) and interincisal distance (23.8 ± 3.4mm vs. 20.6 ± 3.5mm vs., p=0.027).  Mixed regression showed TheraBite use to have a sEMG of 7.79 ± 9.53mV greater than without use (p=0.271); interincisal distance was 1.0 ± 1.1mm greater with TheraBite use (p=0.377).  Critically significant increase of sEMG occurred in the fourth month (42.1±18.7mV, p=0.024) and interincisal distance in the third month (5.5 ± 1.7mm, p=0.001)  Conclusion: Univariate analysis demonstrated improvement of sEMG and interincisal opening after TheraBite use following LTM.  There appeared to be a significant rise in sEMG of the temporalis muscle approximately one month after initiation of TheraBite use.  Future studies will need to investigate implementation of TheraBite earlier in postoperative course and prior to surgery.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jacqueline Diels

Title: Targeted Botox for managing synkinesis: a therapist perspective

Introduction   Recovery from facial nerve injury can result in synkinesis, abnormal movement patterns that distort facial movement, limiting communicative facial expression. Targeted Botox injections can assist in managing the abnormal movements that typify synkinesis.    Objective   Synkinesis can be a devastating condition resulting in abnormal movement patterns after faulty recovery from facial nerve injury. Botulinum toxin injections are being increasingly used to assist in management of synkinesis. A well trained facial neuromuscular retraining (NMR) therapist can provide input to the treating physician regarding injection sites to maximize outcome. This paper discusses the process used for identifying the biomechanical relationships between the desirable muscular movements/expressions and those that cause restriction or distortion of expression. It will also highlight how collaboration between therapist and treating physician enhances outcomes in the synkinetic patient.    Methods   Through the course of facial NMR, therapists spend a great deal of time analyzing movement patterns in the synkinetic patient to determine which erroneous muscle contractions most restrict normal functional motor patterns, mobility and range of motion. Facial paralysis patients were seen for neuromuscular retraining and identification of targeted Botox sites just prior to Botox injections administered by the treating physician. Botox sites were marked on the patients face and a diagram was created to indicate the sites prior to injection. Multiple factors were considered when determining appropriate injection sites including patient goals, vectors of abnormal muscular co-contraction and minimization of co-morbidity.    Results   Therapist/physician collaboration resulted in increased accuracy of injection sites that led to consideration of new sites not previously injected. Ultimately, this resulted in further reduction of synkinesis and improvement of facial movement patterns.    Conclusion   Patients demonstrated excellent results as indicated by self-report, synkinesis assessment questionnaire (SAQ) and Facial Grading System (FGS) scores after detailed and precisely targeted Botox injections.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jacqueline Diels

Title: Incorporating surface electromyographic (sEMG) feedback into facial retraining

Introduction   Surface EMG feedback has long been used in conjunction with neuromuscular retraining for evaluation and treatment of facial paralysis. Conditions treated include the full spectrum of recovery ranging from flaccidity to synkinesis and contracture.   Objective   The presentation will discuss therapeutic incorporation of sEMG as a useful adjunct to the retraining process. Attendees will learn to identify patients who would benefit from inclusion of sEMG, techniques for maximizing outcomes, and pitfalls to effective integration.    Methods   SEMG brings unconscious facial movement into consciousness allowing patients to observe, analyze and modify erroneous patterns. Surface electrodes are placed on the skin overlying the targeted musculature. Analogous muscles are monitored on the unaffected side for simultaneous comparison. Using a 4-channel surface EMG unit (Therapeutic Alliances neuroEducator4ä), patients learn to modify muscular activation patterns as they watch the signal output displayed on a computer monitor in real time.    Results   Patients report increased understanding and ability to modify their facial muscular movements using sEMG feedback. SEMG results obtained in clinic must be correlated with sensory/proprioceptive feedback to ensure accurate follow through in the home program and effect long-term learning. In a subset of patients, sEMG usage increased synkinetic activity and led to frustration during the treatment process and was therefore discontinued.   Conclusion   SEMG feedback, within a comprehensive facial NMR program, is a powerful tool in a select group of patients, to assist in learning improved motor patterns and function after facial paralysis and synkinesis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jacqueline Diels

Title: Training vs. Treatment: optimizing motor learning in facial neuromuscular retraining

Introduction   Historically, treatment for facial paralysis has ranged from passive electrical stimulation and gross motor exercises to in-depth neuromuscular retraining which employs extensive patient education and individualized instruction to enhance motor learning for improving outcomes.    Objective   This presentation will outline passive therapy vs. active NMR techniques as a model for improving function after facial nerve injury. Jackie Diels, facial retraining therapist, will discuss effective training techniques, practical tips and lessons learned over thirty years of dedicated practice treating approximately 20,000 facial paralysis patients. Challenges to using a comprehensive NMR approach will also be addressed.    Methods   A wide variety of NMR techniques have been developed over almost 40 years. The first comprehensive retraining program was described by Bach-y-Rita and Balliet in 1980. NMR employs specific, individualized retraining techniques in a clinic setting to enhance motor learning and improve coordinated movement patterns. Educational techniques enable patients to better understand their specific dysfunction, improve functional abilities and increase program compliance. Precise training methods using sensory feedback and self-mimicry, and advanced techniques for inhibition of synkinesis, enhance awareness and engagement. Patients learn accurate self-analysis, enabling them to become “their own therapist”.   Results   Patients with flaccidity, paresis and/or synkinesis can recover function, even many years after facial nerve injury, through active participation in facial neuromuscular retraining (NMR). Late recovery is based on the work of Paul Bach-y-Rita who described concepts of human late brain plasticity as a basis for the ability of the brain to reorganize after neural injury.     Conclusion   Facial NMR is an effective treatment paradigm for engaging active patient participation to improve function after facial nerve disorders.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Ellie Frayne

Title: Orofacial laterality and proprioception using a novel psychophysical movement discrimination task

Introduction   The universally identifiable nature of emotions suggests that the facial muscles have high proprioceptive ability, despite not having muscle spindles. Muscle spindles are considered the primary receptors involved in proprioception, therefore without such receptors the orofacial muscles must use differing mechanisms for this sense, and this has implications for exercise-based rehabilitation of the facial muscles of expression.    Objective   The current work constitutes the first quantification of the proprioceptive acuity of neurotypical orofacial muscles compared to the receptor-rich jaw muscles, and was conducted using an active movement extent apparatus for testing acuity for extent of lip and jaw closure.    Methods   A novel active movement extent apparatus was designed for the action of lip and jaw closure. This task was completed at the midline of the mouth to assess midline proprioceptive acuity of the lips compared to the jaw in twenty-two neurotypical participants. This task was also competed to the left and right sides of the mouth in sixteen participants to determine the presence of proprioceptive laterality in the lips and jaw.     Results    Paradoxically, the lips were found to have higher proprioceptive acuity than the jaw. When converted to millimetres the lips were found to have a discrimination ability of 0.298 mm compared to the jaw 0.398mm.  Additionally, a strong correlation was found between lip and jaw proprioceptive acuity scores. Subsequently, this method was employed to determine whether the laterality of proprioception observed in the upper and lower limbs is also evident in the orofacial muscles.    Conclusion:    The lips, void of proprioceptors were found to have higher proprioceptive acuity than the receptor-dense temporomandibular joint. Proprioceptive scores for the lips and the jaw were found to correlate strongly, a finding that was replicated on the right side of the mouth at specific ranges and has implications for clinicians and theorists alike.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Ellie Frayne

Title: The three-dimensional analysis of the accuracy of return to resting position in the orofacial muscles

Introduction   The reproducibility of facial expression has been investigated in the context of production of expression but not with respect to the ability to return to resting position between facial movements. Reproducibility of facial resting position is an assumption in the biomechanical analysis of facial expression, and also for neuromuscular retraining of the face post injury or illness. Commonly, participants and patients are cued to return to facial resting position between movements, and in the case of biomechanical analysis, bite pieces are used to stabilise the head.    Objective   This paper investigates the reproducibility of facial resting position between movements in the presence of bite pieces and cues, using 3D motion analysis.    Methods:    The 3D analysis program Cortex 3 with a six-camera set up and retroflective markers were used to track still and moving points. Error of return to rest was tested in several conditions including smile and unilateral smile, smile and unilateral smile with a bite piece, smile and unilateral smile with verbal cues to return to rest.     Results:    Results indicate the orofacial muscles have a return to rest error of between 0.43mm - 0.96mm in conditions ranging from smile and unilateral risorius contraction, presence of a bite piece with smile and unilateral smile movements and the use of verbal cues to aid in return to resting position. It was also found that the error rate increases with fatigue. Laterality of error and gender did not play a significant role in error size.      Conclusion:    Results indicated that the face is in an almost constant state of flux, and suggest the effectiveness of cues in particular conditions. The error of reproducing the same position in return to rest significantly increases in the presence of a bite piece and this has implications both for clinical practice and research.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Jocelyne Copeland

Title: The significance of the A-HA moment for parents in post-operative treatment following facial reanimation in children

Background: Dynamic facial reanimation using free gracilis muscle transfer is the standard of care to improve smile function in children with facial palsy. Post-operative exercises are initiated at the first signs of muscle innervation. Home exercise programs for young children programs rely on parental supervision.  It is essential that parents understand the exercise goals and rationale.  The tendency is to want their child to perform more frequent or more forceful exercises than recommended.  There is an A-HA moment when parents differentiate neuromuscular retraining principles from conventional muscle training. This presentation describes strategies used to teach children and parents post-operative facial rehabilitation techniques.    Methods:  The literature was reviewed to determine documented guidelines, protocols and strategies for post-operative paediatric treatment following facial reanimation surgeries.  Due to paucity of paediatric facial rehabilitation strategies and protocols in the literature, the therapists’ reflective journal was reviewed and strategies collected.    Results: Strategies and insights to parent and patient education of post-operative rehabilitation treatment is documented   Discussion: Parents want their children to have the best smile possible.  Conventional wisdom asserts that more and bigger is better when it comes to exercises.  Therapists must carefully reinforce the principles of neuromuscular training when teaching parents post-operative exercises.  There is a moment during the teaching session when parents verbalize their understanding of treatment.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Peggy GATIGNOL

Title: Interest of a specific tongue's rehabilitation after hypoglossal-facial anastomosis

Introduction: Classic hypoglossal-facial nerve anastomosis (AHF tt) is a traditional technic for rehabilitation of facial palsy. The sacrifice of the hypoglossal nerve generates a paralysis and an atrophy of the tongue which is held to be responsible for disorders of the articulation, the chewing and swallowing. After having shown that there were not disorders of the articulation in the AHF tt, we propose a comparative study of the verbal communication with patients having a specific and early lingual rehabilitation versus patient not having been dealt with.   Objective : The aim of this study was to address the efficiency of specific rehabilitation of the tongue after hypoglossal facial anastomosis.   Patients and Methods: We conducted a retrospective study of 95 patients after end to end anastomosis. Two groups of patients were comparated with a battery of tests including motor possibilities, articulation, facial and lingual electromyography’s.  Group A is made up of patients rehabilitated at J + 1, Group B patients never having rehabilitation or reeducated 2 years after surgery.   Results: This study brings to light the interest of a premature rehabilitation of the tongue and put in evidence that premature rehabilitation (from J+1 post surgery ) allows the decrease of the lingual atrophy and the improvement of the tongue ‘s mobility.   Conclusion: This study brings to light the interest of a premature care(p<0.001) of the tongue from the first postoperative days. The rehabilitation is above all a functional rehabilitation, main results with a better and faster reinnervation of the face, less hypertonia and synkinesis.


 

TOPIC: Facial Rehabilitation (Physical/Occupational/Speech Therapy)

Submitting Author: Gerd Fabian Volk

Title: Clinical value of selective functional electrical stimulation in facial nerve paralysis with chronic denervation or misdirected reinnervation

Introduction:    Facial nerve paralysis results in neuromuscular atrophy or in a combination of muscle atrophy and misdirected reinnervation. Facial reanimation by nerve reconstruction suffers the disadvantage of long nerve regrowth time. Former research showed good results stimulating denervated extremity muscles using functional electrical stimulation (FES) to prevent muscle atrophy and maintain muscle tonus [W. Mayr et.al.2002“Functional Electrical Stimulation (FES) of Denervated Muscles: Existing and Prospective Technological Solutions”Eur.J.Transl.Myol.]. Nevertheless FES has been neglected so far for facial muscles and may also be relevant for patient selection for future facial pacing. For facial pacing it is mandatory to show that the long-term denervated or falsely reinnervated facial muscles are in principle still able to be stimulated and perform specific movements.   Object:   To find an optimal FES setting to detect denervated and condition facial muscles selectively.    Methods:   To encourage non-invasive screening methods for reinnervation procedures or facial pacing, surface electrodes were used to estimate the optimal settings for stimulations. The use of surface electrodes caused the need for optimized electrode positioning, size and shape, which was also investigated.    Results:   Already in 1983, F. Martin and T. N. Witt showed that selective recruitment of denervated muscles, avoiding recruitment of innervated muscles and minimizing discomfort by minimal activation of pain fibers in the skin requires exponentially shaped pulses with long phase durations (>200ms). We confirmed these findings also for facial muscles. Best performance was seen when recruiting paralyzed facial muscles with biphasic long-duration impulses. Interestingly, unlike other skeletal muscle denervated facial muscle showed this selective reaction in shorter stimuli (around 80ms) even after longer denervation periods (>1year).   Conclusions   Surface electrodes, combined with the optimal stimulation settings, offer a screening possibility for facial pacing but also a therapeutic option to prevent atrophy. Further research is necessary to show effectiveness of training using the determined exponential patterns.


 

TOPIC: Grading Facial Movement

Submitting Author: Matteo Alicandri-Ciufelli

Title: A step backward: The ‘Rough’ facial nerve grading system

Objectives:    Several modalities currently exist to rate the degree of facial function clinically but even   though it has significant limitations, the most widely used scale is the HouseeBrackmann grading system   (HBGS). A simplified scale is introduced here, the ‘Rough’ Grading System (RGS e Grade I: normal   movement; Grade II: slight paralysis; Grade III: frank paralysis with eye closure; Grade IV: frank paralysis   without eye closure; Grade V: almost complete paralysis with only slight movements; Grade VI: total   paralysis). The aim of the present study was to verify the interrater reliability and the interscale validity   of this simplified grading system.   Study design: Scale validation study based on a prospective cohort.   Methods: Fifty patients with facial palsy, consecutively referred to our department were filmed while   performing some codified facial movements. Then two independent groups (one rating using the HBGS,   the other rating using the RGS) assigned a grade after reviewing the videos. The time required for the   rating was also noted.   Results:    The HBGS showed a mean value of interrater agreement of 0.46 while the RGS showed a mean   value of 0.59. The concurrent validity between HBGS and RGS ranged from 0.86 to 0.90 (p < 0.001 for   every comparison). There was no statistically significant difference between HBGS and RGS in the mean   time taken for rating (p ¼ 0.15).   Conclusions:    The RGS reached an adequate level of interrater reliability, higher than the HBGS. The   correlation between the two scales is high and the times required for rating are similar. The present   results may justify the use of the RGS in routine clinical practice.   Level of evidence:


 

TOPIC: Grading Facial Movement

Submitting Author: Lauren Chong

Title: Validation of the clinician-graded electronic facial paralysis assessment: the eFACE

Introduction   Facial paralysis remains a debilitating condition despite advances in medical, surgical and adjunctive interventions. Established grading systems used to assess facial paralysis and interventional outcomes have well described limitations. The Electronic Facial Paralysis Assessment (the eFACE), a clinician-graded zone-based facial function scale, has recently emerged as a grading tool that may provide greater sensitivity when assessing incomplete paralysis and post-surgical improvement.    Objective   To perform the first comprehensive validation of the eFACE.   Methods    Video recordings of eighty-three facial paralysis patients were assessed. Grading was performed in two sittings by three individuals with varying degrees of experience in assessing facial paralysis. Inter-observer reliability, intra-observer reliability, administration time, and agreement with the Facial Disability Index, House-Brackmann, Sunnybrook and Sydney facial grading systems were assessed.    Results    eFACE scores demonstrated high intra-observer and inter-observer reliability (intraclass correlation coefficient 0.84-0.91and 0.81-0.83, respectively). The eFACE correlated well with the House-Brackmann, Sunnybrook and Sydney facial grading systems (Spearman rho 0.73, 0.77 and 0.77, respectively). In sub-domain analysis, the eFACE correlated well with the Sunnybrook and Sydney systems in dynamic movement (Spearman rho 0.90 and 0.89, respectively) and synkinesis (Spearman rho range 0.74 and 0.72, respectively). Agreement between the eFACE and the Facial Disability Index was poor (Spearman rho 0.25). The mean time to completion of the tool was 116±61 seconds.   Conclusion   The eFACE is a valid facial assessment tool with high reliability and correlation with the established facial paralysis grading systems. It also provides an efficient and detailed analysis of paralysis according to each zone of the face.


 

TOPIC: Grading Facial Movement

Submitting Author: Yohei Sotsuka

Title: Could Microsoft Kinect V2 be an alternative grading system for facial paralysis?

Introduction and Objective  Grading systems for evaluating facial movements in facial paralysis can be classified into traditional and computer-based grading systems. Traditional systems include the House-Brackmann Grading System, the Sunnybrook system and many others. These systems are subjective systems, and the results can only be approximate. Computer-based grading systems provided quantitative repeatable results, they required significant time for manually using software and required high cost which limited their widespread clinical use. Recently, three-dimensional depth cameras in commercial gaming systems have been common, and reduced their cost. A few studies have used depth sensors for face detection. One of the three-dimensional depth cameras in commercial gaming systems is Microsoft Kinect V2 sensor for Microsoft Xbox One. This paper presents the results of using Microsoft Kinect V2 sensor for grading facial paralysis.   Methods  The facial grading system software was implemented using Kinect for windows SDK 2.0 running under the environment of Visual Studio 2013. The software can display the 17 animation units automatically in real time once the face has been tracked. The software program was written by the author in Visual C#.   First, facial emotions of two healthy subjects were captured by Kinect V2 and were graded by the software described.   Second, facial emotions of one facial paralysis patient were captured by Kinect V2 and were graded by our software before and after the botulinum toxin injections for treatment of synkinesis.   Results  Facial emotions of two healthy subjects were able to grade by Kinect V2. For facial paralysis patient with synkinesis, after the botulinum toxin injections, the synkinetic eye closure movements improved both clinically and also in our facial grading system software.  Conclusion  Microsoft Kinect V2 can be an alternative grading system for facial paralysis.


 

TOPIC: Grading Facial Movement

Submitting Author: David Jensson Lars Jonsson

Title: Synkinesis in Bell’s palsy

Introduction: Large controlled long-term follow-up studies regarding synkinesis in Bell’s palsy are few. Longitudinal research is needed to better understand the development of synkinesis and identify patients at risk.    Objective: To study the development of synkinesis in Bell’s palsy. Frequency, severity, gender aspects and predictors were analysed.    Methods: Data from the randomised controlled Scandinavian Bell’s palsy trial including 829 patients. Frequency and severity of synkinesis at 12 months were the main outcome measures. Mean Sunnybrook synkinesis scores, voluntary movement scores and composite scores between 6 and 12 months were compared.    Results: In 743 patients with a 12-month follow-up, synkinesis frequency was 21.3%. There was no gender difference. Synkinesis was moderate to severe in 6.6% of patients. Those with synkinesis at 6 months had a synkinesis score of 4.1 (+/- 2.8 SD), which increased to 4.7 (+/- 3.2) (P = 0.047) at 12 months (n = 93). Sunnybrook composite score at 1 month was the best predictor for synkinesis development with receiver operating characteristics and area under the curve 0.87. Risk for synkinesis increased with a lower Sunnybrook composite score.  Conclusion: Synkinesis frequency in Bell’s palsy was 21.3% at 12 months. The mean synkinesis score increased between 6 and 12 months, and outcome should therefore be evaluated after at least 12 months. Sunnybrook composite score at 1 month was the best predictor for synkinesis. The incidence of Bell’s palsy is around 30 to 40 per 100 000.  Since 6,6% suffered moderate to severe synkinesis, 2–3 per 100 000 a year may require treatment options like botulinum toxin, physiotherapy and/or surgery.


 

TOPIC: Grading Facial Movement

Submitting Author: Maurizio Barbara

Title: A VIDEORECORDING SYSTEM FOR ASSESSMENT OF FACIAL PALSY

Objectives: To propose a new objective, video-recording procedure to assess and monitor over time the severity of facial nerve palsy.  Methods: The face of a series of subjects presenting with different degrees of Facial Nerve deficit, as derived from the House-Brackmann grading system, was videotaped after positioning, at specific points, five grey circular markers made of a retro-reflective self-adhesive material, both in the affected and in the healthy side. The video-recording included the resting position and six ordered facial movements in close succession. Editing and data elaboration was performed using a specific software for visual programming language that uses a graphic programming language (G language) and is instructed to assess three vertical marker distances. The differences of the marker distances between the two sides were then given as a score.  Results: Higher scores were recorded in the worst FP degrees. The statistical significance differed during the various movements between the different FP degrees, being uniform when closing the eyes gently; whereas when wrinkling the nose, there was no difference between the HB grade III and IV groups and when smiling, no difference was evidenced between the HB grade IV and V groups. A global range index was between 6.2 and 7.9 in the normal subjects (HB grade I); between 10.6 and 18.91 in HB grade II; between 22.19 and 33.06 in HB grade III; between 38.61 and 49.75 in HB grade IV; and between 50.97 and 66.88 in HB grade V.    Conclusions: The proposed objective methodology could provide numerical data that can be matched with the different degrees of FP assessed by the subjective HB grading system. These data can in addition be used singularly to score selected areas of the paralysed face when recovery occurs with a different timing in the different face regions.


 

TOPIC: Grading Facial Movement

Submitting Author: Koen Ingels

Title: Digital consulting of Facial paralysis patients and potential home use of the RealSense camera

Objectives   The RealSense is a webcam-based 3D camera to potentially work with any computer, laptop or smartphone, specifically designed for close range (<20 m) recordings.    To determine the depth accuracy of the RealSense camera in facial palsy patients performing the 6 Sunnybrook movements.    To investigate if the RealSense can determine the effects of botulinum toxin in facial palsy patients.    Is there a place for digital multidisciplinary consultation in facial palsy patients?     Methods   For the verification of the RealSense camera, data of Sunnybrook movements of 34 patients with facial palsy were compared with the golden standard of a 3dMD system with a known accuracy of 0.25mm. Additionally some patients were measured before and after botulinum toxin injections with the RealSense while performing the 6 Sunnybrook exercises.   Results   An accuracy of 1.6-1.7mm was found in the RealSense depth data for all Sunnybrook exercises.   Conclusion   The accuracy  of the automatic facial tracking RealSense is reasonable for an inexpensive and portable 4D system and opens opportunities in the future for Digital consulting, automatic Sunnybrook grading, assessment of therapeutic effects,  …


 

TOPIC: Grading Facial Movement

Submitting Author: YOUNG HO KIM

Title: Assessment of facial nerve palsy using PC-based measurement program

Objectives   The objective assessment of facial nerve palsy (FNP) is essential for the diagnosis, treatment, and prognosis of patients. The aim of this study is to evaluate the usefulness of PC-based facial grading system (FGS) in patients with various degrees of FNP.    Methods  Facial photographs of 8 healthy people and 16 FNP patients were used. Participants were divided into 3 groups in accordance to the House-Brackmann grading (H-B); group l [normal] = H-B I, group II [mild-to-moderate] = H-B II-III, and group lII [severe] = H-B IV-V. The facial asymmetry was evaluated using PC-based FNP grading system that we developed. Mouth asymmetry ratio (MAR) was calculated by comparing tracking pointed lip area centering around vertical midline. Eyebrow asymmetry ratio (EAR) was measured using distance from midpoint of medial and lateral canthal line to low eyebrow point when lifting of eyebrows. Complete eye closure asymmetry ratio (CAR) was estimated using area between point-tracked low eye line and low eyebrow line of the identical distance from medial canthal line. Then, FNP grading score was calculated with weighting for MAR, CAR, and EAR of 5:3:2.   Results   The mean MAR, EAR, CAR, and FGS in group I were 0.93, 0.97, 0.96, and 0.95, respectively. The MAR, EAR, CAR, and FGS demonstrated statistically significant differences among groups. The mean MAR was 0.77 in group II and 0.39 in group III (P=0.001). The mean EAR was 0.87 in group II and 0.74 in group III (P<0.001). The mean CAR was 0.87 in group II and 0.77 in group III (P=0.007). The mean FGS was 0.82 in group II and 0.67 in group III (P=0.001).    Conclusions   The objectively measured MAR, EAR, CAR, and FGS showed significant differences in accordance to the degree of FNP. Further studies for the establishment of objective FNP grading system are needed.


 

TOPIC: Grading Facial Movement

Submitting Author: Susan Coulson

Title: Towards the Development of an International Facial Nerve Registry – Preliminary Findings and future directions

Introduction: To enable future international research collaborations with larger participant numbers to investigate the best practice management of facial nerve paralysis, the development of an International Facial Nerve Registry, such as those that exist in other health conditions (Gliklich etal,2014), is required.   Multidisciplinary patient management maximizes treatment outcomes, however inconsistency remains in reporting. There has been a long-standing drive for consistency of assessment and outcomes recording since agreement was reached by Facial-Nerve- Disorder-Committee of American Academy of OHNS, to adopt t he House-Brackmann Scale (1985). Although it has shortfalls (eg. Coulson etal,2005), this system remains among the most commonly used, alongside Sunnybrook System (Fattah etal,2015). Recent studies have reinforced the need for international agreement and uniformity (Bhama etal,2014; Hadlock,2016; Fattah etal,2014; Santosa etal,2017).   Objective: The aim of this project is to investigate assessment and treatment outcomes used in international multidisciplinary facial nerve centres, and by individual practitioners, with the goal of achieving consensus within the international facial nerve community. The focus will be on physiotherapists, and other allied health professionals. Completion of this component would facilitate the development of an International Facial Nerve Registry to enable international research collaborations with larger participant numbers.   Methods: Data collection formats are based on those used by previous studies, however indepth qualitative reporting with photo/video documentation of individual and multidisciplinary assessment, reporting and treatment practices will provide a comprehensive picture of current practice in the management of facial nerve disorders.   Results: Preliminary findings and future directions will be reported.   Conclusion: Although the goal here would be to achieve a consensus agreement on the broad and specific details of international systems used to document assessment and treatment outcomes at the 13th International Facial Nerve Symposium, LA2017, this research further emphasises the need for standardisation as part of the development of an International Facial Nerve Registry.


 

TOPIC: Grading Facial Movement

Submitting Author: Yasuhiro Abe

Title: A modified Yanagihara grading system for evaluating severe facial paralysis by non-specialists

Introduction: The prognosis for facial nerve paralysis (FNP) with a viral etiology depends on its severity for Bell’s palsy, Ramsey Hunt syndrome or zoster sine herpete. Mild to moderate FNP will usually resolve quickly and without treatment. However, severe FNP requires more intensive, long-term treatment and potentially hospitalization. FNP is typically assessed using the Yanagihara, House-Brackmann, and/or Sunnybrook grading systems. These systems are difficult to use for non-specialists who usually are the first to evaluate patients.    Objective: To create a simpler but accurate grading system for FNP which can easily be used by non-specialists to distinguish mild to moderate FNP from severe FNP. This modified Yanagihara grading system is a pared-down version of the ten-item Yanagihara system using only the two evaluation items of “tight eye closure” and “blowing out cheeks.”    Methods: We treated 490 patients with viral FNP in our department between 2001 and 2015. These patients were assessed using the modified Yanagihara grading system and divided into four groups: Group I, tight eye closure/positive, blowing out cheeks/positive; Group II, tight eye closure/positive, blowing out cheeks/negative; Group III, tight eye closure/negative, blowing out cheeks/positive; and Group IV, tight eye closure/negative, blowing out cheeks/negative. We separately compared these four groups with electroneurography (ENoG) values and complete recovery rates to confirm the validity of our system.    Results: The 108 patients in Group IV exhibited significantly lower ENoG values (23.0%) and complete recovery rates (69.0%) in comparison with the 210 patients in Group I at 56.5% and 98.9%; 98 in Group II at 38.1% and 93.5%; and 74 in Group III at 30.7% and 80.3%. Conclusion: Our modified Yanagihara grading system is a simple method for distinguishing between moderate and severe FNP. This grading system can be used by non-specialists to provide an accurate prognosis and facilitate prompt treatment for severe cases.


 

TOPIC: Grading Facial Movement

Submitting Author: Sjaak Pouwels

Title: A prospective cohort study assessing differences in cosmetic appreciation of lateralization while smiling in patients with a peripheral facial palsy

Objectives   In this study we investigated the differences in cosmetic appreciation of patients with a left and a right peripheral facial palsy (PFP) while smiling.    Methods   The smiling pictures of patients with a facial palsy with House-Brackmann II-VI were reversed as a mirror image and offered as a pair of pictures, together with the true image. Twenty-six patients with a PFP and twenty-four medical professionals familiar with facial palsy were asked to choose the most attractive photograph.     Results   Medical professionals preferred the pictures of patients with a right and left PFP in respectively a mean of 43.00 ± 12.25% and 57.00 ± 12.28% (p=0.005). Patients with a right PFP chose their mirror and true image in 65% and 35% in smiling pictures (p = 0.01). Patients with a left PFP facial palsy chose their mirror and true image in 58% and 42% in smiling pictures (p = 0.02). The House-Brackmann score and age of the patients did not influence preferences of medical professionals and patients.    Conclusion   We have found that medical professionals have a significant preference for pictures of patients with a left PFP. Patients with a left PFP and right PFP significantly prefer their mirror image in smiling pictures.


 

TOPIC: Grading Facial Movement

Submitting Author: Jeremy Corcoran

Title: Insights into agonist-antagonist muscle balance after facial palsy by correlating sub-scores of the Sunnybrook Facial Grading System

Introduction   Facial functions derive from complex interplays of agonistic and antagonistic motor activity within and between the hemifaces.  Facial nerve disorders disrupt the intricate motor patterns, causing dysfunctional communication, feeding and/or eye protection.  Hypertonicity and synkinesis are recognised sequelae of facial palsy.  These can be assessed using the Sunnybrook Facial Grading System (SFGS).  Hypertonicity means that agonists have disadvantageous resting length-tension relationships.  Synkinesis means that antagonistic muscle activity is promoted during purposive facial movement.  By extrapolation, both hypertonicity and synkinesis should correlate negatively with desirable facial excursion.  Such associations have not been delineated.   Objective   To describe the association between voluntary facial excursion and ratings of hypertonicity and of synkinesis.   Methods   A retrospective study of objective facial grading of all patients attending a multi-disciplinary facial nerve clinic in London, UK, since 2014 was undertaken.  The covariances of scores on the ‘Symmetry of Voluntary Movement’ [Excursion] section of the SFGS with scores on the ‘Resting Symmetry’ [Resting] and on the ‘Synkinesis’ sections of the same measure were calculated separately.     Results   A full set of objective ratings, whereby scores for each of the SFGS sections had been recorded, was available for 30 of 258 patients.  The majority of patients had had idiopathic facial palsy.  Pearson’s correlation coefficients derived from covarying Excursion scores with Resting scores were of weak effect (r = - .071).  Similarly, coefficients relating to Excursion and Synkinesis scores represented a weak effect (r = .022).     Conclusions   Correlations involving the Resting scores may be uninformative given that high scores in this section can just as much indicate hypotonicity as hypertonicity.  The correlation between Excursion and Synkinesis is more assured.  The weak effect indicates recovery from facial nerve disorders can result in agonistic activity that may still be able to overcome disadvantageous antagonistic activity, no matter how strong the latter may develop.


 

TOPIC: Grading Facial Movement

Submitting Author: Gerd Fabian Volk

Title: Instruction Video for video recording of facial movement of patients with facial palsy

Background: Photography and video are useful tools to document the severity of a facial palsy and to allow a reliable grading with a standard grading system. Nevertheless, there is so far no international standard for the video recording urgently needed to allow a standardized comparison of patients’ outcome.   Object: Providing a standard for video recording of patients with facial palsy.    Methods: An instruction video on English (https://vimeo.com/203921699) and German was developed. The instruction was shown to the patient and presents in succession several mimic movements. At the same time the patient is recorded while repeating the presented movements using consumer electronics. A variety of facial movements was selected in such a way that it is afterwards possible to evaluate the recordings with standard grading systems (House-Brackmann, Sunnybrook, Stennert, Yanagihara) or even with (semi)automatic software. For quality control, the patients evaluated the instruction using a questionnaire.    Results: The instruction video takes 10 min and 40 and is divided in three parts: 1) Explanation of the procedure; 2) Demonstration and recreating of the facial movements; 3) Repeating of sentences to analyze the communication skills. So far 13 healthy subjects (eight females, five males) and ten patients (seven females, three males) with acute or chronic facial palsy were recorded. All recordings could be assessed by the above mentioned grading systems. The instruction was rated as well explaining and easy to follow by patients and healthy persons.    Discussion: There is now an instruction video available for standardized recording of facial movement. This instruction is recommended for use in clinical routine as well as in clinical trials. This will allow comparing patients intraindividual before and after therapy but also interindividual between different patient cohorts to compare different therapeutic options.   Funded by the Federal Ministry of Education and Research (BMBF), grant No. 16SV7209, IRESTRA.


 

TOPIC: Grading Facial Movement

Submitting Author: Jong Dae Lee

Title: Preliminary study for deep learning-facial grading system : Autonomic facial recognition system assisted-facial asymmetry scale using pre-set facial landmarks

Introduction:    To get more precise and regional measurement be absent in HB grading system without losing fast and high reliability, we planned to use autonomic facial recognition systems to enhance the objectivity without time-consuming for good agreement among clinicians.   Objectives:    The purpose of this study aimed to prove the adaptation of the developed autonomic facial recognition system to measure facial nerve function using pre-set facial landmarks and to show the correlation between the severity of facial palsy assessed by this method and other conventional systems as a preliminary study of deep learning-facial grading system.   Methods:    Six independent facial motions, resting, smile, lip pucker, gentle eye closure, firm eye closure and eyebrow raise were recorded with our system and the images were then analyzed by pre-set facial landmarks using facial recognition software(CLK-II, laonbud, Korea). Each facial expressions had 10-12 linear measurements of facial landmarks, and allocates additional numerical weight to specific region of face to enhance descriptive accuracy. The predicted scores were calculated and compared to the Sunnybrook scale and HB grading system.    Results:     We had proven the usefulness of autonomic facial recognition system assisted-facial asymmetry scale using pre-set facial landmarks. The developed results had good reliability and correlation with other grading systems without time consuming(the Sunnybrook scale (r2 = 0.83) and H–B(r2 = 0.72) grading scales)   Conclusion:    Our objective method shows good correlation with Sunnybrook scale and HB grading system. This study could be used as an application in a variety of electronic devices, including smartphones, tablets and be expected to role as a preliminary study of deep-learning special equipment for facial grading system.


 

TOPIC: Grading Facial Movement

Submitting Author: Katherine Santosa

Title: Photographic standards for patients with facial palsy and recommendations by members of the Sir Charles Bell Society

Introduction: There is no widely accepted assessment tool used by clinicians caring for patients with facial palsy, making exchange of information challenging. Standardized photography is imperative for information exchange and outcomes assessment.   Objectives: To review the literature regarding the use of facial photography in management of patients with facial palsy and to examine practice patterns of Sir Charles Bell Society (SCBS) members regarding the use of photography for documentation of patient examinations.   Methods: A literature search of EMBASE, CINAHL, and MEDLINE databases was performed from their inception to September 2015 to review photographic standards in patients with facial palsy. A cross-sectional survey of SCBS members was performed to examine use of medical photography in documentation of facial nerve function. The survey consisted of 10 questions related to facial grading scales, patient-reported outcome measures, other psychological assessment tools, and photographic and videographic recordings.   Results: In total, 393 articles were identified in the literature search, 7 of which met inclusion criteria. The SCBS member survey had a 55% response rate. All respondents used photographic documentation, and 82% of respondents used some form of videography. There was variation in assessed facial expressions.   Conclusions: There is no consensus on photographic standardization to report outcomes for patients with facial palsy. We propose a set of minimum photographic standards, including 10 static views (repose, small smile, largest smile, brow elevation, gentle eye closure, tight eye closure, lip pucker, lower lip depression, snarl, and nasal base view) and videography of dynamic movements. We hope that such standardization will facilitate communication among providers caring for patients with facial nerve disorders.


 

TOPIC: Head and Neck Surgery

Submitting Author: Maria Grosheva

Title: Parotidectomy for benign lesions: Does the extent of resection matter? Preliminary results of a prospective multicenter trial.

Objective: Benefit of limited approaches in parotid surgery for treatment of benign tumors is still highly controversial. The objective of this prospective multicenter trial was to analyze the morbidity of superficial parotidectomy dependent on the extent of resection.    Methods: From July 2014 to April 2016, 131 patients underwent a parotidectomy for benign parotid lesion in the superficial lobe. The number of dissected main facial nerve branches and the volume of the excised specimen determined the extent of surgery. Postoperative complications and facial nerve function were assessed on the first postoperative day; final prevalence of sialocele was assessed 4 weeks after surgery.    Results: During surgery, 2 main branches of the facial nerve were dissected in 14 (11%), 3 in 25 (19%), 4 in 23 (18%), and 5 in 69 patients (53%). Average specimen´s volume was 22.6±11.0ml (range, 4.0-50.0). Surgery duration increased, though not significantly, with the number of dissected branches (p=.328) and correlated significantly to specimens´ volume (p<.0001). Immediate postoperative complications were evident in 20 patients (16%). There were hematoma / bleeding in 5%, pain / locked jaw in 5%, sialocele in 4%, and wound dehiscence in 1%. In 46% incomplete transient facial palsy was evident. After 4 weeks, 14 patients (11%) presented a sialocele. All postoperative complications, including the transient facial palsy and sialocele, appeared independent of surgery extent (all p>.05). However, the grade of facial palsy was significantly higher in patients with higher number of dissected facial nerve branches (Stennert facial paralysis score, motility, p=.026, House Brackmann, p=.062).   Conclusions: The extent of parotid resection did not influence significantly the prevalence of immediate postoperative complications. However, surgery duration correlated significantly to specimens´ volume and increased with the number of dissected facial nerve branches.


 

TOPIC: Head and Neck Surgery

Submitting Author: Ruben Kannan

Title: Supermicrosurgery-based motor and sensory re-functionalization of the forehead following iatrogenic injury.

Introduction:                The forehead is perhaps one of the most difficult and neglected areas to treat in terms of movement while forehead and scalp sensory neuromas are often treated conservatively. In this study, we assessed the feasibility re-establishing the sensation and motor function of the brow and forehead.    Methods:    In a prospective study over eighteen months, we treated seven patients; four with damage to the frontal branch of the facial nerve and three with evidence of supra-orbital neuromas. The latter was diagnosed with pre-operative nerve blocks. Patients in this cohort were assessed at six weeks, three and six months post-surgical refunctionalization, in terms of the Sunnybrook facial and CADS grading scale for muscle function. Sensory return was evaluated using fine touch and two-point discrimination (2-PD) while the reduction in pain was assessed using a visual analogue score.    Results:    Demographically, there were five males and two females with ages between 23 and 83 years. Those with muscle denervation times longer than 18 months were excluded from this cohort. Using supermicrosurgery, primary nerve coaptations, fascicular nerve flaps and direct neurotisations were performed. Denervation times ranged from 0 to 6 months for the motor nerves and up to three years for the sensory nerves. Relief from neuroma symptoms was almost immediate while sensory function returned within three months. Some motor function was observed by six months post-op; the brow muscles first, followed by the frontalis.   Conclusion:                Supermicrosurgery allows for the repair of the tiny branches of the forehead/scalp (up to 0.3 mm in diameter). Apart from motor re-innervation, this also allows for the surgical management of supra-orbital branch neuromas as a means of treating numbness, chronic headaches and tenderness following forehead/scalp surgeries.


 

TOPIC: Head and Neck Surgery

Submitting Author: SUNIL KUMAR

Title: Extended Cervico-mastoid versus Cervicomastoidfacial incision for parotid surgery

Purpose of the study-   The purpose of this study was to compare the functional and cosmetic outcome of parotid surgery using extended Cervico-mastoid incision with conventional cervicomastoidfacial incision (modified Blair’s incision) with or without sternocleidomastoid obliteration.   Material and method-   In this study patients with parotid tumors who underwent parotidectomy in ENT department in last 2 yrs. were undertaken. The patients underwent parotidectomy via conventional cervicomastoidfacial (modified Blair’s incision) and extended Cervico-mastoid incision with or without sternocleidomastoid obliteration. All the patients were followed for at least 6 months following their parotid surgery. Information on the basis of symptoms, patient satisfaction, subjective Frey’s syndrome, retromandibular and pre-auricular depression and scar was studied on a 0-5 visual analogue scale (VAS), where 0 indicates normal appearance, symmetrical to the opposite side and 5 severe asymmetry, with deep pre-auricular and retromandibular groove with obvious scar. Outcome data were analyzed.   Results-   Total 39 parotid surgeries for benign tumors performed in ENT department. Of these 39 cases, 18 (46%) were operated via cervicomastoidfacial incision without sternocleidomastoid flap reconstruction, 11 (28%) via extended Cervico-mastoid incision with sternocleidomastoid flap reconstruction and 10 cases (26%) were operated via cervicomastoidfacial incision with sternocleidomastoid flap reconstruction. On the basis of VAS satisfaction level in patients operated via cervicomastoidfacial incision without sternocleidomastoid flap reconstruction was less in comparison to patients operated via extended Cervico-mastoid incision with sternocleidomastoid flap reconstruction.    Conclusion-   The cervicomastoidfacial incision is frequently used for parotid surgery which offers excellent exposure to the parotid gland, but leaves a visible scar particularly in the pre-auricular area. Alternatively, for benign parotid tumors, a more cosmetic extended Cervico-mastoid incision can be considered which leaves no visible facial scar. In addition obliteration of parotid defect using sternocleidomastoid muscle flap gives excellent cosmetic as well as functional outcome in terms of distressing Frey’s syndrome.


 

TOPIC: Head and Neck Surgery

Submitting Author: Nelson Lai

Title: Comparison of Blair and Modified Facelift Incisions for Parotidectomy

Introduction   Blair incision (BI) was traditionally used in parotid surgery for better. However, it often leaves a sighted upper neck scar. To avoid the scar, modified facelift incision (MFI) was suggested as the posterior limb was placed along or into the hairline. There are much debates on whether MFI increases the operative time and the complication rates   Objective   To compare the operative time and complication rates of both incisions and to decide whether modified facelift incision can safely be applied to parotid surgery   Methods   We retrospectively reviewed 10-year parotidectomy data from January 2007 to December 2016.  97 parotidectomies were included (37 BI, 60 MFI) for benign parotid lesions after malignant cases and those with simultaneous neck or temporal bone surgery were excluded. Facial nerve monitoring was routinely used for parotidectomy. A suction drain was inserted at the end of the procedure for all cases. Outcome measurements included operative time and complications such as skin flap necrosis, wound collection (hematoma, seroma or sialocele), facial nerve branches palsy, scar (hypertrophic or keloid), ear lobe numbness and gustatory sweating.   Results   60 parotidectomies were performed via a modified facelift incision. The mean age for both groups was 56.68 years. The mean tumor size was 2.90 +/- 1.53cm (2.08 BI, 2.79 MFI). There was no significant difference on age, smoking history, diabetes mellitus and extent of surgery (total or partial) between the two groups. In our review, no statistically significant difference was found between the groups in terms of operative time (240.35 +/- 67.81 min BI, 218.83 +/- 55.83 min MFI) and complication rates although a tendency of shorter operative time (p=0.093)and lower rates of wound collection (p=0.080) were noted with MFI.   Conclusion Modified facelift incision was a safe alternative incision for parotid surgery with comparable operative time and complication rates.


 

TOPIC: Head and Neck Surgery

Submitting Author: WooYeon Han

Title: Quantitative Analysis of Paralyzed Low Quantitative Analysis of Paralyzed Lower Eyelid Elevation Technique : Suspension sling vs Supporting Midcheek Lift

Introduction   Restoration of eyelid aesthetics is a major component of the surgical management of facial paralysis. The author’s experiences for suspension sling and lower eyelid supporting lift using midcheek lift were presented. Quantitative measurement of lower eyelid elevation after surgery were analyzed and compared.   Patients and methods   From January 2014 to December 2016, total of 37 surgeries(26 patients) were performed for established paralyzed eyelid. Mean age was 45.6 (7-80) years old, and mean denervation time was 13.5 (0.2-44) years. Mean follow up period was 407days (31-1010). All surgeries were grouped into 3 groups: Autologous tendon (palmaris longus, plantaris) group (n=9), Mitek (Ethicon, USA) suspension group (n=12), and midcheek lift group (n=16). Distance between center of pupil and lower eyelid margin was measured on photo. The distance ratio of paralyzed side to normal side were analyzed using FACEgram software.   Result   Ratio change for pupil center to lid margin distance in autologous tendon sling group was 0.131 (preoperative ratio 1.264 to postoperative ratio 1.133), in Mitek suspension group was 0.129 (preoperative ratio 1.231 to postoperative ratio 1.102) and in midcheek lift was 0.188 (preoperative ratio 1.234 to postoperative ratio 1.046). (p<0.05) Two patients who underwent Mitek suspension sling suffered from foreign body infection.   Conclusion   Among lower eyelid restoration surgeries in facial palsy patients, ratio change for distance between pupil center and lower lid margin after surgery showed greatest in midcheek lift. Also postoperative lower lid height were restored closest to normal in midcheek lift. Eyelid supporting midcheek lift is a superior in restoration of paralyzed eyelid compared with suspension sling.


 

TOPIC: Head and Neck Surgery

Submitting Author: Callum Faris

Title: Diagnostic Dilemmas In Facial Paralysis, The Role Of Facial Nerve Biopsy, Who, When And Where?

Introduction:   As an adjunct to cross-sectional imaging facial nerve biopsy can be employed to aid diagnosis in facial paralysis. The role of facial nerve biopsy in facial paralysis is poorly documented with only a few case series reported in the literature.   Objective:   We review our experience at the MEEI Head and Neck Oncology and Facial Nerve Center of facial nerve biopsy. We propose a diagnostic algorithm with its inclusion.   Methods:   Retrospective chart review of patients undergoing parotid exploration with planned facial nerve biopsy for diagnosis of facial paralysis at Mass Eye and Ear.   Results:   18 patients underwent parotid exploration with biopsy of the facial nerve. In the 7 cases where a parotid mass was appreciated on repeat imaging, facial nerve biopsy was not additive over biopsy of the mass alone. Where no mass could be appreciated on imaging, parotid exploration with planned nerve biopsy was helpful in securing the diagnosis in the remaining 11 cases. Of these 11 cases, 8 had enhancement of the facial nerve and 3 cases had no abnormality on imaging.   Conclusion:   Where diagnostic investigations have been exhausted, facial nerve biopsy can helpful in revealing the etiology to facial paralysis. Appropriate patient selection is paramount.


 

TOPIC: Neural Transfer Techniques

Submitting Author: Nobutaka Yoshioka

Title: Combined nerve transfers for facial paralysis

Introduction: Various nerve transfers have been used to reanimate paralyzed facial muscles after irreversible proximal injuries to the facial nerve. The author initiated masseteric-facial nerve transfer for facial paralysis in 2009. Since 2013 this procedure has been modified to improve resting symmetry and reduce mass movement.    Objective: To present the case series of seven patients with facial paralysis who underwent reanimation with combined nerve transfers..   Methods: From 2013 to 2016, seven patients with unilateral facial paralysis caused by resection of a brain tumor underwent this modified procedure. The patient ages ranged from 14 to 67 years (mean, 45 years). The average denervation period was 7 months. Six patients had Facial Nerve Grading System 2.0 (FNGS2.0) grade and one had gradepreoperatively. The modified procedure consists of three nerve transfers; masseteric nerve transfer to the main zygomatic branch of the facial nerve, mini-hypoglossal nerve transfer to the lower trunk of the facial nerve with nerve graft, and staged cross-face nerve grafting between the both zygomatic branches that is intended to reconstruct smiling. Secondary neurorrhaphy between the cross-face nerve graft and distal branches of the main zygomatic branch in the affected side was conducted with preserving the previously performed masseteric to the main zygomatic branch neurorrhaphy.    Results: The average follow-up period after the secondary neurorrhaphy was 15months. Four patients showed FNGS2.0 gradeand three showed grade. Most of the patients achieved nearly symmetrical resting symmetry and voluntary elevation of the corner of the mouth without synkinesis. No spontaneous smile was acquired in every patient during the follow-up period.   Conclusions: The combined nerve transfers provide voluntary movement without synkinesis as well as improve resting symmetry. Further follow-up is necessary to evaluate the synchronized movement of the corners of the mouth and spontaneous smiling.


 

TOPIC: Neural Transfer Techniques

Submitting Author: Ji Hyuk Han

Title: Facial reanimation using hypoglossal-facial nerve anastomosis after schwannoma removal

Objective: This study compared surgical techniques for hypoglossal-facial nerve anastomosis after schwannoma removal and evaluated which technique achieves better facial outcomes and less tongue morbidity.   Method: This study included 14 patients who underwent hypoglossal-facial nerve anastomosis after schwannoma removal and were followed for more than 1 year. Three surgical techniques were performed: end-to-end, end-to-side, and split anastomoses. Facial palsy and tongue atrophy after anastomosis were evaluated using the scales suggested by House-Brackmann and Martins, respectively. Tumor volume and the time to surgery were also evaluated, and the effects on facial outcomes were analyzed.   Results: Overall, nine of 14 (64.3%) patients had favorable facial outcomes, and eight of 14 (57.1%) had favorable tongue outcomes. Regarding facial palsy, five of seven (71.4%) end-to-end, three of four (75%) split, and only one of three (33.3%) end-to-side patients had favorable facial function. Regarding tongue atrophy, all three (100%) end-to-side, three of four (75%) split, and two of seven (28.6%) end-to-end patients had favorable tongue outcomes. The effects of tumor volume and time to surgery on facial outcome were not significant.   Conclusion: In this series, the split type hypoglossal-facial nerve anastomosis resulted in more favorable outcomes in terms of both facial function and tongue atrophy.


 

TOPIC: Neural Transfer Techniques

Submitting Author: Ayato Hayashi

Title: Combination of hypoglossal nerve transfer using an interpositional nerve graft with end-to-side neurorrhaphy and masseter nerve transfer for the acute to subacute facial reanimation.

Objective: Nerve transfers are established surgical procedures to treat acute/subacute facial paralysis. However, reanimating entire facial mimic muscles with single motor source could create synkinetic movement.     In this presentation, we report our experience of combining hypoglossal nerve transfer using interpositional nerve graft and masseter nerve transfer to obtain better facial expression separating the movements of the eyelid and the mouth.    Method: The operation was performed on seven patients with acute to subacute complete facial paralysis. The hypoglossal nerve and the interpositional nerve graft was coapted with end-to-side neurorrhaphy (with partial neurectomy) and the other side of the graft was coapted either with end-to-end neurorrhaphy to the facial nerve branches or with end-to-side neurorrhaphy to the facial nerve trunk. The masseter nerve was coapted with end-to-end neurorrhaphy to the buccal branch which selectively innervates around the mouth.   Results: We could obtain good cheek movements from masseter nerve transfer within 5 months without synkinetic movement; however, the movement occurred only when the patients bite and static appearance of the face was not improved at that period. Static tone of the facial mimic muscles has recovered after reinnervation with the hypoglossal nerve occurred, and it took 12 to 17 months after the surgery.    Conclusion: By combining the hypoglossal nerve and the masseter nerve transfer for facial reanimation, we could successfully obtain good facial movements without synkinetic phenomenons. Masseter nerve showed quick and strong recovery; however, to improve the static appearance of the face, another motor source is required. Hypoglossal nerve transfer is effective even with interpositional nerve graft with two end-to-side neurorrhaphies at both edges, however, it took long time to obtain recovery. Each motor source has its own character and we should carefully select motor sources and facial nerves for coaptation in each situation.


 

TOPIC: Other

Submitting Author: Dr. Sharfi Ahmed

Title: Etiology ,clinical presentations and Managment of Lower Motor Neuron Facial Nerve Palsy in Khartoum, Sudan .

ABSTRACT   Facial nerve is the seventh cranial nerve having important function, and hence its paralysis can lead to a great deal of mechanical impairment and emotional embarrassment. Etiopathogenesis of lower motor neuron facial palsy is still a diagnostic challenge and the literature has shown varying results.       Objectives:           This study is designed to sketch out the causes and clinical presentation of LMN FNP presenting to ENT Khartoum teaching hospital in the period from Jan 2014 to Jan 2016.   Materials: This is a prospective, hospital-based study from Jan 2014 to Jan 2016 included 83 patients presenting to Khartoum ENT teaching hospital with LMN FNP. Variables included age, gender, common presentation, diagnosis, treatment and prognosis.    Data was collected by using pre-designed questionnaire, then analyzed by using Statistical package for social science (SPSS).    Results: Eighty three patients included, there age ranged between 3-70 years with high incidence in age group (31-40) years. Two third of the patients were males (61.4%). The main presenting symptoms were sudden onset of facial palsy (67.5%) and progressive onset in  (32.5%). The most frequent causes were Bell's palsy (33.7%) followed by trauma and CSOM (24.1%, 18.1%) respectively. Out of total, 60(72.3%) received steroids, 30(36.1%) received antiviral, 15(18.1%) received antibiotics. All patients were advised to take care of their eyes (88.0%), physiotherapy and rehabilitation (43.4%). Outcome of treatment showed response in different grade forms in 54(65.1%).   Conclusion: The causes of facial nerve palsy in children and adults are many, however idiopathic facial palsy or, Bell's palsy, is the most frequent.


 

TOPIC: Other

Submitting Author: Matteo Alicandri-Ciufelli

Title: Surgical Anatomy of Transcanal Endoscopic Approach to the Tympanic Facial Nerve

Objectives/Hypothesis:    Until recently, tympanic facial nerve surgery had been performed using microscopic   approaches, but in recent years, exclusive endoscopic approaches to the middle ear have increasingly been used, particularly   in cholesteatoma surgery. The aim of this report was to illustrate the surgical anatomy of the facial nerve during an exclusive   endoscopic transcanal approach.   Study Design:    Retrospective video review of cadaveric dissections and operations on living patients in a tertiary university   referral center.   Methods:    Between November 2008 and July 2010, a total of 12 endoscopic cadaveric dissections were performed by an   exclusive endoscopic transcanal approach. All dissections were recorded and stored in a database. In July 2010, video recordings   from those dissections were reviewed, and the anatomic variations and accessibility of the tympanic facial nerve were   studied and noted. Two further video recordings from living patients affected by middle ear chronic disease were also   included in our study.   Results:    In all 14 subjects, the transcanal endoscopic approach guaranteed direct access to the entire tympanic segment   of the facial nerve after ossicular chain removal, allowing decompression of the nerve from the geniculate ganglion and the   greater petrosal nerve to the second genu of the facial nerve. As in microscopic techniques, the cochleariform process and   transverse crest (cog) may represent useful landmarks.   Conclusions:    The tympanic facial nerve can be thoroughly visualized by an exclusive endoscopic transcanal approach,   even in poorly accessible regions such as the second genu and geniculate ganglion. Further clinically based reports may   strengthen our preliminary results.


 

TOPIC: Other

Submitting Author: Sarah Alshami

Title: The Epidemiology and Surgical Outcomes of Facial Nerve Palsy in a Population-Based Cohort

Introduction: Herpes zoster likely plays a causal role in many cases of Bell’s palsy. The incidence of herpes zoster has increased substantially over the last 4 decades.    Objective: We sought to evaluate whether the incidence of facial nerve palsy is also changing over time. We also describe the surgical management and outcomes of facial nerve palsy rehabilitation surgery in an incidence cohort.   Methods: We used the Rochester Epidemiology Project database to search cases of facial nerve palsy in Olmsted County from 2000 through 2010. Of the 1,316 patients identified, 619 patients met our inclusion criteria. The incidence of Bell's palsy and facial nerve palsy in stroke patients was estimated using the age- and sex-specific population figures. The 95% confidence intervals (CIs) for the yearly incidence rates were calculated assuming Poisson error distribution.    Results: Bell’s palsy and stroke were the most common causes of facial nerve palsy. The annual incidence of Bell’s palsy in Olmsted County per 100,000 population was 39.9 (95% CI 36.1-43.7). The annual incidence per 100,000 for stroke resulting in facial nerve palsy was 17.4 (95% CI 14.1-20.6). The incidence of facial nerve palsy due to Bell’s palsy and stroke did not differ between males and females. Compared to an earlier study performed at our institution from 1968 to 1982, Bell’s palsy incidence increased from 25.0 per 100,000 (95% CI 21.7-28.7), a 14.9 per 100,000 absolute increase and a 60% relative increase. 11 of 619 patients (1.7%) required surgical intervention for facial nerve palsy. The most common procedures were gold weight placement, performed in 3 patients, and tarsorrhaphy, performed in 5 of 11 patients.    Conclusions: The incidence of Bell’s Palsy has increased significantly over 35 years. This increase has occurred in the context of increasing rates of herpes zoster infection. Only a minority of patients underwent surgical management.


 

TOPIC: Other

Submitting Author: Hay Mar Htun

Title: Incidental findings on MRI scans of patients with audiovestibular symptoms

Introduction: Magnetic Resonance Imaging (MRI) is considered the gold standard in detecting cerebellopontine angle (CPA) or internal acoustic meatus (IAM) lesions such as vestibular Schwannoma in patients presenting with unilateral audiovestibular symptoms - sensorineural deafness, tinnitus and vertigo. However, vestibular Schwannoma is rare in both patients with audiovestibular symptoms and in the healthy population. It is therefore much more likely for otolaryngologists to encounter the report of an incidental finding in the imaged brain than a vestibular Schwannoma itself.   Aim: To determine the frequency of these incidental findings and to determine the best next steps in counselling and investigations when they arise.   Materials and methods: We retrospectively reviewed all MRI IAM scan reports during a 3 month period at the Radiology department at Blackpool Victoria Hospital, Blackpool, Lancashire, UK, noting relevant IAM and incidental findings.   Results and conclusion: Out of the 109 scans, eight scans were reported to have ‘abnormal’ IAM - one was found to have a small vestibular schwannoma (0.9%) and seven had vascular loops (6.4%). The remaining 101 scans were reported as having ‘normal’ IAM (92.7%). However, two scans needed further action as a deep lobe parotid tumour and an empty sella with benign intracranial hypertension were found (1.8%). 45 of the 101 scans (41.3%) showed various incidental findings such as age related ischaemic changes and small vessel disease, sinonasal disease and benign neurological pathologies. 54 of them (53.5%) were found to be entirely normal.   Our study demonstrated that almost half of the scans were reported with incidental findings albeit only two patients needed further action. Otolaryngologists should have a basic understanding of the significance of the most commonly encountered incidental findings, and be able to appropriately counsel their patients with reassurance or an initial explanation of the implications of the finding and any onward referral.


 

TOPIC: Other

Submitting Author: Andrew Boldyrev

Title: Microvascular decompression for hemifacial spasm. Results surgical treatment of the first hundreds patients in Burdenko Neurosurgical Institute.

Objective: Microvascular decompression (MVD) is an effective and highly accepted method for the treatment of cranial nerve compression syndromes. The aim of this study was to evaluate the results of surgical treatment of 109 patients with hemifacial spasm (HFS), who underwent MVD.   Materials and methods: 109 patients with HFS have been operated in the Burdenko Neurosurgery Institute between June 2003 and May 2016.  There were 21 male and 88 female. Their age ranged from 19 to 68 (median - 49). Intraoperatively we found that the facial nerve root exit zone was compressed by the following arterial vessels: anterior inferior cerebellar artery in 79  patients (72%); posterior inferior cerebellar artery in 5 patients (4,5%); vertebral artery in 11 patients (10%), superior cerebellar artery in 2 patients (1.8%), basilar artery in 2 patient (1,8%) and vein in 1 patient (0,9%). Multiple vascular compression was found in 9 cases (8%),  including:AICA + VA in 3 patients (2.75%), AICA + SCA in 2 patients (1.8%), AICA + PICA in 3 patitents (2.75%), PICA + VA in 1 patient (0.9 %).   Results: Results classified as excellent in 73 patients (67,8 %), good in 35 (32,1 %), poor in 1 (0,9 %). 12 patients have been operated because of recurrence in the period of time from 3 months to 3 years. The complications includes facial nerve paresis in 11,9%, hearing loss in 6,4%, disturbance of V nerve in 4,5%, cerebro-spinal fluid leakage in 5,5%, epidural haematoma in 0,9%. There was no intraoperative mortality. 15 patients have been operated with the usage of the endoscopic assistance, which is helpful for identification compressive vessels, invisible on the operating microscope view.   Conclusion: The microvascular decompression is an effective and safe method of surgical treatment of hemifacial spasm. Endoscopic assistance is useful for MVD in cases with hemifacial spasm.


 

TOPIC: Other

Submitting Author: Sarah Alshami

Title: Outcomes of Scleral Lens Therapy in Patients with Exposure Keratopathy Secondary to Facial Nerve Palsy at a Tertiary Referral Center

Introduction: Scleral lenses can provide excellent therapeutic benefits for patients with exposure keratopathy. Although the use of proprietary lenses in the management of this condition has been described, current literature lacks reports of outcomes of the use of less expensive commercially available scleral lenses to treat patients with exposure keratopathy secondary to facial nerve compromise.   Objective: We describe outcomes of scleral lens therapy (visual acuity and corneal epithelial integrity) in patients with exposure keratopathy secondary to facial nerve palsy.   Methods: A retrospective chart review was performed for patients diagnosed with exposure keratopathy from 2006 to 2016 at our institution. Data were collected regarding age, gender, visual acuity and corneal assessments before and after scleral lens therapy, and duration of use. Of the 69 patients that met our inclusion criteria, 40 patients (45 eyes) completed the fitting process. Complete data was available for 38 patients (38 eyes).  We analyzed improvements in visual acuity (using a paired t-test) and corneal epithelial integrity following scleral lens therapy. Improvements in corneal epithelial integrity were assessed as complete resolution, moderate improvement, or no improvement following scleral lens wear.     Results: The starting visual acuity in the right eye was logMAR 0.50 + 0.3, and after scleral lens wear it was logMAR 0.19 + 0.2 (p=0.0002, n=20). The left eye starting visual acuity was logMAR 0.37 + 0.5, and after lens wear was 0.16 + 0.2 (p=0.12, n=18). All patients experienced at least some resolution of keratopathy; thirty-five patients had complete resolution of exposure keratopathy, and three patients showed moderate improvement. Two patients were lost to follow up. The average duration of wear was 19.4 months.    Conclusions: Commercially available scleral lenses are effective in restoring and maintaining corneal epithelial integrity in patients with exposure keratopathy. Improvements in visual acuity were observed in our patient population.


 

TOPIC: Other

Submitting Author: Takashi Fujiwara

Title: Influence of dose response of steroid in Bell's palsy

Objectives: Steroid is essential treatment agents of Bell's palsy. Some clinical guidelines recommend steroid in Bell's palsy but the dosage of steroid is under debate. The purpose of this study was to evaluate dose-response of steroid in Bell's palsy.    Study design: Retrospective study of patients at a single trial center   Patients: 489 adult Bell's palsy patients, who had steroid within 1 week after disease onset.   Intervention: low dose prednisolone (less than 100mg/day) or high dose prednisolone (100mg/day or more)   Main outcome measure: The rate of non-recovery at 6 months after onset.   Results: 489 Bell's palsy patients were included and overall recovery rate was  10.6%. Non-recovery rate of Bell's palsy was 13.9% in low dose prednisolone and 8.2% in high dose prednisolone (relative risk reduction = 0.41). The relative risk reduction of non-recovery was 0.80 in patients with initial HB(House-Brackmann) score 4, 0.84 in HB score 5 , 0.21 in HB score 6.   Conclusion: The dosage of prednisolone improved the prognosis of Bell's palsy patient.


 

TOPIC: Other

Submitting Author: Alexander Cárdenas-Mejía

Title: CROSS-FACE NERVE GRAFTING FOR SENSITIVITY RECONSTRUCTION OF TRIGEMINAL NERVE

The trigeminal nerve provides sensitivity to most of face. In the past, the sensitivity deficiency as considered acceptable sequel, but the impact in day life activities like chew, swallow, kissing, protective sensation and others, as well as dysesthesia, and neuropathic pain justify the reconstruction.    Medical Research Council Scale, adapted for maxillofacial region is the tool for evaluation, and the primary repair is the gold standard for acute nerve damage if warned.     In case of absence of proximal stump, nerve transfer is a valuable option when healthy nerve recipients: extra-trigeminal and intra-trigeminal for simple nerve grafting or cross face nerve grafting are available.   Case report: 32 years old female, with history of schwannoma resection and secondary left facial palsy and facial sensory impair. Sensitivity examination: left-upper lip: “S0”, rest of left-hemiface: “S1” without neuropathic pain or dysesthesia. Due to central origin, two months after oncological resection three cross-face nerve grafts were done for facial reanimation (zygomatic-zygomatic, buccal-bucal, marginal-marginal), good functional result with blinking and rest/dynamic oral commissure symmetry was achieved, mild synkinesis were documented.      Four years later the patient complains leak of liquids when swallow, difficulty for plosive pronunciation, frequent cheek biting and anesthesia when kiss with sensitivity deficit as the cause. Two cross-face nerve grafts were done for sensitivity recovery (infraorvital-infraorvital and mental-mental). Using superficial fibular nerve as graft end-to-side in the right side, and end-to-end in the left side neurorrhaphy were done. Eighteen months’ follow-up the patient improved sensitivity, reaching “S3+” in left hemi-lip and “S4” in the rest of the left hemi-face, also enhancing in lip continence, pronunciation, sensitivity when kiss and less cheek biting. At present, there are many options for sensitivity recovery in case of trigeminal nerve damage, although prospective studies are needed, the quality of life of patients with trigeminal nerve lesions can be improved.


 

TOPIC: Other

Submitting Author: Aniruddha Patki

Title: Congenital Non-syndromic Facial Palsy in a Newborn

Introduction: We present a case of a newborn with unilateral congenital facial palsy in the absence of any other syndromic features and normal appearance of the inner ear and cranial nerve eight.    Objective: To present a case of a rare clinical scenario with limited reporting in the literature.   Case description: The patient was born full-term with right sided facial paralysis noted at birth, following atraumatic delivery. Some improvement of facial function was noted within the first five months. Imaging of the internal auditory canal and face demonstrated atrophy of right facial muscles and normal appearing vestibular nerves and cochlear nerve. The facial nerve was not positively identified on imaging. The parents were counseled to closely observe the patient, with interventions used as appropriate if inadequate function is present when the recovery plateaus.   Conclusion: The facial nerve is likely hypoplastic rather than absent, given the presence of facial muscle tone. Although cochlear nerve hypoplasia is a well-recognized clinical entity, hypoplasia of the facial nerve is much more rare. Congenital facial palsy in the absence of syndromic features has historically been attributed to perinatal factors including birth trauma, including intrauterine posture, and intrapartum compression. We present here a case where these features are absent.  The literature on non-syndromic congenital facial palsy is reviewed, and demonstrates that either isolated nerve hypoplasia or abnormalities of the facial nucleus may account for this outcome.


 

TOPIC: Other

Title: The role of vascular compression on the brain stem in the surgical treatment of hemifacial spasm.

Objective: Hemifacial spasm (HFS) is an involuntary twitching or contraction of the facial muscles on one side of the face, which is caused by vascular compression of the facial nerve in the cerebello-pontine angle. Microvascular decompression (MVD) is an effective and highly accepted method for the treatment of this disease.   Materials and methods: Between June 2003 and May 2016, 109 patients with HFS have been operated in the Burdenko Neurosurgery Institute. There were 21 male and 88 female. Their age ranged from 19 to 68 (median - 49). MVD of the facial nerve has been performed in all cases.   Results: Results classified as excellent in 73 patients (67,8 %), good in 35 (32,1 %), poor in 1 (0,9 %). 12 patients have been operated because of recurrence in the period of time from 3 months to 3 years. 2 of these patients had no intraoperative signs of compression of the facial nerve. However, the vessels compression on the brain stem was visualised. After separation of these vessels from the brain stem with synthetic pad, the patients had a complete regression of hemifacial spasm.   Conclusion: During microvascular decompression of the facial nerve it is necessary to aspire separation of the vessels from the nerve and the brain stem.


 

TOPIC: Other

Submitting Author: Myung-Whan Suh

Title: Facial nerve stimulation in the narrow bony cochlear nerve canal after cochlear implantation

OBJECTIVES: To evaluate the correlation between a narrow bony cochlear nerve canal (BCNC) and facial nerve stimulation (FNS) after cochlear implantation (CI) and their underlying mechanisms and to predict the risk of FNS preoperatively.   METHODS: A total of 64 pediatric cases that underwent CI were included. Among them, 32 cases experienced FNS after CI, and another 32 cases were selected from 817 pediatric implantees by stratified random sampling. The width of the BCNC, the status of the cochlear nerve (CN) and the internal auditory canal (IAC), T level, and C level were compared and analyzed. Strategies for eliminating FNS were also analyzed.   RESULTS: The FNS group showed a narrower BCNC (1.09 ± 0.52 mm) than the control group (1.99 ± 0.61 mm; P < .01), a lower CN/facial nerve ratio (0.32 ± 0.36) than the control group (1.34 ± 0.76; P < .01), and narrower IAC diameter (4.06 ± 1.71 mm) than the control group (5.66 ± 1.36 mm; P < .01). The FNS group also showed higher T level (165.7 ± 28.3 μA) than the control group (142.2 ± 21.2 μA; P < .01). Adjustment of the C levels and/or pulse width and switching off offending electrodes were attempted to eliminate FNS, with a 75.0% success rate. The FNS group still showed low Categories of Auditory Performance scores (3.00 ± 1.90) compared with the control group (5.94 ± 1.41, P < .01) after adjustment.   CONCLUSIONS: A narrow BCNC could be a cause of FNS after CI. Therefore, careful selection of the side for CI and programming strategies are required to reduce FNS.


 

TOPIC: Other

Submitting Author: Yoon Se Lee Yoon Se Lee

Title: Predicting factors of facial synkinesis after peripheral facial palsy

Introduction    Healing process after facial palsy sometimes enhances involuntary static and dynamic facial asymmetry or movement. Aberrant regeneration after more than axonotmetsis induces such as unwanted simultaneous facial expression and synkinesis. Although the incidence of synkiensis is not so high, substantial numbers of patients with facial synkinesis may suffer from psychological and social problems due to that.    Objective   This study was designed to analyze the factors affecting facial synkinesis after treatment of Bell’s palsy.   Materials and methods   We reviewed the medical records of the patients who diagnosed with unilateral Bell’s palsy and treated with steroid therapy from January to September 2016. Age, gender, hypertension, diabetes mellitus, House-Brackmann grade, additional management methods, recovering period, and initial neural degeneration (ENoG findings) were clinical variables. In addition, we analyzed involving areas of synkinesis.    Results   Among the enrolled 96 patients, facial synkinesis was found in 12 patients. On univariate analysis, incomplete recovery (28.1%) and high House-Brackmann grade (27.6%) at the 1st 1month after treatment were related to occurrence of facial synkinesis. Upon multivariate analysis, incomplete recovery increased the risk of facial synkinesis more than 4 times (p = 0.046, confidence interval; 0.85 – 27.03). Among the patients with complete recovery, synkinesis (+) group presented longer recovery period (6.1 ± 3.5) than synkinesis (-) group (1.51 mon ± 0.25, p = 0.025).   Conclusions   Delayed healing process after facial palsy was risk factor facial synkinesis. This implies the possible relationship between delayed healing and other aberrant facial nerve regeneration.


 

TOPIC: Other

Submitting Author: Adel Fattah

Title: Establishment of a Multidisciplinary Clinic for Moebius Syndrome and Suggested Protocol for Management

Introduction: Moebius and related syndromes are multi-system disorders necessitating the input of many specialties. Families attend numerous appointments and care is fragmented across hospitals and healthcare professionals.    Objective: To establish a multidisciplinary model of care for patients and build a protocol for management. The hypothesis is that this would streamline the number of appointments and facilitate interdisciplinary care.    Methods: A clinic comprising plastic surgery, specialist nurse, speech therapy, facial therapy, psychology and genetics in one room allows multidisciplinary management together with audiology and ophthalmic appointments on the same day. Professionals discuss cases together and a team plan is agreed.    Phenotyping by genetics and plastic surgery confirms minimum diagnostic criteria for Moebius syndrome or make an alternative diagnosis. Families are offered Comparative Genomic Hybridisation array (“microarray”). Whole genome sequencing is available for families on a research basis. A detailed oro-motor history and examination focuses on feeding and airway safety: videofluoroscopy is performed. In older children, formal speech assessment and diagnostic therapy can be provided. Developmental assessment in younger children is performed using the Ages and Stages Questionnaire (ASQ3) and Strengths and Difficulties Questionnaire in over 3’s. Neuro-psychological assessment is performed using WISC-V or WPPSI-II as required. The specialist nurse performs a sleep assessment and provides advice. Facial therapists begin tactile and stretching exercises. MRI scanning is performed to evaluate brainstem morphology.   Results: Objective results demonstrate fewer appointments for families with improved patient experience. It has facilitated understanding of the condition between healthcare professionals and rapid communication to coordinate care. A protocol of management has evolved from this and based on “ABC”-style priorities: airway/breathing, feeding, vision, hearing, speech etc.   Conclusions: A multidisciplinary team centralises experience and facilitates interdisciplinary communication and learning. It provides more efficient care using fewer appointments with greater family satisfaction.


 

TOPIC: Other

Submitting Author: Jocelyne Copeland

Title: Establishing an interdisciplinary team approach to paediatric facial palsy assessment and treatment

Background: Children with facial palsy are evaluated and treated in our plastic surgery clinic.  Historically, limited availability of rehabilitation services and geographic barriers prohibited comprehensive rehabilitation management.  The benefits of rehabilitation therapy in the functional recovery of patients with facial nerve paralysis have been recognized.  As such, the role of occupational therapy role in our facial palsy clinic is evolving.  The journey towards establishing an interdisciplinary team approach is described and reflected upon; future directions are recognized.    Methods:  The plastic surgeons and the occupational therapist treating patients with facial palsy reviewed the practices and processes used in the facial palsy clinic.  Barriers and opportunities towards an interdisciplinary approach were identified and implemented.  These included the introduction of patient reported outcome measures and tele-medicine post-operative therapy sessions.     Results: This presentation documents the evolution of the occupational therapy role in the facial palsy clinic and the process of establishing and incorporating a comprehensive inter-disciplinary approach.      Discussion: Establishing best practices and improving service delivery towards an inter-disciplinary clinic is a journey.  A growth mindset and on-going communication are essential to our learning and development.  In an effort to share our current best practice, we share our processes and discoveries.


 

TOPIC: Other

Submitting Author: Åsa Wiberg

Title: Multidisciplinary Team Approach in Facial Paralysis: The Uppsala Experience

Introduction   Since autumn 2014 we have made a shift of paradigm in the organization and management of facial palsy patients by creation of a multidisciplinary facial palsy clinic. During the first visit patients meet an ENT doctor, plastic surgeon, physiotherapist and a microsurgery co-ordinator nurse to provide an overall evaluation and a patient-centered treatment plan. By this approach we observed an increase number of referrals by 16% from 2014 to 2015 and by 32% from 2015 to 2016. We assessed this new approach by using patient satisfaction survey.   Methods   All first time visits from autumn 2014 to autumn 2016 received a patient satisfaction survey to evaluate the experience after a multidisciplinary team visit at our clinic.   Results   84 first time visits from autumn 2014 to autumn 2016 were evaluated by the team with a response rate to the survey of 87%. The hospitality during the visit was graded as very good or good by 99% and the atmosphere during the visit was graded as very relaxed (4-5 on scale of 1-5) by 96%. The quality of the information received by the patients was graded as good by 86%. Sixty-five % felt that they received complete answers to their questions, and 30% almost complete answers to their questions, respectively.   Conclusion   The use of value-based care in the management of facial paralysis is based on the multidiscipline approach to gather competence around the patient and to provide best possible care.  In our survey we observed a positive feedback from of the patient with simultaneous evaluation by different specialists.


 

TOPIC: Other

Submitting Author: Lovisa Lansing

Title: Bell’s palsy in pregnancy and puerperium

Authors: L. Lansing, E. Marsk, M. Hultcrantz   Introduction: Previous studies have shown an increased risk of being affected by Bell’s palsy during pregnancy, but no convincing data have been put forward. There has also been reported a tendency to a connection between Bell’s palsy and hypertension, diabetes as well as preeclampsia. The risk seems to be higher during the third semester of the pregnancy. The healing of Bell’s palsy among pregnant women has been believed to bee poorer than in non-pregnant women, but no validated studies have been performed.    Objective: To examine the incidence of Bell’s palsy among pregnant women in Stockholm during a 10-years period, to find risk factors for developing Bell’s palsy during pregnancy and the puerperium (in this study 14 days postpartum) and to see how these women heal compared to non pregnant women with Bells palsy.    Methods: Women that have been affected by Bell’s palsy during pregnancy or puerperium in 2005-2015 will be collected by their diagnosis number. Information regarding age, when in pregnancy Bell’s palsy has occurred, associated diseases and healing will be collected.    Results and conclusions: The average age of the women that got affected by Bell's palsy in pregnancy was 31,6 years and in puerperium 32,2 years, compared to the average age of women giving birth in the same time period, that was 31,5 years. The incidence of Bell’s palsy during the 10 year period in Stockholm was 74 (1 in 4054) pregnancies and 19 (1 in 15789) among women in the puerperium (among 300 000 births totally). Of the pregnant women 75 % were affected in the third trimester. Further data will be presented.


 

TOPIC: Other

Submitting Author: Asa Laestadius

Title: Peripheral facial nerve palsy in children in a Borrelia high endemic area: epidemiology and evaluation of clinical recovery. A retrospective one-year follow up

Introduction: Acute peripheral facial nerve palsy (FNP) in children is more common in Borrelia high endemic areas. The incidence is 20-60/100000/year. Prognosis is generally believed to be good with full recovery in 80-100% of affected children. Neuroborreliosis (NB), a tick-borne infection, is the most common identifiable cause and significantly more common in children than adults. Other causes are Varicellae zoster virus or Bells palsy (BP, unknown origin).   Objective: We were interested to identify the incidence, etiology and prognosis in the Stockholm region, a Borrelia high endemic region in Sweden. Clinical description according to the medical charts and two different facial grading scales, the House Brackman (HB) and SunnyBrook (SB) facial grading scales, were used to measure the clinical outcome.   Method: We performed a retrospective study, identifying children, 1-18 years of age, with a diagnosis of FNP through the electronic hospital chart system. Epidemiological data for children visiting the pediatric emergency department was collected during one year 2014-15.    Results: We identified 77 children with FNP with an incidence of 20/100000 children/year. 58% were diagnosed with NB, 42% with BP. NB was common from June-November and more often diagnosed in boys (mean age 6,5 years). On the other hand, BP was diagnosed all year around and more often in girls (mean age 8,9 years). Surprisingly NB was almost only seen in children below 10 years of age while BP were more evenly spread among age groups. Only 3/77 patients had remaining symptoms 3 months after onset. They were all older than 12 years of age, had SB score >83 (max 100) and two had BP and one NB.   Conclusion: We conclude that PFP in children have a general good prognosis. NB dominates in younger age. Our results indicate a slower recovery among older children with BP which should be further investigated prospectively.


 

TOPIC: Other

Submitting Author: Leahthan Domeshek

Title: Anatomic characteristics of supraorbital and supratrochlear nerves relevant to their use in corneal neurotization

Introduction: Corneal anesthesia is disastrous in combination with facial paralysis, leading to opacification and blindness. Surgical corneal neurotization targets the underlying pathophysiology to improve healing potential. Surgical technique may employ end-to-side nerve grafts from the proximal, contralateral, supraorbital (SO) or supratrochlear (ST) nerves to the limbus of the affected eye. This technique preserves contralateral forehead sensation and enhances procedural versatility. We hypothesized that proximal SO and ST nerves contain greater axon counts, providing robust innervation sources for neurotization, despite use of a nerve graft, compared to the distal nerve ends used in direct transfer.    Methods: For each of nine adult cadaver heads, bilateral SO and ST nerves were dissected from the supraorbital rim to the anterior hairline.  For each specimen, the following data were recorded:  the presence of notches versus foramina, horizontal distance from midline at the supraorbital rim, and distance from the exit of each nerve to its first branch point.  Histomorphometric analyses were performed on each specimen’s left SO and ST nerves at the level of the supraorbital rim and at points 3cm and 6cm distally.     Results: One specimen had no identifiable ST nerve on the right.  Four SO foramina, 14 SO notches, 2 ST foramina, and 5 ST notches were identified. The SO is 5mm lateral to ST, on average. The SO branches at 2.4mm from the rim, compared to 7.3mm for ST. Myelinated axon counts were 2- to 6- fold greater at the rim than distally. On average, SO myelinated axon counts are greater than ST counts at all distances from the rim.   Conclusions: The proximal SO nerve is the most robust innervation source for corneal neurotization, with 2-3-fold greater fiber counts than at distal locations, and greater counts than ST nerves throughout their lengths.  This robust innervation source may potentiate improved functional outcomes following neurotization.


 

TOPIC: Other

Submitting Author: Nate Jowett

Title: Steroid Use in Lyme Disease-Associated Facial Palsy Is Associated With Worse Long-Term Outcomes

Objective: The purpose of this study was to determine whether differences in long-term facial function outcomes following   acute Lyme disease-associated facial palsy (LDFP) exist between patients who received antibiotic monotherapy (MT); dual   therapy (DT) with antibiotics and corticosteroids; and triple therapy (TT) with antibiotics, corticosteroids, and antivirals.   Study Design: Retrospective cohort.   Methods: All patients with a prior diagnosis of unilateral LDFP who presented to our center between 2002 and 2015   were retrospectively assessed for inclusion. Two blinded experts graded static, dynamic, and synkinesis parameters of facial   functions using standardized video documentation of facial function.   Results: Fifty-one patients were included. The mean time of assessment following LDFP onset was 15.1 months (range   0.3–84 months). Significantly worse facial outcomes were seen among those who received DT and TT as compared to those   who received MT, most pronounced among those assessed 12 months or later following onset of LDFP (Dynamic—P 5 0.031,   post hoc MT vs. TT: mean difference [MD], 15.83; 95% confidence interval [CI], 1.54–30.13; P 5 0.030. Synkinesis—P 5   0.026, post hoc MT vs. DT: MD, 21.50; 95% CI, 0.68–42.32; P 5 0.043, post hoc MT vs. TT: MD, 19.22; 95% CI, 2.23–36.22; P   5 0.027).   Conclusion: An association between corticosteroid use in acute LDFP and worse long-term facial function outcomes has   been demonstrated. Care should be taken in differentiating viral or idiopathic facial palsy (e.g., Bell palsy) from LDFP..


 

TOPIC: Other

Submitting Author: Yona Vaisbuch

Title: Dehiscent Fascial nerve overhang in stapedotomies - A systematic review

Background   Otosclerosis effects about 0.3% of the papulation, in a friction of those cases there is a chance to encounter facial nerve anatomical variation. In the case of facial nerve overhang and dehiscence, this narrow oval window niche possess two technical challenge to the surgeon. The first is trying to perform a stapedotomy either with a drill or with a laser that is aiming at the foot plate while endangering the fascial nerve that is in a close proximity. The second challenge is to place the piston prosthesis while the vertical angle from the Incus long process to the footplate is blocked and the dehiscent nerve is vulnerable to friction caused by the prosthesis.  When encountering this anatomical variation during stapedotomy procedure, the intraoperative decision making whether to abort the case or to proceed should be based on evidence.     Methods   A systematic review of the literature was conducted searching in PubMed and The Cochrane Library for the terms otosclerosis, stapedotomy, facial nerve, dehiscence, overhang and their synonyms in the English literature up to January 10, 2017.   Results   Fascial nerve overhang is reported to be around 6% and less than 1% with a simultaneous dehiscence of all stapedotomies cases.  We will describe several techniques that can be utilized, from Promontory partial drilling or laser assisted to enable wider oval window niche exposure to prosthesis manipulation.   Conclusion   Proceeding with stapedotomy in the case of partial facial nerve overhang and dehiscence is safe and does not possess significant additional risk to the facial nerve from the stapes prosthesis.


 

TOPIC: Other

Submitting Author: Sofia Lyford-Pike

Title: Predicting the Social Burden of Your Patient's Paralysis and Determining Socially Mediated Treatment Goals

Background: Social reintegration is a primary goal in the treatment of facial paralysis. Currently, no clinical tool assesses the social burden of the condition. This is needed to guide physicians and patients in treatment priorities and evaluate outcomes.  We use the eFACE clinical grading tool for this purpose by correlating it to social perceptions of disfigurement, allowing this grading scale to guide discourse for patients and providers of the social consequences of paralysis. The eFACE is a comprehensive, electronic, clinician-graded facial function scale that improves provider and patient communication and is easy to use. We demonstrate socially mediated eFACE score thresholds for disfigurement that can serve to guide treatment goals.    Methods: Naïve-observers were recruited at the 2016 Minnesota State Fair. They were shown short facial expression videos of unilateral facial paralysis patients representing a range of facial function and eFACE scores. Impressions by observers of disfigurement were recorded and logistic regression and linear regression analyses were performed. An equation for predicting lay person disfigurement ratings was developed from eFACE scores.     Results: We obtained 1,794 responses from 548 participants. eFACE total scores demonstrated excellent correlation with naïve-observer rated disfigurement (R2=0.64). Improved function (higher eFACE score) led to decreased disfigurement.  Disfigurement was a factor of static, dynamic, and synkinesis scores but more heavily weighted on the dynamic function. Threshold eFACE scores for specifically defined disfigurement burden were defined.    Conclusion:  Facial dysfunction from paralysis is correlated to naïve-observer judgments of disfigurement. We present a model to predict the social burden of facial dysfunction using the easily accessible and comprehensive eFACE clinical tool. This presents a tangible method to contextualize the social morbidity of paralysis and use social perception to prioritize and assess treatment.


 

TOPIC: Other

Submitting Author: Sofia Lyford-Pike

Title: The Effect of Facial Paralysis on Interpersonal Trait Inferences by Lay Observers

Background: A significant focus of the reconstructive process is to improve or restore an individual’s social engagement.  This is manifested in daily interactions with others and the ability to form relationships. In daily interactions, individuals are consistently scanning faces, making inferences of personality which, in turn, direct the interest of social interaction. In this domain, individuals with facial dysfunction, such as facial paralysis, suffer significant negative consequences; however, the burden of facial paralysis on social interaction has not been quantified.    Methods: Naïve-observers were recruited at the 2016 Minnesota State Fair. They were shown short facial expression videos of unilateral facial paralysis patients representing a range of facial function and eFACE scores. Participants rated each short smiling clip on a series of trait adjectives that explored the dimensions of nurturance and dominance, based on the Interpersonal Adjective Scale, Revised (IAS-R). This is an established psychological assessment for personality trait inferences. Participants also rated the video clips on attractiveness, disfigurement and competence. Assessments were performed using the eFACE clinical score to represent the degree of facial dysfunction.    Results: We obtained 1,794 responses from 548 participants and demonstrated that facial paralysis influences naïve-observer inferences of personality. Total eFACE score is highly positively correlated with Nurturance, the greater degree of facial dysfunction (lower eFACE score) leads to public inferences of decreased warmth and agreeableness. Total eFACE score is not correlated to Dominance, thus no association was seen between facial dysfunction and public inferences of extraversion.   Conclusion:  Facial dysfunction is correlated to naïve-observer inferences of personality, specifically interpersonal traits valuable for social interaction. This effect is correlated to the clinical function score as measured by the eFACE tool.


 

TOPIC: Other

Submitting Author: Sofia Lyford-Pike

Title: If You’re Happy How Do You Show It?: The Application of 3-D Facial Tracking for Analysis of Spontaneous Smiles Versus Volitional Smiles

Study Objective: To develop a computer program capable of measuring timing and anatomic changes in spontaneous and volitional smiles in order to gain important insight for facial reanimation techniques.   Design: Prospective cohort study   Methods: Study participants were recruited from the 2016 Minnesota State Fair. Participants were excluded from the study if they were less than 18 years old or had a history of facial paralysis. The participants were seated in a booth positioned in front of a laptop computer screen and an Xbox Kinect system, capable of capturing 3-D objects as they move in space. Participants were asked to perform several volitional expressions and subsequently were shown stimuli for spontaneous emotional responses. These were recorded and analyzed for anatomic displacement of landmarks and temporal characteristics.   Results: Two hundred twenty five videos were obtained, all of which captured both volitional and spontaneous smiling expressions. The data was analyzed using the custom software written by our laboratory, the Applied Motion Lab at the University of Minnesota. The different characteristics of anatomic displacement and timing were compared between the two types of expressions. The 3D capture system consistently and reliably captured the facial expression data.    Conclusion: Using the measurements obtained from our video analysis, normative data for spontaneous smiles exists and can be replicated using the computer program created by the University of Minnesota’s Applied Motion Laboratory. Additionally, we demonstrate the reliability of facial expression 3D capture with an easily accessible Kinect system. The different characteristics of the two types of smiles are presented.


 

TOPIC: Other

Submitting Author: Adel Fattah

Title: Defining Moebius Syndrome by Systematic Review

Introduction: Moebius syndrome is an etiologically heterogeneous disorder. At present there is no characteristic gene.  One confounding factor is the variability in the diagnostic criteria used to make the clinical diagnosis. Minimum diagnostic criteria (MDC) as defined by the 2007 Moebius Foundation Symposium are defined as “congenital uni- or bi-lateral non-progressive facial weakness with limited abduction of the eyes”.    Objective: Review the literature to extract phenotypic information to determine the frequency of associated anomalies.    Hypothesis: “Moebius syndrome” comprises a group of closely related disorders with common core features.    Methods: A systematic review was performed using PubMed and the NHS Evidence Databases. To avoid selection bias, inclusion and exclusion criteria were formalized before data extraction/analysis. Inclusion: [MDC fulfilled; case series/report; documented clinical features]. Exclusion: [overlapping case series; inadequate clinical data, foreign language]. Citation retrieval was performed by two authors independently, they subsequently compared selections to establish consensus.    Results: A broad primary search with the terms [Moebius], [Mobius], [Möbius], [sequence], [anomaly], and [syndrome] using permutations of Boolean operators generated a list of 1010 titles. Titles and abstracts were evaluated using the inclusion/exclusion criteria for relevance. Before consensus, kappa statistic was calculated to determine agreement for article retrieval (k= 0.992) indicating clear selection criteria. After consensus, 281 articles were reviewed. Findings include that all patients meeting MDC have a strong correlation with epicanthic folds, swallowing difficulties and abnormal tongue. Poland anomaly occurred in 22%. Meta-analysis of a cohort is underway.   Discussion: A large composite case series was extracted from the literature and analyzed. This study relies on source material accuracy. Nonetheless, given the paucity of large series, it provides useful information regarding the frequency of anomalies in patients reported in the literature. Distinct groups of anomalies cluster together; there is scope for sub-classifying Moebius syndrome pending future genetic studies.


 

TOPIC: Periocular Interventions

Submitting Author: Tuija Yla-Kotola

Title: Eyelid Weightloading in facial palsy: Gold or Platinum?

Introduction   Oculoplastic rehabilitation is one of the main aims of treatment in facial paralysis. Weight lid loading has been for many years a reference method in restoration of eye lid closure and still is one of the most performed procedure in facial palsy. Gold is the most often used metal for lid loading because of its high density, relative inertness, and low ratio of allergic reactions; nevertheless in recent years new materials as platinum, have been introduced.    Objective   Comparison between the two different load materials ,gold and platinum,  is the  main aim of this study.    Methods   All facial paralysis patients operated on between 2004 and 2014 receiving eye lid weight load were included in this study.   Data on each patient was collected by a retrospective review of the clinical files.   65 patients were implanted a total of 121 eye lid weight loads (ELWL), 100 of which were gold ELWL and 21 were platinum ELWL.    Results   Gold weights were significantly longer lasting than platinum chains, p=0,015. There were no significant differences in the ratio of early complications (p=0,37).   35 primary ELWL´s-21 gold (21%) and 4 platinum (19%)- never needed to be extracted.   53 gold (53%) and 8 (38%) platinum ELWL developed either early or late complications over the years.   Mean follow-up time was 4 years (range 1 month to 10 years and eleven months). Re-implantation of weight in eyelids previously operated seems not to have impact on the retaining time of the load.    Conclusion   Both materials showed good outcomes correcting the logophthalmos but gold weights seemed to stay intact significantly longer than the platinum ones.


 

TOPIC: Periocular Interventions

Submitting Author: Osan Ho

Title: The Cosmetic Results of Upper eyelid platinum chain implant in Asian patients for the treatment of lagophthalmos due to facial paralysis

Introduction:     Upper eyelid platinum chain placement is the most common technique for treating lagophthalmos due to facial paralysis. The authors evaluated the cosmetic results of platinum eyelid chain implant placement in an Asian population.     Objective:     To review cosmetic outcomes and complications after platinum chain implant for lagophthalmos.     Methods:     We retrospectively reviewed 11 patients after upper eyelid platinum chain placement from Sept 2011 to Nov 2016. Information recorded included patient demographics, etiology for facial palsy, weight of the implant, associated surgical procedures, intraoperative and postoperative complications and analysis of cosmetic results which were judged by patients and 2 medical officers with no facial plastics training.     Results:     Total of 11 platinum chain implants were placed between September 2011 to November 2016. Of the 11 patients studied, 5 were male and 6 were female. The mean age was 52.9 (range, 24-75 years). The most common etiology for facial palsy was acoustic neuroma. The mean weight of the implant used is 1.36 gram (range from 1.0 to 1.8gram). Only one patient had previously undergone gold weight implantation and complicated by implant extrusion. Other procedures performed together with platinum weight implantation included endoscopic brow lift, division of lateral tarsorraphy and temporal fascia sling. There were no intra-operative complications. Only one case showed prominent implant underneath the skin but no extrusion. Seven patients showed upper eyelid asymmetry after all swelling subsided. All patients reported good improvement in both functional and cosmetic results. The cosmetic rating is significantly improved from the perspective of doctors (from 4.8 to 5.3, p-value=0.002, and from 5.5 to 8.4, p-value=0.003) and have a very good agreement with interclass correlation coefficient of 0.953 for pre cosmetic rating and 0.956 for post cosmetic rating.      Conclusions:  Upper eyelid platinum weight is a safe method with good cosmetic result in treating paralytic lagophthalmos in the series.


 

TOPIC: Periocular Interventions

Submitting Author: Michael Reilly

Title: Impact of eyelid weight placement on synkinesis development and recovery after idiopathic facial palsy.

Introduction:  The definitive indication for performing an upper eyelid loading procedures on a patient suffering from paralytic lagophthalmos is corneal damage.  However, there may be beneficial effects to the placement of an upper eyelid weight or palpebral spring in the prevention of orbicularis oculus synkinesis for patients with incomplete recovery of idiopathic facial palsy.  This study serves to compare the degree of synkinesis and synkinesis recovery in patients who have undergone eyelid loading procedures versus those who have not.   Methods   All patients presenting to the study authors with idiopathic facial palsy persisting for more than 3 months after onsent were considered for inclusion in the study.  The study was limited to those patients with presumed or confirmed viral etiology to their condition.  Sunnybrook Facial Grading System synkinesis scores were recorded for each patient at each office evaluation throughout recovery.  Comparisons were made between the baseline synkinesis scores and rates of synkinesis recovery between the two groups.   Results   Synkinetic muscle activity was identified in all patients with incomplete recovery of idiopathic facial palsy within 3 months of onset.  Baseline synkinesis rates  and long term degree of synkinesis were found to be lower in patients having undergone upper eyelid loading procedures compared to those who did not.   Conclusions   While more study is needed regarding the optimal timing for performing upper eyelid loading procedures. these procedures may indeed prove to have beneficial effects in lowering the degree of synkinesis in patients with incomplete recovery of idiopathic facial palsy.


 

TOPIC: Psychology of Facial Paralysis

Submitting Author: Kathleen Bogart

Title: Psychological Benefits of Support Conferences for Parents of and People with Moebius Syndrome

Introduction: People with Moebius syndrome and other forms of facial palsy face stigma and limited social support. Support groups or conferences that allow others to meet people with similar conditions may help address these concerns.    Objective: To examine whether support conferences provide measurable benefits to parents of and people with Moebius syndrome, a rare disorder that causes facial paralysis. Parents of and adults with Moebius syndrome were predicted to receive different benefits from the conference. Adults with Moebius were predicted to receive psychosocial benefits including increased social comfort, emotional and companionship support, and reduced stigma, anxiety, and depression. Parents of people with Moebius were predicted to gain rare disease self-efficacy, including increased informational and instrumental support, disability self-efficacy, and knowledge about Moebius.   Method: 4 weeks before and 6 weeks after a Moebius syndrome conference, 47 adults with Moebius and 48 parents who did or did not attend the conference completed an Internet survey containing standardized psychosocial questionnaires and open-ended questions about perceptions of the conferences.   Results: In partial support of our predictions, repeated conference attendance was correlated with standardized measures of stigma, social comfort, companionship support, emotional support, informational support, and knowledge in adults with Moebius. For parents, repeated attendance was correlated with rare disease self-efficacy, knowledge, and lower anxiety and depression. Pre-post analyses of standardized measures showed that adults with Moebius received social comfort benefits, reduced stigma and increased knowledge from support conferences, but parents did not show pre-post change. Content analysis of open-ended items revealed facilitators and barriers to conference attendance.   Conclusion: Rare disease support conferences are promising quality of life interventions for facial palsy. Future work should examine ways to provide more low-cost, accessible support avenues, such as regional support groups and online support groups with video conferencing.


 

TOPIC: Psychology of Facial Paralysis

Submitting Author: Kathleen Bogart

Title: Social interaction from the perspectives of people with and without facial palsy

Introduction: Facial palsy results in significant consequences for social interaction.    Objective: Provide an overview of six quantitative and qualitative studies examining the expressive behavior of people with facial palsy, the way others interpret their behavior, and training to improve interactions.    Methods and Results: In Studies 1 and 2, focus groups of teenagers and adults with Moebius syndrome investigated social experiences. Results revealed a range of stigmatizing experiences and resilience. Participants used compensatory expressive strategies such as vocal tone, gestures, and humor. In Study 3, people with congenital facial palsy were found to display more expressivity in their bodies and voices to compensate compared to people with acquired facial palsy. In Study 4, we examined observers’ judgments of the emotions of people with facial palsy to test how observers integrate a paralyzed face with an expressive body and voice. People with severe facial palsy were rated as less happy than people with mild facial palsy, but use of compensatory expressive behavior improved observers’ impressions. In Study 5, educating observers about facial palsy and instructing them to attend to compensatory expressive channels improved their impressions of people with facial palsy, but not their accuracy. In Study 6, teenagers with Moebius syndrome participated in a social skills intervention which improved observer-judged rapport and use of compensatory expression.  Conclusion: Although facial palsy can be highly stigmatizing, people with facial palsy can compensate for their lack of facial expression, and people interacting with them can learn to look beyond the face to some extent. Practical implications for facilitating social interaction will be discussed.


 

TOPIC: Psychology of Facial Paralysis

Submitting Author: Susan Coulson

Title: Perceived Face Value: The Cost of Facial Nerve Paralysis

Introduction During healthcare consultations, patients with facial nerve paralysis (FNP) report that their faces are perceived as less attractive, less happy and less symmetrical than pre-injury.    Objective The aim of this study was to investigate these concerns using observer’s ratings so as to inform patient-centered care.   Methods 35 observers rated 48 smiling faces of photographs with and without FNP using a 7 point scale for perceived attractiveness, happiness and symmetry. These ratings were compared between faces and related to level on the House-Brackmann Facial Grading system.   Results Faces with FNP were rated as less symmetrical (p < 0.001), and although they were smiling, as less happy (p < 0.001) and less attractive (p < 0.001) than unaffected faces. This negative impact was proportionately greater for the rated symmetry (p < 0.001) and happiness (p < 0.001) of female faces. All ratings were related to House-Brackmann severity grade in a linear downwards fashion.    Conclusion Following FNP, faces, particularly those of females, appear less symmetrical, less happy and less attractive than unaffected age and gender-matched smiling faces, in a way that is linearly related to severity of injury. This study adds quantitative reality to patients’ reports of difficulties during face-to-face social interactions, and can inform clinicians in a patient-centered approach to decision-making during healthcare consultations.


 

TOPIC: Psychology of Facial Paralysis

Submitting Author: Jin Kim

Title: Social attention of diverse facial paralysis using eye-tracker for the better treatment of facial deformities

Objectives   To objectively measure the attentional change to diverse facial paralysis using eye-tracking, and to evaluate negative facial perception for the effective treatment of facial deformities.   Methods   Fifty observers viewed images of paralyzed face(Sunnybrook(SB) scale 25-80 for detailed discrimination of facial function) of six type facial expressions. The SMI iViewRED250(SensoMotoric, Inc, Teltow, Germany) eye-gaze tracker recorded eye movements of observers gazing on the face. For the detailed analysis, faces were divided 4 area(affected upper(AU), affected lower(AL), non-affected upper(NU) and non-affected lower parts(NL)). Sequence, dwell time, hit ratio, average fixation, revisits were calculated.   Results   Most observers gazed on central triangle region deviated by their facial deformities. In resting face, wide eyelid(AU), pronounced cheek(AL), corner drooping(NL) gave significant perceptual impact on paralysis deformity. In voluntary movement with muscle excursion, forehead wrinkling(AU or NU), gentle eye closure(AU, NU), open mouth smile(AL or NL) and obvious synkinesis induced negative facial perception depending on their severity of facial paralysis..    Conclusion   Social attention of facial paralysis could be affected by patients’ severity and by some facial expressions. Most of facial deformities increased negative facial perception and their treatment should be focused on any improvement of social perception.


 

TOPIC: Psychology of Facial Paralysis

Submitting Author: Diane Picard

Title: Emotion processing in Bell’s Palsy.

Facial palsy is a common occurrence. Oro-facial functions and the ability to convey emotional facial information are seriously affected by facial palsy, thereby reducing patients' quality of life. The main purpose of the present study was to determine whether peripheral facial deficit is involved in processing emotion, especially facial emotional expression production and recognition. According to the embodied theory, are they any difficulties of emotion perception? The second aim was to understand the influence of the facial palsy side on emotion processing.   To this end, 35 patients suffering from peripheral facial palsy and 133 control participants were recruited. All the participant performed a computerized emotional facial expression recognition task. Facial motor skills, severity grades were estimated. The range of the smile was measured as well. The mirror-effect was tested and specific questionnaires were proposed. Control participants empaneled a naïve jury by completing the same protocol.   Facial emotional expressions of paralyzed patients were not identified as well as actors' by the control participants. Patients' expressions were appraised as less intense and more ambiguous (p < .0001). Therefore, these expressions required a lengthened processing time.    Laterality effect was observed for 37,5% of patients' smiles : smiles are significantly considered more intense when the facial palsy is left-sided. Facial motor deficit hinders facial emotional recognition on dynamic modality (p = .0245), what strengthens the facial feedback hypotheses. Moreover, perception scores are influenced by the duration of the facial palsy: the longer the palsy is, the worse the emotional perception is.   Facial rehabilitation, inspired by Neuromuscular retraining, could be completed by a specific therapy based on the production and the perception of emotional expressions in order to improve nonverbal communication skills of paralyzed patients.


 

TOPIC: Psychology of Facial Paralysis

Submitting Author: Jeremy Corcoran

Title: State anxiety and depression predict societal engagement in patients with facial palsy – correlational research grounded in the International Classification of Functioning

Introduction   Scores on patient reported outcome measures (PROMs), which infer activity- and participation-level functioning [ref. WHO ICF] of patients with facial palsy, have only weak or moderate correlation with objective grading of facial movement.  This indicates that variables beyond neuromusculoskeletal function must influence how patients perceive their ability to engage in daily activities and with the social system.  In many health conditions, activities and participation are more closely associated with mental than physical functioning.  This has yet to be shown in patients with facial palsy.   Objective   To describe the association between select mental functions and PROMs in patients with facial palsy.     Methods   A retrospective study of subjective ratings completed by all patients who attended a multi-disciplinary facial nerve clinic in London, UK, since 2014 was undertaken.  Scores on the Hospital Anxiety and Depression Scale (HADS) were used as surrogates of mental function.  The covariance of these scores and those inferring daily functioning (Synkinesis Assessment Questionnaire [SAQ]; Facial Disability Index – Physical Function [FDI-P]) and social functioning (Short-Form 36 Emotional Well-being and Social Functioning [SF-36 EW/SF]; Facial Disability Index – Social/Well-Being Function [FDI-S]) was calculated.     Results   A full set of subjective ratings was available for 79 of 258 patients.  Within this cohort, facial nerve dysfunction was predominantly idiopathic.  Pearson’s correlation coefficients derived from covarying HADS with activity-level functioning were positive with medium-to-large effects (SAQ, r=.361; FDI-P, r=.483).  Coefficients relating to HADS and participation-level functioning were negative but indicated particularly large effects (FDI-S r=-.831; SF-36 EW/SF, r=-.884).   Conclusion   These analyses indicate that higher levels of anxiety and depression are associated with stronger perceptions of daily facial dysfunction, e.g. in feeding, and with lower self-efficacy in social engagement.  The latter association is particularly strong, reinforcing the emphasis that should be placed on assessing and managing mental function in patients with facial palsy.


 

TOPIC: Quality of Life Studies

Submitting Author: Amr Hamour

Title: Development of the Edmonton Facial Clinical Evaluation (E-FaCE) Scale: A Patient-Centered Outcomes Instrument for Facial Nerve Paralysis

Introduction: Facial nerve paralysis has functional, psychological, and social consequences for patients. Traditionally, outcome measurements for facial nerve injuries have been clinician derived. Recent literature has shown that patient perspective is valuable and necessary in outcomes research. Currently, there are no validated patient-centered instruments that appropriately assess functional and social implications of facial nerve injury.   Objective: This study aimed to identify patient domains of concern and subsequently, to develop a point-of-care questionnaire for clinical use.   Methods: This mixed-methods prospective study was completed in three phases.   In Phase I, 15 facial nerve injury patients interviewed individually. Interviews were digitally recorded, transcribed, then coded with NVIVO software. Analysis led to a conceptual framework detailing the most important quality of life outcomes. During Phase II, a focus group was held with 5 new patients in order to prioritize the outcome domains to a top five list. A second focus group was held with 5 Otolaryngology – Head and Neck staff surgeons to create a 25-item questionnaire based on the five outcomes domains. In Phase III, the questionnaire was administered to 10 new patients to test for comprehension.   Results: Patients identified a total of 16 domains of concern encompassing both functional and psychological deficits related to their facial nerve injury. From these findings, a 25-item Likert-type scale, the E-FaCE scale, was developed for clinical use.   Conclusion: Patients with facial nerve paralysis experience functional and psychological deficits. This study led to the creation of a reliable and feasible 25-item questionnaire that addresses these quality of life implications.


 

TOPIC: Quality of Life Studies

Submitting Author: Daniel Butler

Title: Developing consensus on outcome measurement in paediatric facial palsy

Introduction:   Standardising patient outcome measurement has an important role in improving the quality and value of care offered to patients.  The outcomes selected for inclusion in a standard outcome measurement set should be clinically important, feasible to collect and represent the end result of care.   Objective:   The International Consortium for Health Outcomes Measurement (ICHOM) is a not-for-profit organisation tasked with creating standardised outcome measurement sets for a broad spectrum of medical conditions.  In December 2016, ICHOM began a collaborative process to create a standardised outcome measurement set for paediatric facial palsy.   Methods:   The ICHOM approach involves multiple phases.  In phase one, a multidisciplinary group of 24 healthcare professionals and patient representatives involved in paediatric facial palsy have been brought together by ICHOM.  Through a series of seven teleconferences, each followed by a two-round Delphi process, the contents of the standard set will be agreed upon.  From this, a standard outcome measurement set will be prepared.  In the second phase, ICHOM will support the implementation of routine outcome measurement.   Results:   This project is currently within its first phase, which will be completed in September 2017.  At the time of the Sir Charles Bell Society Meeting, five of the seven teleconferences will be complete and a provisional standard set created.  We propose a panel discussion lead by the core working group (TAH, GB, AOG) to follow-on from an oral presentation (DB) on the ICHOM process and the provisional contents of the paediatric facial palsy standard set.   Conclusion:   Creating agreement upon the outcome measurements that matter most to children with facial palsy will have an important role in optimising care in these patients.  The ICHOM approach of multidisciplinary healthcare professionals working with patient representatives through a structured process is facilitating the creation of a standardised outcome measurement tool for this patient group.


 

TOPIC: Quality of Life Studies

Submitting Author: Carien Beurskens

Title: The person behind the palsy

Introduction: Facial palsy is a disfiguring disease that, apart from being a physical disorder, adversely affects the patient’s psychosocial status. Anxiety, depression and decreased quality of life are seen among patients with facial palsy and many studies have shown the prevalence of psychosocial stress in patients facial palsy. However, less is known about the prevalence of anxiety and depressive disorders in patients with facial palsy.   Objectives: The aim of this study is to assess the prevalence of anxiety and depressive disorders in patients with facial palsy and to investigate possible differences between patients with a left- or right-sided facial palsy.   Methods: Fifty-nine patients with facial palsy and 59 healthy individuals were included in this study between March and December of 2014. The Hospital Anxiety and Depression Scale was used to assess the prevalence of anxiety and depression among these groups.   Results: The mean age of the patients and controls was 56 ± 15 and 40 ± 16 years, respectively. Twenty-eight patients had left-sided, 30 patients had right-sided facial palsy, and one patient had bilateral facial palsy. In the patient group, approximately 30% had anxiety and 25% had a depressive disorder. Compared with the control group, significantly more patients presented with mild anxiety (p = 0.031), mild depression (p = 0.047), and moderate depression (p = 0.006). No significant differences were found in terms of the prevalence of anxiety between left- and right-sided facial palsy. However, significantly more patients with left-sided facial palsy had mild depression (p = 0.018) than those with right-sided facial palsy.   Conclusion: This study found a significant difference in anxiety and depression between patients with facial palsy and healthy controls. No clinically significant difference was noted in the prevalence of anxiety or depression between patients with left- and right-sided facial palsy.


 

TOPIC: Quality of Life Studies

Submitting Author: Jin Kim

Title: Quality of life differences in patients with right- versus left-sided facial paralysis: Universal preference of right-sided human face recognition

Introduction: We investigated whether experiencing right- or left-sided facial paralysis would affect an individual’s ability to recognize one side of the human face using hybrid hemi-facial photos by preliminary study. Further investigation looked at the relationship between facial recognition ability, stress, and quality of life.   Materials and methods: To investigate predominance of one side of the human face for face   recognition, 100 normal participants (right-handed: n Z 97, left-handed: n Z 3, right brain dominance: n Z 56, left brain dominance: n Z 44) answered a questionnaire that included hybrid hemi-facial photos developed to determine decide superiority of one side for human face recognition. To determine differences of stress level and quality of life between individuals experiencing right- and left-sided facial paralysis, 100 patients (right side:50, left side:50, not including traumatic facial nerve paralysis) answered a questionnaire about facial disability index test and quality of life (SF-36 Korean version).   Result: Regardless of handedness or hemispheric dominance, the proportion of predominance of the right side in human face recognition was larger than the left side (71% versus 12%, neutral: 17%). Facial distress index of the patients with right-sided facial paralysis was lower than that of left-sided patients (68.8  9.42 versus 76.4  8.28), and the SF-36 scores of right-sided patients were lower than left-sided patients (119.07  15.24 versus 123.25  16.48, total score: 166).   Conclusion: Universal preference for the right side in human face recognition showed worse psychological mood and social interaction in patients with right-side facial paralysis than


 

TOPIC: Quality of Life Studies

Submitting Author: Yang-Sun Cho

Title: Prevalence and associated factors of facial palsy and life style characteristics: Data from the Korean National Health and Nutrition Examination Survey

This investigation evaluated the prevalence of facial palsy in South Korea based on survey data obtained from the 2010 to 2012 Korea National Health and Nutrition Examination Survey (KNHANES) and to investigate associated factors. In addition, we assessed the life style characteristics of participants with facial palsy. KNHANES is a cross-sectional survey of the civilian, non-institutionalized population of South Korea (n=23 621). A field survey team that included an otolaryngologist performed physical examinations and interviews.    Among the population over 1 years of age, the prevalence of facial palsy over House- Brackmann grade III was 0.12 % (95% CI, CI, 0.07% – 0.17%). Facial palsy was more prevalent in women (p = 0.01) and the prevalence rate increased with age (p < 0.001). In participants aged 19 years or older, age, gender, history of cardiovascular disease and the serum total cholesterol level were associated with facial palsy in multivariable analysis. Besides, the individuals with facial palsy complained of a lower quality of life and they were restricted in their daily activities and had higher rate of depressive mood in univariable analysis.   In summary, facial palsy is a rare condition in general population in South Korea. Considering the significance of facial expression in psychosocial activities, public acknowledgement and further intervention are required for management of this distressing condition.


 

TOPIC: Quality of Life Studies

Submitting Author: Sjaak Pouwels

Title: Quality of life before and after different treatment modalities in peripheral facial palsy: a systematic review

Objectives    A systematic review was conducted to investigate the effect of peripheral facial palsy (PFP) on the Quality of Life (QoL). Secondly, we investigated if different treatment modalities influence the QoL of patients with PFP.   Methods    A multi-database systematic literature search was performed using the following databases: Pubmed, Embase, Medline, and The Cochrane Library from the earliest date of each database up to August 2015. The inclusion criteria were either prospective and/or retrospective cohort trials and/or case series measurement of QoL before and after treatment, patients with PFP (irrespective of aetiology), and various treatment modalities (medication, physical therapy, botulinum toxin injections, and several types of surgical procedures). Two authors rated the methodological quality of the included studies independently using the ‘Newcastle – Ottawa Quality Assessment Scale’ for nonrandomised studies’ (NOS).   Results    Two hundred and fifty-eight studies were found of which fourteen studies met the inclusion criteria. Most studies were assessed to be of ‘fair’ to ‘good’ methodological quality. The Cohen’s kappa (between author RL and SP) was 0.68. Eight different questionnaires were used to measure QoL, of which the FaCE scale was used most frequent. After different modalities, all studies showed significant improvements in terms of QoL.    Conclusion    This study has found significant improvement when measuring the quality of life before and after different treatment modalities in patients with peripheral facial palsy. Future research should focus on patients with PFP due to the same aetiology and use of valid QoL instruments for outcome measures.


 

TOPIC: Quality of Life Studies

Submitting Author: Marta Beranuy Rodriguez

Title: QUALITY OF LIFE AND FACIAL PALSY IN A PATIENT SAMPLE INTERVENED OF AN ACOUSTIC NEUROMA

INTRODUCTION   There are a few published studies that evaluate the quality of life (QoL) in patients with acoustic neuroma (AN) undergoing surgery, and there are more scarce those  using an specific and validated instrument that evaluates the impact in QOL of patients suffering facial palsy (FP).    OBJECTIVE   Evaluate the impact of FP on QoL in patients with AN undergoing surgery that perform a facial rehabilitation program (FRP)   MATERIAL AND METHODS   34 patients (13 men and 21 women), ages ranging between 48+/-11.9  and  50+/-12.6  years respectively were evaluated. 41% of the patients had a medium AN. Retrosigmoid way was the most commonly approach used (73.5%). The 26% of the patients needed an ocular intervention (cantoplasty or eyelid spring surgery)   All patients underwent a program of reeducation of facial muscles consisting in 10 sessions of 1 hour, 2-3 times/week.  Botulinum toxine infiltration was considered in all patients in the 6th session. The Facial Clinimetric Evaluation (FaCE) Scale was used before, during and after FRP   RESULTS   Younger patients had a greater deficit in social relations compared with older patients (p< 0.05). There wasn’t a significant correlation between facial deficit and social function. There were no statistically significant differences between genre and perception of QoL. The facial mobility, the oral function and the ocular comfort were the parameters that most affect the QoL. The oral function was directly related with a deficit in social relations.    CONCLUSIONS   The FaCE Scale is the most practical and specific tool to evaluate the impact of FP in QoL. Treatment of the young patients should be prioritized.  Despite the fact that young patients showed a deficit in social relations, this was not associated with the severity of FP. The greatest discomfort was found at the oral and ocular functions, factor to take into account before starting the treatment.


 

TOPIC: Quality of Life Studies

Submitting Author: Michael Reilly

Title: The Impact of Facial Paralysis on Personality Perception

Introduction:  Human beings are judged throughout life based on many perceived characteristics and personal qualities conveyed by their faces.  The term facial profiling has been used to describe this act of determining personality attributes through visual observation.  The purpose of this study is to link this concept to the condition of facial paralysis and to evaluate and quantify the changes in personality perception that occur after facial paralysis.    Methods   This study was a retrospective evaluation of preoperative and postoperative photographs of 20 patients who suffered from facial paralysis.  The 40 photographs (20 pre/20 post) of these patients were split into 4 groups, each with 5 images of unilateral paralysis and 5 images of the patient's unaffected side mirrored on itself to best approximate the patients' pre-condition facial appearance.  The same patient’s pre and post op photos were not included in any single group in order to avoid any recall bias.  Independnet observers rated each photo for 6 personality traits, as well as for attractiveness and masculinity or femininity.  The raters were blinded as to the intent of the study.     Results   Each of the eight traits was evaluated with a two-tailed t test  that revealed differences in the perception of the paralyzed faces versus those that had been altered to appear without paralysis.   Conclusion   Facial paralysis changes the perception of patients by those around them.  We believe there has been limited research and funding for this condition based on the lack of understanding of how dramatically this condition can affect the way a patient is perceived by society.  The data in this sample population demonstrate a significant alteration in perceived likability, social skills, and attractiveness, among other traits.  This is the first study to evaluate these broader outcome measures after facial paralysis.


 

TOPIC: Quality of Life Studies

Submitting Author: James Kim

Title: Speech and Communication in Patients with Facial Paralysis

Introduction: Facial paralysis causes a variety of functional and aesthetic consequences, affecting oral competency, expression of emotions, speech, and psychological wellbeing.  Patient-reported, quality of life assessment instruments are routinely used in both research and clinical settings to quantify the impact of these consequences on daily life.   Although problems with speech and verbal communication in facial paralysis are frequently noted by both patients and clinicians, there has been little research quantifying the impact of facial paralysis on verbal communication.    Objective: To describe how facial paralysis affects verbal communication using a patient reported outcome measure.  Secondarily, we sought to correlate changes in verbal communication with a disease-specific quality of life measure.    Methods: A national survey of patients with facial paralysis was conducted.  All participants completed the CPIB Short Form Questionnaire, which is a validated, patient-reported quality of life assessment instrument that measures the degree to which a patient’s condition affects his or her participation in various speaking situations.  These data were compared to patient groups with known verbal communication impairment, as well as a control group without such impairment.  CPIB scores were correlated to the FACE scale, which is a facial paralysis specific, quality of life instrument that provides a comprehensive evaluation of functional disability in facial paralysis.   Results: Data collection is ongoing at this time. We hypothesize that the CPIB will add valuable information regarding a critical, but sometimes overlooked sequelae of facial paralysis.     Conclusion: Problems with speech is an important consequence of facial paralysis that significantly impacts quality of life.  The CPIB is a useful tool to evaluate the impact of speech related symptoms in facial paralysis patients, and offers comparisons to groups of patients with other diagnoses.  We suggest that this simple 10-item survey can be quickly incorporated into prospective data collection at facial paralysis treatment centers.


 

TOPIC: Quality of Life Studies

Submitting Author: Katharina Geißler

Title: Improvement of patient-reported motor disabilities and psycho-social well-being in patients with chronic facial palsy by EMG biofeedback training

Introduction: Patients with chronic facial palsy not only suffer from their facial movement disorder, but also from social and psychological impairments. In our Facial-Nerve-Center we offer a two-week-course of intense EMG and video biofeedback training for patients with a stable chronic facial palsy with motor deficits and synkinesis. The therapeutic objectives are improvement of facial symmetry and mobility and systematical relaxation.   Objective: To quantify the therapeutic effect by patient-reported outcome measures (PROMs), assessed by the quality-of-life Short-Form 36 Item Questionnaire (SF-36), and the facial palsy specific instruments Facial Clinimetric Evaluation Scale (FaCE) and Facial Disability Index (FDI).   Methods: All 121 patients treated between October 2012 to December 2016 were asked to fill out the questionnaires before (T1) and after training (T2). To compare T1 with T2 paired-samples t-tests were used and effect sizes (eta²) were calculated.   Results: 60 patients (77% female, mean age: 49) filled out the survey at T1 151±66 days (median±standard deviation) before the training (minimum 20 days; maximum 314 days) and at T2 207±77 days after the training (minimum 7 days; maximum 540 days). Three of these patients (5%) received additional injections of Botulinumtoxin A to reduce synkinesis during the observed period of time; 57 (95%) received no additional treatment specific for facial palsy. The total FaCE score improved by 13% (p<.001,eta²=.202), and the subscale social function of FaCE by even 18% after training (p<.001,eta²=.202). Furthermore, medium effect sizes were found for the FDI total score and the subscale physical functions, the FaCE subscales facial movement score, facial comfort score, and oral function score, as well as for the score of mental well-being in the SF-36 (all: ps<.001, eta²>.070). Conclusion: Even though our short intense EMG and video biofeedback training primarily targets motor deficits, strong increases in psychosocial well-being are measured by different PROMs following the training.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Austin Hembd

Title: Correlation Between Facial Nerve Axonal Load and Age and its Relevance to Facial Reanimation

Introduction: Two­-stage facial reanimation procedures with a cross-­facial nerve graft often yield unpredictable results in the older patient. Although the cause of result variability is likely multifactorial, some studies suggest that increased donor nerve axonal load improves function of a free muscle transfer after a cross-­facial nerve graft. However, strong studies characterizing the relationship between age and facial nerve axonal counts do not exist.    Objective: By characterizing that relationship, this study attempts to provide a possible explanation for the variable results in the aging patient.      Methods­: In the largest study of its kind, 63 fresh, cadaveric heads were dissected to expose the facial nerve. For each hemi­-face, two facial nerve samples were taken: one proximal as the nerve exits the stylomastoid foramen, and one buccal branch sample at a point 1-cm proximal to the anterior parotid border, a donor location previously described as having appropriate donor axonal load. 252 nerve samples were stained and quantified. Correlation analysis was completed using a Pearson's correlation coefficient.   Results­: 36 females and 27 males were dissected with an average age of 71 (age range 22-­97). At the proximal (r = -.26; p< .01; n=104) and distal (r= -.45; p<.001; n=114) sampling points, there was a significant negative correlation between age and axonal load.   Conclusion­: As age increases, the axonal load of the facial nerve decreases. These results indicate that decreasing axonal load could be a contributing factor in the variable outcomes of cross-facial grafting in the elderly. Moreover, this underscores the importance of recruiting more donor axons in attempting to improve facial reanimation in the older patient.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Austin Hembd

Title: Facial Nerve Anatomic and Axonal Analysis: Optimizing Axonal Load for Cross Facial Nerve Grafting in Facial Reanimation

Introduction: Donor nerve axonal count over 900 is associated with improved outcomes in facial reanimation with free functional muscle. However, where along the facial nerve to coapt a nerve graft or muscle to in order to achieve this axonal load is unclear.    Objective: We measured axonal counts of facial nerve zygomatic branches at multiple points to determine the ideal location for optimizing axonal load, thus maximizing donor axon input in facial reanimation surgery.  Methods: 28 fresh unpreserved cadaveric hemi-faces were dissected to expose the extracranial facial nerve branches. Zygomatic branches were harvested in 2 cm sections from the pes anserinus distally, noting their position relative to the zygomatic arch, posterior border of ramus, lateral border of zygomaticus major and anterior border of parotid gland. Nerves were fixed, sectioned, stained with SMI-31 anti-neurofilament stain, and digitally analyzed for axonal counts.   Results: The mean number of axons in the facial nerve at the pes anserinus was 4220. All specimens had one or more intraparotid zygomatic branches with over 900 axons, and 96% had an extraparotid branch with over 900 axons. The likelihood that a zygomatic branch would have over 900 axons at its last intraparotid point (mean 6mm posterior to parotid border) was 92%. By contrast, this likelihood was only 61% when sampled at the first extraparotid point (mean 14mm anterior to parotid border). The cross-sectional area of a branch was positively correlated to its axonal count (R² = 78%, p=<.0001), with nerve diameter over 0.6mm predicted to have over 900 axons.   Conclusion: Branches with adequate axonal load were found in all specimens. The likelihood of selecting an adequate branch improved from 61% to 92% when dissected intraparotid. Nerve diameter positively correlated with axonal load.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Austin Hembd

Title: The Deep Temporal Nerve Transfer: An Anatomical Feasibility Study and Implications for Upper Facial Reanimation

Introduction: Facial paralysis has a profound impact on the brow, and currently static procedures are the mainstay to restore its position. The deep temporal branches of the trigeminal nerve, given their proximity to the brow, may serve as possible donor nerves for both potential innervation of a free muscle transfer in cases of prolonged facial palsy or nerve transfers in cases of acute or sub-acute facial palsy.   Objective: We present the detailed surgical anatomy of the deep temporal nerve to assess the feasibility for both functional muscle transfer and nerve transfer including a proposed surgical technique.   Methods: Thirty cadaver hemi-faces were dissected to establish deep temporal nerve anatomy. In addition, axon counts were performed.   Results: Two (53%) or three (47%) divisions of the deep temporal nerve were noted with the most consistent division being the middle division (30/30 specimens). This division was consistently found approximately 4.1 (3.7-4.5) cm anterior to the tragus at the level of the zygomatic arch. For each 1cm cranial to the arch, the nerve courses approximately 1mm posteriorly. The number of axons in the proposed temporal branch is 1469 as it emerges from the behind the zygomatic arch, 889 at 1cm, 682 at 2cm, 534 at 3cm, 355 at 4cm, 377 at 5cm, and 256 at 6cm.   Conclusion: Given its anatomic consistency and expendability, the middle division of the deep temporal nerve is a viable donor nerve for dynamic upper facial reanimation with either nerve transfer or functional muscle transfer, depending on the duration of facial palsy.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Teresa O

Title: Autologous gracilis and semitendinosus tendon and fascia – an alternate source for static rehabilitation of the paralyzed face

Importance: Rehabilitation of facial symmetry is necessary for restoration of oral competence, nasal valve collapse, eye closure, and normal lacrimation.  We propose a new and minimally invasive approach to harvesting autologous gracilis and semitendinosus tendons for static suspension. Unique to these tendons is their ability to regenerate after harvest, compared to other previously described autograft materials. The procedure is commonly performed and well known in the orthopaedic literature. By translating the technique into the head and neck literature, we provide another source of autologous material for static suspension.   Objective: To describe a novel autologous graft source and minimally invasive harvest technique or static suspension of facial paralysis.   Design: Four patients with flaccid facial paralysis underwent primary or adjuvant static suspension using autologous gracilis and/or semitendinosus tendon and fascia. Harvesting the allograft uses a minimally invasive technique via a small popliteal incision when harvested alone or via the same medial thigh incision as an adjunctive procedure during gracilis free muscle transfer.   Main outcomes and measures: We hypothesize that autologous gracilis and semitendinosus tendon/fascia graft harvest can be safely and efficaciously utilized for static facial suspension. Main outcomes measured included patient satisfaction, postoperative complications, follow-up, and improvement in smile symmetry.   Results: Four patients underwent harvest of hamstring tendon allograft for either primary or adjuvant use. The semitendinosus tendon was harvested in three patients, while both were used in one patient. In one patient, the same medial thigh incision was used during the gracilis muscle harvest. All patients had restoration of resting symmetry, and maintenance of nasal alar position with dynamic smile.   Conclusions: Autologous semitendinosus and gracilis fascia/tendons provide a safe, alternative choice in rehabilitation of facial paralysis. The harvest is straightforward, minimally invasive, and the graft provides excellent tensile strength, length and shape with minimal donor site morbidity and even regenerative potential.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Shai Rozen

Title: Implications of Intracranial Facial Nerve Grafting in the Setting of Facial Reanimation

Introduction: Intracranial facial nerve grafting can be performed after intracranial tumor extirpation that requires nerve resection. Results, while dependent on multiple factors, can vary from complete palsy to varying degrees of tonicity, synkinesis, effective motion, and ocular protection.   Objective: Evaluate the varying degrees of facial reanimation by facial region after intracranial nerve grafting and identify implications for future facial reanimation and pre-operative consultation.   Methods: Between the years 1997-2012, twenty-seven patients underwent intracranial nerve grafting after tumor extirpation. Of the 26 candidates, 14 completed evaluations. All patients were prospectively evaluated and scored with Facial Disability Index (FDI), and two regional grading systems - Facial Nerve Grading System 2.0 (FNGS 2.0), and SunnyBrook Facial Grading Score (SFGS). Additionally, all patients underwent photos and videography to assess quality of motion and tonicity in repose. Demographic and surgical variables were analyzed as to their possible effect.   Results: The average age was 43 (22-66). The average time interval between nerve grafting to evaluations was 44 months (12-146). Average total FDI was 67.5%. FNGS 2.0 demonstrates best outcomes in Eye and Oral Commissure portions and worse in Brow and Nasolabial fold and final FNGS 2.0 grade average was 4.3 (1-5) i.e. moderately severe dysfunction. The SFGS reveals 64.3% have oral resting symmetry, but only 28.6% resting symmetry in eye and nasolabial fold. Symmetry in voluntary movement revealed gentle eye closure and lip pucker as best – 3.6 and 3.0 respectively, while brow lift as worst - 1.0 and open mouth smile at 2.0 (5-25). Total synkinesis score averaged low at 3.6 (0-15).   Conclusion: Intracranial nerve grafting does not provide consistently good facial animation but may provide periocular protection, although not symmetry. It does afford good symmetry of the midface in repose, thus potentially improving results of midface reanimation surgery by providing improved tonicity with minimal synkinesis.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Wei Wang

Title: Masseter nerve based comprehensive reanimation strategy for early stage facial palsy

Masseter to facial nerve transfer has been preferred for early stage facial reanimation due to its superiority in the abundance of nerve fibers, vicinity in location and reliability of outcome. In contrary to the verified improvement in smiling symmetry, improvement in resting symmetry varies greatly from case to case.    This study was designed to understand the effectiveness of masseter nerve transfer on the improvement of resting symmetry and to come up with a comprehensive reconstruction scheme.   35 cases of facial palsy patients reanimated by masseter nerve transfer were included in a retrospective study. Facial symmetry both at rest and during facial expression were evaluated before and after the procedure during follow-up visit. Different combinations of reanimation procedures were applied based on this result and evaluated for postoperative resting symmetry.   Our retrospective study of 35 cases suggested that a single procedure of masseter nerve transfer is effective in restoring smiling symmetry with an efficacy rate of 93%. Despite the statistical significance of resting symmetry improvement, this procedure has limited effect on resting symmetry restoration with an improvement of resting scoring from 1 to 0, 2 to 3, or no improvement in patients with preoperative score of 4. Based on this result, a comprehensive restoration scheme was suggested: masseter nerve transfer for patients with preoperative resting score 1; masseter nerve transfer +fascia sling for score 2 or 3; masseter nerve transfer + fascia sling + facelift with High SMAS for score 4. A postoperative evaluation with follow up time over 12 months suggest significant improvement in both smiling and resting symmetry.   Masseter to facial nerve transfer has limited effect in improving resting symmetry despites its effectiveness in smiling symmetry restoration. A comprehensive and individualized restoration scheme should be planned based on preoperative resting symmetry.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Wei Wang

Title: Symmetry restoration at rest after masseter-to-facial nerve transfer: Is it as efficient as smile reanimation?

Masseter-to-facial nerve transfer is a highly efficient technique for   reanimating paralyzed muscle and has been reported to restore facial symmetry at   rest. However, no systematic studies have been performed, and the effects of   preoperative droop oral commissure on postoperative symmetry at rest have rarely   been reported.   The authors retrospectively analyzed 35 patients with masseteric-facial nerve   anastomosis and assessed the quality and quantity of the dynamic recovery and the   oral commissure symmetry at rest. The dynamic and static effects were then   compared.   All of the patients' Terzis scores were increased post-operatively, and over   half of the patients presented restored symmetrical smiles (Terzis scores of 4 or 5).   The postoperative symmetry scale of oral commissure at rest improved in 18 of 35   patients. Both the mean postoperative AD-OCE (altitude difference of oral commissure   excursion) and the postoperative AD-OCP (altitude difference of bilateral oral   commissure position) were decreased compared to preoperative values. The   preoperative symmetry had a significant effect on the postoperative AD-OCP. The   effects of the dynamic and static symmetry improvements were transformed to a   comparable factor "α". The dynamic α was significantly greater than static α.   Masseter-to-facial nerve transfer is a reliable technique for smile   reanimation. However, it has only a limited effect on the improvement of symmetry at   rest. Assessing the preoperative symmetry of oral commissure at rest can be used to   predict postoperative outcomes, and patients with severely droop oral commissure   (symmetry scale III or IV) should receive static suspension.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Heloisa Juliana Zabeu Rossi Costa

Title: Neural chemical repair in late injuries of the facial nerve

Purpose of the study: Accident victims with severe injuries of the facial nerve, most of the times have to be clinically stabilized before the nerve anastomosis procedure. Our project tested neural chemical repair (based on the plasma membrane restoration at a molecular level) in late injuries of the rat facial nerve. Method:The method consisted of removing calcium of injured axons (which makes a chemical sealant) and reattaching the two ends of the severed axon with polyethylene glycol. Wistar rats were submitted to neurotmesis of the mandibular branch of the facial nerve. After 5 days (group A) and after 10 days (group B) the injured nerve were resutured with nylon 10.0 and embedded in a free calcium solution with metilene blue, followed by polyethylene glycol and a calcium-rich saline solution.  Controls (groups C and D) were made with simple nylon 10.0 suture. After 6 weeks, animals were sacrificed and  morphometric histological analysis  was performed.  Functional analysis through compound muscle action potential (CMAP) was made before the procedure, and after 3 and 6 weeks. Results: axon densities and axon diameters averages were statistically equals in relation to kinds of suture (p = 0,862 e p = 0,929  respectively) . Mean CMAP amplitudes were statistically similar between the groups (p = 0,830). Conclusion: neural chemical repair wasn’t better than simple neural microsuture in late injuries of the rat facial nerve .


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Gazi Hussain

Title: A modification of the direct brow lift technique for facial paralysis

Background: The direct brow lift is a well-described technique to correct brow ptosis in patients with isolated frontal nerve or complete facial nerve palsy. However, the crescentic excision of skin and frontalis which is commonly described fails to correct the ptosis and displacement of the medial brow, which results in continued brow asymmetry. We describe a novel modification with the addition of a right-angled triangular excision at the medial extent of the brow to address this problem.   Methods: A retrospective chart review was conducted from 2013 to 2015 of all patients who underwent the modified direct brow lift. Patient demographics, aetiology and severity of brow ptosis and post-operative outcomes were collected.   Results: A total of 8 patients underwent the modified procedure with a minimum of 3 months follow up. All eight patients had good to excellent scar outcome and brow symmetry at rest. Only one patient reported mildly diminished forehead sensation.   Conclusion: This modified direct brow lift technique provides an improved correction of the medial brow ptosis in facial paralysis patients with a low risk of long-term forehead hypoesthesia and good scar outcome.It results in a superior aesthetic and functional result of the brow position in patients with facial paralysis, without the need for significant over correction.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Aruna Dharmasena

Title: Dynamic Muscle Transfer in Facial Nerve Palsy: The Use of Contralateral Orbicularis Oculi Muscle

Introduction: Facial reanimation procedures refer to interventions that restore facial symmetry, resting tone, voluntary movement, or a combination of these. In severe cases of facial weakness, the transfer of functional innervated musculature into the face offers the only possibility of meaningful facial movement.   Objective: To describe the results of dynamic muscle transfer with an orbicularis oculi muscle flap from the contralateral side to the paralyzed side in patients with House-Brackmann grade 6 facial nerve palsy.    Methods: A case series    Results: This case series included six patients who underwent dynamic muscle transfer with a flap of healthy orbicularis oculi muscle fibers from the contralateral side into the paralyzed orbicularis oculi muscle. All patients had a House-Brackmann grade 6 facial nerve palsy. They all had previous multiple surgical procedures to improve the eyelid function. In spite of this, they were all symptomatic in terms of corneal exposure before orbicularis muscle transfer. All patients had postoperative follow up in excess of 2 years after the procedure. All patients improved symptomatically and had clinically reduced lagophthalmos postoperatively. Five patients who had an absent blink reflex showed a significant improvement in their blink reflex postoperatively. No complications occurred at the donor site. All patients showed a significant improvement of their symptoms and their lagophthalmos reduced postoperatively. Most importantly, the blink occurred involuntarily at the same time as the blink on the normal side.   Conclusion: The authors propose that a dynamic muscle transfer using the contralateral orbicularis muscle may be considered to improve the voluntary lid closure and spontaneous blink reflex to improve corneal exposure in patients with grade 6 facial palsy who have not benefited from conventional surgical procedures.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Glen Croxson

Title: Iatrogenic facial nerve injury in tympanomastoid surgery

Introduction     The incidence of iatrogenic facial nerve injury (IFNI) during tympanomastoid surgery in Australia is decreasing due to improved teaching, development of sub-specialty practice and NIM.   Objective   To describe 19 patients with IFNI treated from 1988 to 2016.   Methods   A retrospective review of 1537 patients with facial nerve disorders revealed 19 with IFNI associated with tympanomastoid surgery.   Only those undergoing mastoidectomy for chronic suppurative otitis media were included, excluding exostosis resection, stapedectomy, temporal bone resection and cochlear implant as a cause for IFNI .   The patient demographics, referral details, clinical findings, operative findings and outcomes were recorded   Results   19 patients were identified.    8 patients had chronic, long-standing injuries, and were considered for reanimation.     11 were acute injuries, of which 7 were explored with  complete facial paralysis, and 4 with incomplete paralysis managed conservatively.   7 of 7 were found to have incomplete exposure and residual disease, with 5 having residual cholesteatoma.    2 patients had had lateral canal fenestration with profound SNHL.   4 of 7 required great auricular nerve (GAN) graft   3 required wide surgical decompression.   All required completion mastoidectomy.   Outcomes   3 patients underwent nerve decompression associated with completion mastoidectomy. 1 patient achieved a HBG II, 2 patients achieved HBG III   4 patients underwent GAN graft. 2 patient achieved a HBG III, and 2 achieved HBG IV    Conclusions   IFNI is decreasing in incidence in Australia. Clinically complete injuries in mastoidectomy are associated with incomplete eradication of disease, incomplete surgical exposure and lateral canal fenestration.   Management requires completion mastoidectomy, nerve assessment and repair or decompression.    The outcomes of repair are modest improvement, with incomplete recovery.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Nobumitsu Honda

Title: Facial nerve hernia and fallopian canal dehiscence in severe palsy patients with Bell’s palsy and Ramsay Hunt syndrome

Introduction: Facial nerve hernia is a rare condition. Daqing et al reported that the incidence of facial nerve hernia was 0.2% in stapes operations. In contrast, fallopian canal dehiscence is more common than facial nerve hernia. The incidence of fallopian canal dehiscence reported in the literature was 6.4% to 30%. However, there have been very few reports on facial nerve hernia and fallopian canal dehiscence in patients with Bell’s palsy and Ramsay Hunt syndrome.   Objective: This study was undertaken to determine the incidence of facial nerve hernia and fallopian canal dehiscence in severe palsy patients with Bell’s palsy and Ramsay Hunt syndrome.    Methods: Facial nerve decompression of intratemporal facial nerve was carried out in 142 patients with Bell’s palsy and 101 patients with Ramsay Hunt syndrome in Ehime University between April 1976 and December 2015. The present study examined the incidence of facial nerve hernia and fallopian canal dehiscence in these patients according to the surgically treated area or timing of surgery. Medical records were retrospectively reviewed for surgical findings.   Results: The incidence of facial nerve hernia was found to be 10.6% in patients with Bell’s palsy and 11.9% in patients with Ramsay Hunt syndrome. The incidence of fallopian canal dehiscence was found to be 23.9% in patients with Bell’s palsy and 36.6% in patients with Ramsay Hunt syndrome.   Conclusion: The incidence of facial neve hernia in severe palsy patients with Bell’s palsy and Ramsay Hunt syndrome were higher than stapes operations although the incidence of fallopian canal dehiscence in severe palsy patients with Bell’s palsy and Ramsay Hunt syndrome were not higher than the previous reports. We assume that the swelling of facial nerve is mostly responsible for higher rate of facial nerve hernia in patients with Bell’s palsy and Ramsay Hunt syndrome.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Jin Kim

Title: Temporal Lobe Retraction Provides Better Surgical Exposure of the Peri-Geniculate Ganglion for Facial Nerve Decompression via Transmastoid Approach

Purpose: For the exposure of the labyrinthine segment of the facial nerve, transmastoid approach is not usually considered due to being situated behind the superior semicircular canal. To obtain a better view and bigger field for manipulation in the peri-geniculate area during facial nerve decompression, retraction of temporal lobe after bony removal of tegmen mastoideum was designed via transmastoid approach.   Materials and Methods: Fifteen patients with traumatic facial paralysis [House-Brackmann (HB) grade IV–VI], 3 patients with Bell’s palsy (HB grade V–VI), and 2 patients with herpes zoster oticus (HB grade V–VI) underwent facial nerve decompression surgery between January 2008 and July 2014. In all patients, we performed temporal lobe retraction for facial nerve decompression via the transmastoid approach. Patients were examined using pre operative tests including high-resolution computed tomography,temporal magnetic resonance imaging, audiometry, and electroneurography (degenerative ratio >90%). Facial function was evaluated by HB grading scale before and 6 months after the surgery.   Results: After the surgery, facial function recovered to HB grade I in 9 patients and to grade II in 11 patients. No problems due to surgical retraction of the temporal lobe were noted. Compared to the standard transmastoid approach, our method helped achieve a wider surgical view for improved manipulation in the peri-geniculate ganglion in all cases.   Conclusion: Facial nerve decompression via the transmastoid approach with temporal lobe retraction provides better exposure to the key areas around the geniculate ganglion without complications.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Stephen Morley

Title: Facial reanimation in complex cases - the power of microsurgery

Introduction Facial reanimation surgery to restore emotionally triggered movement is the gold standard in unrecovered facial paralysis. Excellent results can be achieved utilising standard techniques in standard cases but factors relating to the patient or previous treatments lead some cases to be considered complex. Such cases have limited remaining donor sites and depleted recipient vessels locally. Adverse scarring and unexpected operative findings are common. This studies ananlyses the feasibility of microsurgical reanimation techniques in these cases.   Methods A retrospective analysis of 15 consecutice cases where smile reanimation was undertaken in complex cases is presented. Notes of demographics; aetiology and results including scoresheets and video/ photographic images was undertaken. Reasons for defining complexity included previous facial re-animation surgery including cross face nerve graft and free tissue transfer; prior use of local muscle flaps; need for composite reconstruction; previous oncological treatment including neck dissection and radiotherapy and longstanding cutaneous fistula. Simply having had a previous attempt at reanimation was not cause to define a case as complex in this series.   Results Fifteen patients underwent facial reanimation using microsurgical techniques. Nine gracillis muscles were used and six latissimus dorsi flaps. Three flaps were composite in nature and one chimeric muscle flap was used. Recipient vessels included facial; superficial temporal; superior thyroid and maxillary. The motor nerve connected to these flaps included nerve to massater n=9; cross face nerve graft n=3; contralateral facial nerve n=1 and the stump of a severed facial nerve n=1. All free flaps survived and there were no serious complications. Follow up averaged 15 months with14 cases achieving good facial movement.   Conclusion Microsurgical smile reanimation gives good results in complex cases. Attention needs to be focused on flap selection along with choice of donor vessels and nerve. Generally a one stage technique using the nerve to massater is preferred.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Stephen Morley

Title: Successful combination of nerve to massater transfer and cross face nerve grafts to treat facial palsy

Introduction The nerve to massater (NTM) is commonly used in facial reanimation as a motor to power a free muscle transfer or for direct co-aptation to a damaged facial nerve. NTM adds power in reanimation but not  resting tone. Synkinesis can develop if it is used for both smile and eyelid closure. Cross face nerve grafts (CFNG) can also be used to connect contralateral healthy nerve to power a free flap or to directly add strength to a weakened nerve or muscle. A combination of NTM transfer and CFNG in reanimation surgery should add strength and tone without stimulating synkinesis.   Objective To assess the results of combining the nerve to massater transfer to strengthen smile and CFNG to strengthen eye closure in complete and partial facial paralysis.   Methods  A retrospective review of subjects; aetiology and results where CFNG and NTM transfer have been used in facial re-animation. In partial paralysis nerves were co-apted to the weakened nerve end to side via an epineural window to preserve existing function. Nerve conduction studies were used pre-operatively in longstanding cases to assess muscle health.   Results were assessed using standardised photographs and video and direct measurements of resting position, synkinesis and movement (Nottingham Scale).   Results  8 subjects were identified where CFNG for eye re-animation and NTM transfer for smile re-animation were used. Three cases involved complete facial nerve sacrifice and five cases partial paralysis. All cases showed inprovement in global facial movement without increasing synkinesis. Complete eye closure was obtained in all cases and improved symmetry of the face at rest was also always achieved. Impvovement in smile as measured by modiolar movement averaged 55%.   Conclusion - NTM transfer with CFNG is an effective modality for immediate reconstruction following facial nerve sacrifice. Excellent results are also achieved in long standing partial paralysis.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Stephen Morley

Title: Throwing good after bad:  salvage of a sub-optimal smile reanimation result with further free tissue transfer in facial re-animation.

Introduction The surgical approach to facial re-animation in patients who have received a free muscle transfer which has failed to create an effective smile is difficult. Free tissue transfer is regarded by many as the gold standard in reanimation but secondary surgery is complex due to the previously operated field and paucity of recipient vessels and donor nerves. We present a series of patients who received a further free muscle transfer after an initial failed procedure.   Objectives To assess the results of performing a subsequent free flap for facial re-animation following a failed prior free tissue transfer.   Material and Methods A consecutive single operator series of patients receiving further free flap for facial reanimation are reported. Analysis of success includes still and video images and a standardised Nottingham scoring system. The relevant anatomy of appropriate muslce flaps are reviewed with reference to their use in these salvage procedures.    Results 7 further free flaps were performed in 7 patients due to poor or absent facial movement. 8 flaps had been performed previously in this group (5 gracilis, 1 rectus, 2 latissimus dorsi). One patient had three free flaps in total, all others had two. Salvage free flaps were gracilis (5) and mini latissimus dorsi (2) . Donor nerves included nerve to massater and contralaeral facial nerve. Successful free tissue transfer was achieved in all cases with a good quality, spontaneous smile and average  movement of 8mm at the modiolus.   Conclusion Treatment following free flap failure in facial reanimation is a complex  problem as patients have extensive scarring and vessel depleted faces with restricted muscle donor sites. We demonstrate that a spontaneous smile can be achieved reliably by  performing a further free flap. These challenges are surmountable and a good quality, spontaneous smile is achievable in these patients in the long term.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Damian Palafox

Title: An eFACE and electrophysiological characterization of facial palsy in the oculoauriculovertebral spectre

Introduction: The oculoauriculovertebral spectre, refers to a series of malformations in the orbit, mandible, ear, facial nerve as well as spine/vertebral defects. Facial nerve compromise is present in up to 10-45% of the cases. OMENS classification evaluates facial nerve function according to clinical parameters, whereas the eFACE scale system provides a graphic output, it evaluates 3 categories static, dynamic, and synkinetic) Further, eletrophysiological studies are currently one of the most useful and objective methods to evaluate nerve viability and target muscles.    Methods: All cases of Goldenhar’s Syndrome associated to facial palsy from our institution were included. Each patient was evaluated with the eFACE scale system. We excluded patients without electrophysiological studies.   Results: 38 patients were studied. 16 men and 25 women, with a mean age of 11.4 years. 17 had right facial palsy, 19 left facial involvment and 2 were had bilateral compromise. According to the OMENS classification, facial nerve’s superior branches were affected in 9 patients, inferior branches were affected in 3 cases and all branches were compromised in 9 patients. Regarding the eFACE scale, the mean static score was 75, dynamic score was 55. Electromyography revealed that all patients had a mixed type motor axonopathy. 26 patients had fronto-temporal, zygomatic-buccal and cervico-mandibular branches compromise. 13 had masseteric nerve involvement and 4 hypoglossal nerve dysfunction.    Conclusions: eFACE scale and electrophysiological characterization of patients with facial palsy associated to Goldenhar’s Syndrome, provides useful information regarding the facial nerve’s branches involvement and the current state of muscular function, both of utmost importance when clinical evaluation is performed before any type of surgical procedure is planned in this patients.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Damian Palafox

Title: Levator palpebrae superior muscle direct neurotization

Direct muscle neurotization has been proved to be a feasible technique for facial reanimation microsurgical procedures. Direct muscle neurotization is performed by implanting the interposition nerve graft directly into the substance of the muscle .    A 36 year old male patient presented with upper eyelid dysfunction secondary to facial trauma. Physical examination showed left periorbital ecchymosis, severe palpebral ptosis and preserved visual acuity and upper gaze movement . The CT showed multifragmented orbital roof, nasal bone and ethmoid fractures, as well as left frontal intraparenchymal hemorrhage, mild cerebral edema and pneumoencephalus. however Neurosurgery consultation determined that no surgical treatment was further needed. Under general anesthesia, the neurophysiology specialist performed intraoperative neurophysiological monitoring placing needles on selected muscles (ipsilateral orbicularis oculi, corrugators, frontalis and temporalis). An incision was made on the superior palpebral sulcus, the levator palpebrae superioris muscle was macroscopically unaffected, however neurophysiological test proved a selective denervation of the CN III motor branch to the muscle. A sural nerve graft was obtained from the ipsilateral leg. A preauricular approach was performed to identify the frontal branch of facial nerve,  we performed an end-to-end coaptation of the nerve graft to the main trunk of the frontal branch. The free side of the graft was then tunnelized to the superior eyelid and a direct neurotization of the levator palpebrae superioris muscle was performed. Finally, three terminal branches of the frontal nerve were identified and tunnelized to the same site for direct neurotization Postoperatively, the eye was protected with a patch and the use of topical lubricants. Evolution was uneventul and patient was discharged the day after the surgery. No complications were encountered during the procedure or in follow up. 3 months after surgery, we have noted devolopment of upper eyelid movement meaning adequate function of the neurotized muscle.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Damian Palafox

Title: One-Stage Facial Reanimation Surgery For Complete Möbius Syndrome Using 2 Free Gracilis Muscle Flaps

Objective Describe our one-stage facial reanimation surgery for complete Möbius Syndrome using 2 free gracilis muscle flaps, using bilateral trigeminal or spinal nerves as nerve donors.  Evaluate our outcomes using validated international grading scales and determine the effectiveness of the procedure.     Methods: Between March 2014 and October 2016, 5 patients with complete Möbius Syndrome underwent surgery using bilateral gracilis free muscle transfers at the same surgical time. Trigeminal and spinal nerves were used as donors depending if the aforementioned were compromised in the patient. Mean postoperative follow-up time was 17 months. ¨Patients were asked to smile with maximum excursion, and pictures and videos were recorded. Outcomes were assessed using the Terzis Functional and Aesthetic Grading System, Chuang’s Smile Excursion Score, and a questionnaire to evaluate patient satisfaction.    Results: A total of 5 patients with Complete Möbius Syndrome were included (3 male, 2 female). We performed 10 free gracilis muscle transfers in 5 surgical operative times. We used the facial vessels for anastomosis in every flap. Trigeminal nerve was the donor in 3 patients and in the remaining, spinal nerve. No complications were encountered. All patients achieved at least score of III using the Terzis Grading System, and IV in those where we used the spinal nerve. Likewise, the minimum score using Chuang’s Smile Excursion Score was 2, but in those where the spinal nerve was used a score of 3 was obtained. Mean satisfaction score was 3,the patient with the longest follow-up time had a score of 4.    Conclusions: One-stage facial reanimation surgery for complete Möbius Syndrome using 2 free gracilis muscle flaps is an effective and safe procedure. Careful patient selection, adequate physical evaluation, motor nerve donor selection, flawless surgery performance, and adequate postoperative rehabilitation program are mandatory in order to obtain success in this group of patients.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Jun Hui Jeong

Title: Exclusive Endoscopic Transcanal Facial Nerve Decompression for Traumatic Facial Nerve Palsy

Objectives: Endoscopic anatomy from the external auditory canal (EAC) to the internal auditory canal was described by Marchioni et al. This allowed manipulation of the facial nerve from the second genu to the geniculate ganglion (GG) using the EAC as a natural surgical corridor. We introduce exclusive endoscopic transcanal facial nerve decompression from the GG to the second genu for traumatic facial nerve palsy.   Methods: Three patients with complete facial palsy underwent exclusive endoscopic transcanal facial nerve decompression from the GG to the second genu. The reason for facial palsy in all three patients was traumatic temporal bone fracture. From the CT scan, the tympanic segment was the most suspicious traumatized portion. Ossiculoplasty was performed.    Results: After 6 months, all patients experienced favorable facial recovery, better than House-Brackmann grade 2. The air-bone gap of the affected ear in all patients was smaller than 15 dB HL. The average operating time was 102.4±43.5 minutes.    Conclusion: When the compromised site of the facial nerve is limited from the GG to the second genu, an exclusive endoscopic transcanal approach is as compatible as and more efficient than transmastoid approach.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Peter Ku

Title: Management of Facial Sialocele Post Functional Free Muscle Transfer in Facial Reanimation – A Case Series

Introduction   Functional free muscle transfer (FFMT) is a popular technique nowadays to treat chronic facial paralysis. Besides complications related to neurovascular anastomosis, other common complications may include hematoma and wound infection. Facial sialocele is an uncommon complication followed FFMT but its consequence can be disastrous to surgical outcome.    Objective   To report postoperative facial sialocele after FFMT for facial reanimation and to discuss the etiology and management   Methodology   We retrospectively reviewed 5 cases of postoperative facial sialocele after FFMT for facial reanimation done from 2013 to 2015 in United Christian Hospital. The indications of surgery were post-excision of acoustic neuroma and meningioma with chronic facial paralysis. One patient had single stage free latissimus dorsi flap and 3 patients had single stage ipsilateral spinal accessory nerve to gracilis muscle flap. One patient had two stages sural nerve cross-facial nerve anastomosis to gracilis muscle. The surgery, postoperative condition and treatment were reported.   Results   The mean age of patients was 56.5 years. All muscular flaps were survived. Facial sialocele was noted in 5 patients within one week after operation. Treatment of the sialoocele was given by repeated fine needle aspiration and pressure therapy. Patients were given propantheline 30mg to 45mg daily to reduce salivary flow and oral antibiotics. The sialocele was subsided in 2 weeks on average. Four patients had good facial contraction observed on the reanimation side from 4 to 9 months after surgery. One patient who admitted to ICU with facial sialocele developed facial abscess that required incision and drainage and the facial contraction ability was poor. One common condition for all cases of postoperative facial sialocele development was excision of the superficial lobe of parotid to evacuate space for free muscular flap.    Conclusion The series showed postoperative facial sialocele can happen and surgeons should beware of this complication.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Kamal Bisarya

Title: Combined Lip and DLI resection - a simple solution for lower lip asymmetry in head and neck cancer patients.

Introduction   Lower lip asymmetry due to marginal mandibular nerve (MMN) dysfunction is relatively common in head and neck cancer patients. Asymmetry results from the denervated atrophic lip on the affected side and unopposed depressor action on the contralateral side. There are functional and aesthetic consequences. Dynamic reanimation is often not feasible due to cancer treatment. In our experience, a combination of resecting the atrophic lip on the affected side and weakening the contralateral depressor muscle provides a simple solution (both are established techniques used in isolation).    Objective   Assess patient reported outcomes and therefore functional improvement in patients undergoing this combined approach to lower lip asymmetry.   Method   A prospective cohort analysis. Sequential adults treated for acquired lower lip asymmetry in a regional Facial Nerve MDT clinic were recruited over 12-months. Only patients undergoing a combined approach wedge resection on the affected side and contralateral depressor labii inferioris (DLI) segmental resection were included.    Subjective functional and aesthetic analyses were performed with pre- and post-operative FACE Q questionnaires (at 6 months follow-up). Objective measurements of lip symmetry were performed comparing pre- and post-operative photographs.    Results   10 patients with acquired MMN-related lower lip asymmetry were treated with a combined surgical approach following a trial of botox. Median age 60, 6 male, 4 female. Most cases were local anaesthetic. In 5/10 cases the DLI scar was intra-oral, with 5/10 in the labiomental skin crease.  There was no lower lip sensory loss postoperatively. Functional and aesthetic related FACE-Q scales all reported improvement. Objective photographic analysis demonstrated improved lip symmetry.    Conclusion   Lip asymmetry post head and neck cancer is common and causes a characteristic deformity. Surgical management via an ipsilateral lower lip wedge resection and a contralateral DLI resection offers a simple solution that delivers patient and observer reported satisfactory results in the short to medium term.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Jessica Steele

Title: INVESTIGATION OF THE ACTIVATION OF TEMPORALIS AND MASSETER MUSCLES IN SMILE PRODUCTION

Introduction    Masticatory muscles or their nerve supply are options for facial reanimation surgery but their ability to create spontaneous smile has been thought to be limited.  Recent studies have challenged this and Schaverien et al (2011) reported activation of masseter in 40 percent of healthy individuals during spontaneous smile.   Objectives   To assess the percentage of healthy adults who activate temporalis and masseter during voluntary and spontaneous smile.     Methods   This was a single centre volunteer cohort study (HREC/16/RCHM/27). Recruits underwent electromyography (EMG) studies of temporalis and masseter muscles during voluntary and spontaneous smile.  Responses were repeated three times and recorded as negative, weakly positive or strongly positive according to activity observed.  The best response was used for analysis.   Results   Thirty healthy adults (median age 34 years, range 25-69 years) participated. Overall, 96% (n=55) of masseter muscles were activated during voluntary smile (22% (n=13) strong, 70% (n=42) weak).  Seventy eight percent (n=46) of masseter muscles were activated in spontaneous smile (12% (n=7) strong, 66% (n=39) weak).  Temporalis muscle was activated in 62% (n=37) of responses in voluntary smile (15% (n=9) strong, 47% (n=28) weak), and spontaneous smile 45% (n=27) (13% (n=8) strong, 32% (n=19) weak).      No significant difference was found for males vs females or closed vs open mouth smiles.  There was no significant difference in responses between voluntary and spontaneous smile for temporalis and masseter, and use in voluntary smile did not consistently predict activity in spontaneous smile.    Conclusions   Our study has shown that masseter and temporalis are active in a high proportion of healthy adults during voluntary and spontaneous smile.  This confirms good potential of both muscles as donors in facial reanimation.  Further work is required to determine the relationship between pre-operative donor muscle activation and post-operative spontaneous smile and whether masticatory muscle activity can be up-regulated with appropriate training.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Damian Palafox

Title: Facial Reanimation Surgery in Mobius Syndrome. Experience from 124 Cases From a Tertiary Referral Hospital in Latin America

Introduction: Mobius syndrome is characterized by congenital bilateral paralysis of the facial and abducens nerves. At our center, we classify Mobius Syndrome patients accordingly to the Terzis Classification: Classic Mobius Syndrome, incomplete and Mobius-like.    Objective: To present our experience in the surgical treatment of Mobius Syndrome.    Methods From 2008 to 2016, 124 patients with Mobius Syndrome have been treated in our institution. We conducted a retrospective analysis to further determine demographic data and Mobius Syndrome characteristics from our patients. 124 patients were included (45 males and 79 females), age groups were: under 4 years old (40 cases), 5-15 years old (63 cases) and older than 15 years old (21 cases). Age average was 8.61 years, we classified patients as follows: Complete mobius n=88, incomplete n= 28, mobius-like n=8.   Results We follow a treatment algorithm and determine the best surgical management for each type of patient depending on the type of Mobius Syndrome and the nerves affected. Complete Mobius: Free muscle transfer (gracilis) was performed in 34 patients. 4 were bilateral (during same surgery), 20 were unilateral and 10 were bilateral (during different surgical procedures) Hypoglossal nerve as donor was used in 7 cases, masseteric nerve in 18 cases and spinal accessory nerve in 9 cases. Incomplete Mobius: 13 cases were encountered. Free muscle transfer (gracilis) was performed in 9 patients, cross facial nerve grafts (CFNG) in 2 cases and temporalis muscle transfer in 2 cases. Mobius-Like: 5 cases were included. Free muscle transfer (gracilis): 3 cases (one bilateral and two unilateral), 2 CFNG were performed. Patients are also managed at our institution with non-dynamic procedures.    Conclusions At our center, the gold standard of treatment is based on facial reanimation by means of gracilis muscle free transfer. Surgery enhances patients to obtain spontaneous smiles and develop cerebral plasticity as well.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Damian Palafox

Title: Facial reanimation by means of a single branch cross nerve graft versus a double nerve approach. An eFACE evaluation.

Introduction: Evaluating the results of dynamic facial reanimation procedures is imperant in order to perform modifications to surgical techniques and obtain better results for our patients. The eFACE scale system provides a graphic output, it evaluates 3 categories static, dynamic, and synkinetic). As stated recently by Facial Nerve experts worlwide, it is a suitable, cross-platform, digital instrument for facial function assessment.    Aim: We sought to evaluate the outcome of patients with unilateral facial palsy treated by means of a single branch cross nerve graft (buccal-buccal branch) versus a double nerve approach (with the addition of masseteric nerve coaptation). An eFACE evaluation was performed to obtain facial function assessment.     Methods: Patients with unilateral facial paralysis from our department were included (inclusion criteria included patients who underwent a single branch cross nerve graft procedure (buccal-buccal, and patients with buccal-buccal CNG and the addition of a masseteric nerve coaptation, time period 2010-2016). Each patient was evaluated with the eFACE scale system.   Results: 20 patients were studied. Mean age was: 29.1 years old. The main cause of unilateral facial palsy in our cohort were: neoplasias : 40%. Denervation time ranged between 6 months and 2 years in 50% of our patients. 35% underwent single branch cross nerve graft (buccal-buccal branch), and the remaining 65% a double nerve approach (with the addition of masseteric nerve coaptation) There was a mean incrementation of 18.85 points in the postoperative period as expressed bu the eFACE scale. Uneventful evolution was registered. Patients who underwent the addition of a masseteric nerve coaptation to another buccal branch experimented a better outcome as compared with the single branch CNG (in terms of the eFACE evaluation performed)    Conclusion: The eFACE scale proved to be both reproducible and reliable when assessing facial function in the postoperative period for this group of patients.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Yujin Myung

Title: The Importance of Overcorrection During Suprabrow lifting in Frontal Branch Palsy Patients

Introduction   Numerous patients with facial palsy complaints about difficulty of eye opening caused by paralysis of frontalis muscle, as well as accompanied asymmetry of brow position. Suprabrow composite lifting with skin and muscle excision is simple, easy to perform, and at the same time powerful tool for correction of brow asymmetry and frontalis paralysis.   Methods              From January 2009 to June 2016, total of twenty patients received suprabrow excision and composite brow lift in department of plastic surgery, Seoul National University Bundang Hospital. Among them, in thirteen patients, the operation was performed with overcorrection of 5 milimeters compared to contralateral, unaffected side. In seven patients, the operative design and procedure was performed in order to match immediate postoperative symmetry, without overcorrection.   Results                  In overcorrection group, there was only one patient who complained about relapse during follow-up period within postoperative two years. In symmetry group, five of seven patients complained about relapse and descending of operated brow within two years after the surgery. Average difference of brow position after two years of operation was checked in 1.5mm in overcorrection group, and 3.8mm in symmetry group.   Conclusion              When performing suprabrow excision and composite brow lift in frontal nerve paralysis patients, it is important to keep in mind that immediate postoperative overcorrection is essential in obtaining long-term patient satisfaction and good results.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Fumiaki Shimizu

Title: Distal stump of the intramuscular motor branch of the obturator nerve is useful for reconstruction of long standing facial paralysis using double-powered free gracilis muscle flap transfer

Background: Double innervation of the transferred muscle with the contralateral facial nerve plus the ipsilateral masseteric nerve has been recently reported by some authors. The aim of this study was to assess the utility of our procedure of double innervation of free gracilis muscle for reconstruction of long-standing facial palsy.   Patients and methods: In our department, six cases of long-standing facial paralysis (four cases of complete palsy and two of incomplete palsy) were reconstructed using a free gracilis muscle double-innervated with the masseteric and contralateral facial nerves. The patient age ranged from 37 to 79 years (average 56.7 ±15.7). In our procedure, the intramuscular motor branch of the transferred muscle was identified and sutured to the ipsilateral masseteric nerve in an end-to-end fashion, and the obturator nerve of the transferred muscle was sutured to the cross-face nerve graft, which was coaptated with the contralateral facial nerve by end-to-end suturing.    Results: All patients were followed up for more than 18 months and recovered their smiling function. The voluntary movement of the transferred muscle with teeth clenching was observed at about 4.7 months, and this movement combined with contralateral mouth angle elevation was observed at about 9.5 months after the surgery.   Conclusion: Our experience suggests that the distal stump of the intramuscular motor branch of the obturator nerve may be useful for facial reanimation via double-powered free gracilis muscle flap transfer.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: VIJAYENDRA HONNURAPPA

Title: Unrecovered Bell’s palsy-Surgical Management

In my experience, as being tertiary referral centre for facial nerve disorders, from 1994, i have performed surgeries for 47 cases of unrecovered Bell’s palsy. I have regular protocol for Bell’s palsy. First antiviral, Deflacortisone and physiotherapy given then weekly regular followup. I give importance for Schirmer’s test. Almost all cases of Bell’s palsy, it will be negative. Otherway round, in 95% cases of traumatic facial nerve palsy, it will be positive. So its very reliable test to know site of lesion whether its pre or post geniculate ganglion. Clinically i asses prognosis of disease. Particularly if  eye closure is complete or near normal complete. These patiets are sure to recover. If Bell’s phenomenon is positive at the end of 3 weeks, I subject these patients for surgery. So radiological diagnosis is important. I ask for curved reconstruction of facial nerve from labyrinthine segment upto stylomastoid foramen. Always the vertical segment of facial nerve will be of wider diameter when compared to normal side.This is contradictory to popular concept of edema of facial nerve at meatal foramen area and hence facial nerve weakness. Through facial recess approach, facial nerve from Geniculate Ganglion upto Stylomastoid foramen is exposed and decompressed after removing incus and epineurium is incised. Surgically, one observation consistently seen in all cases is thickened and fibrotic bands compressing perineurium which are incised using iris scissor, thin bands compressing perineurium further released using tenotome. The moment epineurium is incised, the normal perineurium will bulge out. In my series,most of patients were recovered completely within 3 months following the surgery, provided surgery has been done between 3 weeks to 6 weeks. Histopathological study of the diseased nerve sheath has shown fibrosis when compared to normal nerve sheath. Mine will be total video presentation.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: VIJAYENDRA HONNURAPPA

Title: Traumatic Facial Nerve Paralysis – New Innovative technique of Transcanal Facial Nerve Decompression

In my experience, as being tertiary referral centre for facial nerve disorders, from 1994, i have performed surgeries for 117 cases of traumatic facial nerve palsy.  If patient has grade V to VI Facial nerve (FN) paralysis, it needs surgical intervention. In longitudinal fracture, patient will have bleeding from ear canal or tympanic membrane rupture or haemotympanum with conductive hearing loss. In transverse fracture, patient will have severe giddiness, vomiting, sensorineural hearing loss. I have popularized Transcanal Facial Nerve decompression for longitudinal fracture causing FN paralysis. It is very easy and safe technique done under local anesthesia in adults. In 95% of cases the lesion will be around  perigeniculate ganglion. Schirmer’s test is very important clue.In 95% cases it will be positive, there is no lacrimation or reduced lacrimation compared to opposite eye. Otherway round in cases of Unrecovered Bell’s palsy, it will be negative. This gives excellent clue that greater superficial petrosal nerve (GSPN) is involved. Through postauricular approach tympanomeatal flaps created. Invariably  fracture line seen crossing over the posterior bony meatal wall from  squamous part of temporal bone extending over the attic. I perform wide canalplasty. If ossicular chain is intact, disarticulate Incudostapedial joint, Incus is removed, Malleus amputated at the neck, head pushed posteriorly into attic, handle of malleus retained with the flap. Then horizontal segment of FN seen clearly. Multiple  fragments of supralabyrinthine bone pieces will be seen compressing Geniculate Ganglion (GG), GSPN and labyrinthine segment. To get best results it is mandatory to decompress GG, GSPN and labyrinthine segment, and then incise the epineurium from the 2nd genu to GG.Primary ossicular reconstruction- Myringostapediopexy with attic reconstruction done in all cases. In all patients, if surgery is performed  early timingly , complete recovery from facial nerve paralysis seen. Mine will be total video presentation.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: VIJAYENDRA HONNURAPPA

Title: Iatrogenic Facial Nerve Paralysis- Facial Nerve Grafting: A suture less technique

In my experience, as being tertiary referral centre for facial nerve disorders, from 1994, i have performed surgeries for 127 Cases of Iatrogenic facial nerve palsy. I have seen varieties of injuries, common site being beginning of the vertical segment. In more than 40% of cases Lateral semicircular canal has been damaged. Coming to the technique,I decompress the normal facial nerve both proximal and distal to the site of lesion, slice at the healthy segment and remove the damaged part of nerve. I incise the normal epineurium more than 2 cms in both proximal and distal segments. Then using ball probe separate perineurium for 360 degrees from the epineurium to make bed for cable graft. Thin piece of areolar fascia placed under the elevated epineurium. After approximating Greater Auricular nerve to cut ends, this fascia is wapped around both normal perineurium and Greater auricular nerve graft. This is called suture less technique. Follow up is for one year and end results should be accessed at the end of 1 year. After many modifications of surgical technique since 1994 and with my experience off late with above mentioned technique, I achieve results from Grade VI/V to Grade II/III, if operated within 15 days from the day of injury. Mine will be total video presentation.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Young woo Cheon

Title: Chronically Paralyzed Facial Muscle Neurotization by a Cross Facial Nerve Graft

Introduction   Facial paralysis is a life altering clinical condition, with functional, aesthetic, and communication implications. Reconstruction of a natural, symmetrical smile is generally accepted as the ultimate goal. For a long standing unilateral facial paralysis, cross facial nerve graft combined with muscle transfer is a well established method. However, the bulkiness of muscle is inevitable problem. To overcome the problem, neurotization of facial muscle could be a good alternative. We report a case of chronically paralyzed facial muscle neurotization by a cross facial nerve graft.   Case reports   A 54-years-old women presented with asymmetry and facial paralysis that was compatible with House-Brackmann scale VI (Fig.1A). The paralysis of the right side of the face had affected the upper eyelid, eyebrow, lips and cheek. She had an operation to remove acoustic neuroma on her right face 14 years ago, since that time had suffered from facial paralysis. She had not received any kind of treatment for facial paralysis. The electromyography showed 95% of denervation. (Fig 2A) We perform cross facial nerve graft with sural nerve in first stage. Under the general endotracheal anesthesia, a left preoricular incision was made and the buccal branch was identified and 17 cm length right sural nerve was harvested. The nerve graft was reversed and end to end anastomosis was performed. Through preauricular incision of right side, the end of the nerve graft was placed in right pretragal region and anchored on parotid fascia with # 3-0 nylon suture. Tinnel’s sign was detected 6 months after the first stage operation and the gain of facial muscle function was observed. The grade of facial muscle fuction was compatible with Brackmann scale III (Fig 1B). The electromyelography showed 30% denervation at 12 months of nerve graft. (Fig.2B)


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Alejandro Orihuela Rodríguez

Title: Changes in bite force in patients with unilateral facial paralysis after facial reanimation surgery using the masseteric nerve.

Introduction: Different donor nerves have been used for facial reanimation, as experts have proved worldwide and demonstrated, the masseteric nerve has been considered as an adequate choice because it confers numerous advantages: fast and strong reinnervation, limited donor site morbidity, synergy with facial nerve, potential for efficacious brain adaptation to produce a smile as well as an easy transoperative identification.    Objective: To determine if there are changes in bite force secondary to using the masseteric nerve as donor for facial reanimation procedures.    Methods: A quasi-experimental, prospective and longitudinal study was made. Following ethical approval, 7 female and 3 male subjects were recruited, aged between 6 and 67 years; 4 of them had right paralysis and 6 were left sided, in all of them the bite force was measured using occlusal sensors before and after 3 months of facial reanimation surgery.   Results: Maximum bite force value preoperatively was 110,36kg and postoperatively 44,89kg. Minimum bite force value preoperatively was 25,35kg and postoperatively 8,27kg. Bite force preoperatively had a mean of 56,8440kg and postoperatively was 30,8020kg. Comparing the presurgical and postsurgical bite force in the Wilcoxon signed-ranks test revealed difference, being identified p=0.28.   Conclusion: When the masseteric nerve is used as donor for facial reanimation surgery in patients with facial palsy, bite force is compromised postoperatively as revealed by occlusal sensor  evaluation. Nonetheless, despite these changes, the masseteric nerve rests as valuable tool in this type of surgical procedures.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Damian Palafox

Title: Free muscle transfer as a replacement for masseter in patients with Hemifacial Microsomia

Introduction: Hemifacial Microsomia is characterized for having phenotypic variability. Patients often have diverse degrees of mandible hypoplasia and auricular malformations. Soft tissue in the hemifacial area affected is affected as well.    Objective: To describe the bite force, masticatory function and electrical activity of the masseter muscle in children with Hemifacial Microsomia. We sought to describe the impact of the free muscle transfer surgery to replace the masseter in this group of patients.    Methods: 20 patients with Hemifacial Microsomia were included in this study and further divided accordingly to the Pruzansky Classification for mandibular hypoplasia. Maximum masticatory force and electromyography studies were performed in both sides of the face. Electromyography was performed in maximum intercuspation and without dentary contact. Mann-Whitney U Test was used for statistical analysis.    Results: Mean age was 7.2 years old. 65% of the patients were currently on primary or mixed dentition. 60% had a Pruzansky IIa and IIB mandible hypoplasia. The electromyographic valules from the non-dentary contact side compared to the contralateral side were 53.2 vs 89.4; p= 0.03. No significative differences were encountered in the bite force of patients. A patient in which a free muscle transfer was performed (gracilis flap), developed an increase in the bite force and increase in the vertical dimension of the mandibular body.    Conclusions: Patients with Hemifacial Microsomia have an evident difference in both bite force and electromyographic activity in the masseter muscles as compared to the non-affected side. Performing a free muscle transfer (gracilis flap) in the infancy period could promote facial skeleton growth in this group of patients.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Zachary Fridirici

Title: Muscle-Nerve-Muscle Grafting in Rats: Effects on Facial Reanimation

Outcome Objectives: Loss of facial and recurrent laryngeal nerve innervation can be devastating for otolaryngology patients. Primary neurorrhaphy and interposition nerve grafting are common methods for reinnervation. Muscle-nerve-muscle (MNM) grafting is an alternative. In this study, we established a viable muscle-nerve-muscle grafting model with the rat facial nerve and demonstrated similar return of facial function as compared to interposition grafting.   Methods:   A prospective study was performed in November of 2015 to April of 2016 using 36 adult male rats that were randomized into four groups. All groups started by having the zygomatic, buccal and mandibular branches of the right facial nerve cut. The first group had repair with interposition grafts, the second group had one muscle-nerve-muscle graft placed between vibrissae muscle pads, the third group had three grafts placed, and the control group had no further intervention. The rats were then blindly monitored for return of movement over the next 16 weeks.   Results: Similar results were seen between all three intervention groups in terms of vibrissae return of movement, nose symmetry and vibrissae orientation, and all were significantly improved as compared to the control.  Interposition graft rats had more axonal regeneration, but with smaller diameter axons than MNM rats. Additionally, the three MNM graft groups had the same amount of muscle mass retention as the interposition graft group.     Conclusions: MNM grafting may provide an alternative to other reanimation techniques and provide similar results. Embedding more grafts also seems to improve movement and muscle mass retention.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Ken Matsuda

Title: Surgical treatments for synkinesis around the orbital region

Objective  In the surgical treatment of orbital region with facial synkinesis, the aim of the operation is mainly to increase the height palpebral fissure of the affected side to improve the symmetry. This situation is quite different from that for the cases with complete facial paralysis, in which most attention is paid to reconstruct the function of the eyelid closure. Here we present our surgical strategies and methods for synkinesis around the orbital region. We present the procedures of the representative cases and results in 39 surgically treated cases.    Methods  1. Eyebrow   Most of the incomplete paralysis cases with synkinesis, the movement of the frontal muscle is still not enough, eyebrow lifting is performed using suprabrow or hairline skin excision.  Levator shortennig in the contralateral upper eyelid also contributed to improve eyebrow symmetry.  2. Upper eyelid  In most cases, levator shortening of the upper eyelid is performed to obtain more height of palpebral fissure. In most cases, simultaneous blephaloplasty and/or double eyelid plasty is planned. Reduction of orbicularis oris muscle is also planned depending on the symptom of the case. Careful attention should be paid not to induce postoperative lagophthalmos.   3. Lower eyelid  After the preoperative marking of the part with strong synkinetic movement, reduction of the orbicularis oris is performed via subcilliary incision. Sufficient reduction of the muscle is necessary to prevent the postoperative regression of the synkinetic movement.   Results  Although there were some cases with postoperative regression which required revision or Botulinum toxin A application, the symptom associated with the synkinetic movement were relieved in all cases. The effect can appear in whole face including contralateral side and perioral region.   Conclusion  These surgical treatments could be useful options for the facial synkinesis. Although the procedures are mostly static, its effects are dynamic.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Naohito Hato

Title: Recent Strategies in the Management of Traumatic Facial Nerve Paralysis

Introduction: In our previous study, the ideal time for decompression surgery for the traumatic facial nerve paralysis was the first 2 weeks in patients with severe, immediate-onset paralysis. Recently, we modified the later decompression surgery using basic fibroblast growth factor (bFGF) in a gelatin hydrogel to promote the regeneration of denervated nerves. Our experimental study suggested that bFGF-impregnated biodegradable hydrogel facilitates regeneration of the facial nerve in guinea pigs due to the sustained release of bFGF.     Objective: The aim of this study was to evaluate the regeneration-facilitating effects of novel facial nerve decompression surgery using bFGF in gelatin hydrogel in patients with severe paralysis after more than 2 weeks following the trauma by analyzing the therapeutic outcome of traumatic facial nerve paralysis.    Methods: Seven patients with facial nerve paralysis after temporal bone trauma who were treated after 2008 were studied retrospectively. The facial nerve was decompressed the fractured segments via mastoid. A bFGF-impregnated biodegradable gelatin hydrogel was placed around the exposed nerve. Regeneration of the facial nerve was evaluated by House-Brackmann (H-B) grading system. The outcomes were compared with our previous study.   Results: The recovery (H-B grade 1 or 2) rate of the novel surgery (85.7%) was significantly better than the rate of conventional surgery. To our knowledge, this is the first clinical report of the efficacy of a bFGF-gelatin hydrogel as a drug-delivery in patients with severe traumatic facial palsy.   Conclusions: When decompression surgery of the facial nerve is needed after more than 2 weeks following the trauma, application of the bFGF-gelatinehydrogel around the nerve might be a promising addition to improve the surgical outcomes.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Ki-Hong Chang

Title: What is the main factors affecting the results of surgical decompression in patients with acute peripheral facial nerve palsy?

Introduction: The surgical decompression in peripheral facial nerve palsy can be used in selected patients whose prognosis was expected to be unfavorable. However, not all patients fully recover from the facial palsy, even though the result of decompression surgery is generally good. In addition, the aspect of recovery is also variable in patients who showed favorable prognosis.    Objective: To analyze the results of decompression surgery and to find the main factors affecting prognosis.    Methods: Middle fossa approach or combined middle fossa and transmastoid approach was applied. This retrospective study was performed between Jan. 2003 and Dec. 2014. Amount of fibrosis was subjectively qualified by surgeon’s inspection when epineural incision was completed. 9 patients who were suitable for surgical decompression but denied operation were enrolled as negative control.   Results: The patients comprise of 5 Bell’s palsy and 6 Herpes zoster oticus, 4 men and 7 women, aged 56.8 years (41- 66 years), and neural degeneration of 95.7% (91-100%) in electroneurography. Time to operation from palsy onset was 24.3 days (16-33 days). It took 9 weeks (1-20 weeks) to reach to HB grade III after operation, and 23 weeks (10-38 weeks) to reach the final degree of facial palsy during 1 year of follow-up. All the surgical groups showed favorable recovery of HB grade I or II. Among 9 negative surgical control, 6 patients were recovered to HB grade I or II and 3 patients showed facial palsy less than HB grade IV.    Conclusion: The surgical group has a better prognosis than the control group, including time to HB grade III and final status of facial palsy. Among patients with decompression surgery, however, there was no relationship in causes of palsy, time to operation from onset of palsy, or amounts of fibrosis with respect to the final degree of palsy.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Li Li

Title: The effect of surgical repair on facial nerve function rebuilding after facial nerve injury

OBJECTIVE: To evaluate the effect of nerve repair after resection of facial nerve lesion.    METHODS: Data were collected for 23 patients undergoing  nerve repair after excision of facial nerve lesion regarding age, sex, the situation of facial nerve lesion, the defect of facial nerve, the methods of nerve repair, and facial electromyogram. Facisl functional was evaluated via the House-Brackmann grading system pre and 12 monthes post operation.   RESULTS: Functional outcomes of the patients preoperation were grade in 2 cases, grade II in1case, grade III in 2 cases, grade IV in 5 cases, grade in 9 cases, and grade in 4 cases. Facial electromyogram indicated motor unit potential decreased in 20 cases and disappeared in 3 cases.   Surgical methods for the patients who undertook partial facial nerve resection included great auricular nerve transplantation for 11 cases, sural nerve graft for 6 cases, hypoglossal nerve graft for 6 cases. Facial nerve function after operation according to the House-Brackmann system distributed were grade II in 8 patient, grade III in 7 patients, grade IV in 6 patient, grade in 1 patient, and grade  in 1patients.    The neurological function was significantly improved after operation. There were no correlation between the pre operatin and post operation facial nerve function. There was also no correlation between the time of facial paralysis preoperative and nerve function after operation   CONCLUSION: After the recetion of facial nerve tumor, as long as facial electromyogram indicated there was still existing motor action, facial nerve repair should be performed.This operation could effectively prevent facial muscle amyotrophy. Facial nerve transplantation or hypoglossal nerve bridge connection might be effective rescute method when the facial nerve coule not be reserved and directly rebuilded. Even if the facial function recoved poorly, they could also provid the condition for the delying repair.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Aurora Vincent

Title: Masseteric Nerve Transfer in the Treatment of Synkinesis

Introduction                 Synkinesis is the involuntary movement of one area of the face triggered by volitional movement of another; it is commonly encountered among patients affected by facial palsy.  Treatments for synkinesis include biofeedback muscular retraining and chemodenervation via the injection of botulinum toxin.  Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long term maintenance injections and may lose effect over time.  A permanent solution for synkinesis remains elusive.     Objective     To evaluate the novel application of masseteric nerve transfer in rehabilitation of the synkinetic smile.       Methods                 We performed masseteric-to-facial nerve transfer for synkinesis in three patients at a tertiary care teaching hospital.  We retrospectively reviewed the charts of these patients and identified demographic characteristics, facial palsy etiology, other interventions tried, changes in facial nerve grading system (FGS) scores, facial clinimetric evaluation (FaCE) scores, and Massachusetts Eye and Ear Infirmary FACE-gram software analysis post-operatively.       Results                 There were no post-operative complications; patients were followed for a mean of 308 days after surgery.  All patients were female, aged 41-53 years.  Bell’s palsy was the etiology in one case, while the other two occurred after acoustic neuroma extirpation.  All patients underwent chemodenervation for synkinesis with botulinum toxin injection on more than one occasion prior to masseteric nerve transfer.  FGS scores ranged from 3 to 4 pre-operatively and improved to 2.5-3 post-operatively.  Two patients reported improved FaCE scores after surgery, while one patient reported a worse score.  All patients noted subjective improvement in symptoms of oro-ocular synkinesis.     Conclusion                 Herein, we describe the novel application of masseteric nerve transfer for smile reanimation in the synkinetic patient.  This technique may allow for long-term improvement of synkinesis in patients who fail botulinum toxin therapy.  Our study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Aurora Vincent

Title: Modiolar Rotational Cheiloplasty: Addressing the Central Oval in Facial Paralysis

Introduction:      Facial paralysis is managed with both static and dynamic procedures, often addressing each third of the face, upper-, mid-, and lower-face, individually.  Some patients, who are not good candidates for dynamic procedures or elect for other reasons not to attempt reinnervation, are instead candidates for static improvement of facial palsy.  Current static procedures for the midface fail to adequately provide functional and aesthetic improvement, however, and there is a need for more effective static procedures for the ptotic midface.     Objective:       To describe a novel method of static midface suspension that produces improved functional and aesthetic outcomes compared to previous techniques.  Specifically, to describe the previously unpublished technique of static alar and oral commissure suspension via modiolar rotational cheiloplasty (MRC) with alar base transposition, and gingivobuccal sulcoplasty.       Methods:      We demonstrate a modiolar rotational cheiloplasty and alar base transposition first in cadaver dissection and second in a series of 10 patients at a tertiary care referral center who desired surgical intervention for paralysis of the central oval of the face.  We present subjective outcomes reported by our patients and objective improvements in facial appearance using the MEEI Face-gram Program.     Results:       We achieved efficient and effective suspension of the midface and lateralization of the alar base with our modiolar rotational cheiloplasty technique.  Our patients noted subjective improvement in drooling, dysarthria, nasal passage obstruction, and overall appearance.  The MEEI Face-gram Program demonstrated objective improvement in our patients’ symmetry of smile and position of the philtrum and nasal base post-operatively.      Conclusion:       Herein, we demonstrate that modiolar rotational cheiloplasty with alar base transposition is an effective and efficient static procedure for midface palsy that improves both function and cosmesis.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Masao Kakibuchi

Title: Management of periorbital deformities and symptoms in facial paralysis

Paralytic lagophthalmos and pseudo-ptosis are common periorbital deformities in the patients of facial paralysis. The causes of lagophthalmos are laxity of lower eyelid and retraction of both eyelids due to orbicularis oculi muscle paralysis. Pseudo-ptosis is the result of two different conditions. One is the combination of brow ptosis and blepharochalasis, and the other is hypertonicity and synkinesis of the orbicularis oculi muscle. Most important clinical problem in the patients is keratopathy caused by lagophthalmos. Pseudo-ptosis causes disfigurement and disturbance of visual acuity.Between January of 2003 and December of 2017, one hundred and twenty-five procedures were applied in ninety-nine patients with periorbital problems for facial palsy. Modified Kuhnt-Szymanowski procedures, wedge excision of lower eyelid, chonchal cartilage graft were used for paralytic ectropion of lower eyelid in thirty-five cases. Upper blepharoplasty was applied to pseudo-ptosis for blepharochalasis in twenty-three cases. Fifty-five cases of brow ptosis were corrected with brow lift using skin excision and/or periosteal flap. In ten cases of pseudo-ptosis for orbital oculi muscle contracture, levator advancement and/or muscle resection were applied. Gold plate implantation was used in two cases.The improvement of lid closure in lagophthalmos group and the visual field expansion in pseudo-ptosis group were obtained in all patients. Aesthetic improvement was also acquired in pseudo-ptosis cases. We experienced prolonged keratopathy and other temporary complications after surgery in five cases.  Although dynamic reconstruction using muscle transposition or transfer is essential for perioral reanimation, other procedures were effective and reliable in the management of periorbital problems for facial paralysis.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Richard Chalmers

Title: Lengthening Temporalis Myoplasty – The First 100 Cases. How We do it and What We have Learned

The Lengthening Temporalis Myoplasty has been used in our unit for over 8 years for facial reanimation in selected patients with facial palsy for a wide variety of causes. We present our operative technique and highlight our learning curve and what we have found to be the advantages and disadvantages of this technique.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: yuechen han

Title: The outcomes of the middle fossa approach facial nerve decompression for traumatic facial paralysis

Abstact   Objective: To report our outcomes of the middle cranial fossa approach facial nerve decompression in the treatment of traumatic facial paralysis.   Methods: 74 patients of traumatic facial paralysis in our department were involved in this retrospective study.   Results: There were 51 male and 23 female cases in these serious. The age was from 3 to 59 years old, and the median age was 32 years. History of facial paralysis was 7 days to 8 months respectively. 21 cases of facial paralysis occurred immediately after injury, while 53 cases were delayed. In 44 cases, the histories of facial paralysis were more than one month. Preoperative facial nerve functions were HB grade III in 2 cases, grade IV in 40 cases, and grade V in 32 cases. Temporal bone HRCT show temporal bone fracture line 95.94%, mastoid hyphema or mucosal thickening 85.13%, facial nerve geniculate ganglion fossa 82.43%. 74 cases of nerve injury were identified in the geniculate ganglion region. During the operation, temporal bone fracture were found 100%, nerve edema 98.64% and nerve sheath damage 17.56%, bone fragments embedded in  nerves 0.04%. All patients were followed up for more than 12 months and facial nerve function improved satisfied, grade HB-I and II in 44 cases, grade III in 28 cases and grade IV in 2 cases. Excepted for 2 cases of cerebrospinal fluid leakage, there were no other serious complications.   Conclusion: Tthe geniculate ganglion of the facial nerve was the most common area which was affected in temporal bone fracture. Most of the patients with serious traumatic facial paralysis could achieved a long-term outcome of HB III or better after middle fossa approach decompression. In our opinion surgical decompression was always helpful even if the facial paralysis was more than 1 months.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Kristin Faschan

Title: The Influence of Age and Etiology on Operative Outcomes in Facial Palsy after Cross Face Nerve Graft with Free Gracilis Muscle Transfer

Intro: Facial palsy etiologies are classified as congenital or acquired. Treatment strategies are based on the subject’s age, severity of disease, and surgeon experience.  It is unclear whether etiology affects outcome. Herein, we seek to compare outcomes after two-stage free gracilis muscle transfer (CFNG-FGMT) for long-standing facial palsy between patients with congenital versus acquired disease    Methods: A retrospective chart review was performed of all patients with facial palsy who received two-stage facial reanimation surgery from 2008-2016 at a single institution.  Postoperative surface EMG and Sunnybrook scores were recorded. Statistical analysis utilized Wilcoxon rank sum and fisher exact test for demographics and etiology. A univariate and multi-level mixed-effects regression analysis was performed to compare congenital vs. acquired patients who underwent CFNG-FGMT.   Results: Fourteen patients met inclusion criteria. Six patients had congenital facial palsy and 8 patients had acquired. The average age at time of surgery was 10.3±4.4 years for congenital and 14.0± 5.7 years for acquired etiology (p=0.20) Causes of congenital disease were idiopathic with 5 total patients and 1 birth trauma.  Causes for acquired facial palsy were tumor resection (5), meningitis (1), and trauma (2).  On univariate analysis, surface EMG scores averaged 55.36 for congenital patients and 33.63 for acquired patients (p=0.01).  However, using a mixed regression model that controlled for sex, age and time after surgery, there was no significant difference between congenital and acquired subjects in surface EMG measurements, open smile Sunnybrook scores, or total Sunnybrook scores (p=0.23, 0.88, and 0.52; respectively).   Conclusion: Our results demonstrate that there is no significant difference in post-operative facial symmetry or muscle activity for patients who have undergone two-stage CFNG-FGMT when comparing congenital versus acquired etiologies.  It appears that etiology in long-standing facial palsy does not affect overall surgical outcome of facial reanimation.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Tessa Hadlock

Title: The dually innervated gracilis free flap for smile- rigorous assessment of outcomes and spontaneity

Gracilis free tissue transfer for facial reanimation has become a commonplace option for patients lacking smile.  The muscle has been historically powered by either a cross face nerve graft, or an alternative cranial motor nerve, with the masseteric branch of the trigeminal nerve representing the most widespread and reliable option.  Several groups have described dually innervated flaps that may yield the benefits of each particular donor nerve.  However, to date there has been no rigorous assessment of smile results, including clinician-graded assessments, quantitative excursion, spontaneity determined by a validated assay, and quality of life improvements.  Herein, we present comprehensive outcomes from a series of 23 dually innervated free gracilis transfer procedures,  Discussion of potential pitfalls and a frank assessment of benefit will be included.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Nate Jowett

Title: Double-paddle free gracilis flap for two-vector smile reanimation: Technique and initial results

Smiling is a multivector action. Muscle transfer for smile reanimation typically re-establishes only the univector pull of the zygomaticus major at the oral commissure, without concurrent re-establishment of dynamic upper lip elevation necessary for social and complex smile. Here we describe in situ thinning and elevation of the gracilis as a double-paddle muscle flap with inset for two-vector smile reanimation, together with preliminary results from a series of patients with long-standing flaccid facial paralysis.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Luis Lassaletta

Title: Facial nerve repair with or without graft interposition: Technical variations according to the etiology and the lesion location.

Purpose: To evaluate the results of facial nerve (FN) reconstruction with or without graft interposition in different clinical scenarios. To analyze technical variations and their impact on the facial function outcome.   Material and Methods: Retrospective review of patients undergoing FN repair between 2001 and 2015. The study included 46 patients. Etiology of the paralysis included: ear surgery (n=3), parotid surgery (n=3), malignant parotid or temporal bone tumors (n= 11), trauma (n=2), vascular malformation (n= 1), petrous bone cholesteatoma (n= 2), facial nerve tumors (n= 7), Cerebellopontine (CPA) tumors (n=10). A reinforcement technique was preformed in 7 cases. FN was rehabilitated using direct coaptation or suture (n=4), or with interposition of different donor grafts (n= 42). Stitching sutures were used in the extratemporal portion and in 2 CPA cases. Fibrin glue was added in all but one case. FN function was evaluated the House-Brackmann (HB) grading system.   Results: The mean time to the first clinical signs of facial reinnervation was 10 months. Among the 46 patients undergoing FN repair in this period, some degree of reinnervation was detected in all but 6 cases, including 3 malignant parotid tumors. Half of these unsuccessful cases had received previous radiation. The rest of the patients achieved House-Brackmann grades III-IV, but 3 patients with a grade V. Additional reinnervation or dynamic techniques were offered to patients with poor results. Eye procedures and static techniques were used in all cases, as well as physical therapy.   Conclusion: FN reconstruction must be performed as soon as possible when a complete transection of the nerve is present. To obtain the best results a multidisciplinary approach is required. Reconstruction of the nerve from the brainstem to its terminal branches may require different technical variations according to the etiology of the paralysis and the lesion location.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Callum Faris

Title: Minimal Incision Nasolabial Fold Creation Technique In Facial Paralysis

Introduction   Flaccidity in facial paralysis results in soft tissue ptosis of the hemi-face through loss of resting muscular tone. This can affect all the facial aesthetic landmarks in the hemi-face. Loss or effacement of the nasolabial fold (NLF) has been shown to be the most important facial landmark contribution to disfigurement in facial paralysis. We described our technique to recreate the NLF through a minimal incision technique in the setting of facial paralysis.   Material and Methods   Institutional review board approval was obtained from the Massachusetts Eye and Ear Infirmary Human Studies Committee. All patients who underwent NLF modification by the Minimal Incision technique at our institution from February 2015 to August 2016 were included in this review. Demographic parameters including gender and age were recorded. Etiology of facial paralysis and type of facial paralysis (i.e., flaccid versus hypertonic) were noted. Duration of for facial paralysis prior to surgical intervention, age at time of NLF modification was also recorded, along with the patient’s chief complaints.   Results   The aim was to create a NLF at rest and during smile. The average age was 41 (range 9-90). 15 of the 21 patients had preoperative FaCE instrument scores were available and postoperative FACE instrument scores were available in all 17. 100% of patients had suitable pre and post-operative photos to allow rating by a clinician experience in facial reanimation surgery. Overall there were significant improvement in all outcome measures, Total eFace, Static eFace, Dynamic eFace, Midface eFace scores and FACE QOL measurements.   Conclusion   The minimal incision NLF creation technique effectively rehabilitates the NLF in facial paralysis without the addition of a long linear scar to the central midface.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Alex Murphey

Title: Masseteric Nerve Transfer for Facial Nerve Paralysis: A Systematic Review

Objective: To systematically review the available literature, and, when applicable, analyze the combined outcomes of masseteric nerve transfer in hopes of better defining its role in reanimation and guiding further research.   Methods: Two independent researchers conducted the review using PubMed-NCBI and Scopus literature databases for studies on masseteric nerve transfer for facial nerve paralysis. Studies that examined masseter nerve transfer with additional cranial nerve transposition/coaptation or muscle flap were excluded.   Results: A total of 13 articles met inclusion criteria with a total of 183 patients undergoing masseteric nerve transfer. Duration of paralysis was 14 (± 6) months. Most common cause of paralysis were cerebellopontine angle tumors (81%). Six studies transferred the masseteric nerve to the main facial nerve trunk, while seven used distal branches (buccal or zygomatic). Three studies used interposition nerve grafts with great auricular nerve. Two measures, improvement in oral commissure excursions and length from reanimation to muscle recovery, were measured consistently across the studies. Oral commissure excursion, reported in 4 studies, was improved by and average of 8.8 mm after nerve transfer. Time from surgery to first facial movement, described in 10 studies, and was found to be 5 (± 1.9) months across all reported studies. Distal branch coaptation significantly improved time to recovery vs. main branch coaptation (3.4 ± 1.1 vs. 6.1 ± 2.5 months, p < 0.0001). The use of interposition graft did not significantly affect length of nerve recovery (6.9 (±3.1) vs. 5.9 (±2.3) months, p=0.1344). Spontaneous smile was reported in seven studies and found to be present in 23% (25/108) of patients. Reported complications were minor and rare occurring in only 6.5% (12/183) of patients. Conclusion: Masseteric nerve transfer represents a good option for facial reanimation in patients and provides quick recovery and comparable facial symmetry and movement to other available nerve transfers.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Sinikka Suominen

Title: Mini-invasive fascia slings for static restoration of the paralyzed face

Introduction: Although facial reanimation with ether direct neurotisation or microneurovascular flaps is the optimal method for treatment of a paralysed face, many of our patients are not suitable candidates for these operations. Elderly patients or patients with major comorbidities need a simpler, more palliative treatment to be socially acceptable.   Patients and methods: Not satisfied with the described static methods the first author designed her own mini-invasive technique for static fascial support.   23-25 cm long and 5-7 mm wide fascia lata strips are harvested with a fascia stripper from 1-2 cm incisions. The strips are fixed to plastic suction drains that are pulled to place with a blunt troacar. The strips pass through the temporalis muscle, under the zygomatic arch to the nasolabial fold through a subperiosteal facelift incision and return subcutaneously to the temporal area.  Scars are placed in the hairline and intraorally. Tension is fixed in a semisitting position to slight overcorrection.   A series of 40 consecutive cases with mean 3 years follow up (1-6 yr)is presented.   Results: . All maintained achieved facial balance during follow up, even at 6 years. 8 patients required tightening of the strips in local anaesthesia at 6-12 mo, none were judged too tight. One active sportsman developed a painful fascia hernia at the donor site, no other donorsite problems occurred. One patient developed a postoperative infection of the cheek. Many of the patients can slightly move the cheek when biting as the strips have adhered to the temporalis muscle.   Conclusions: The described method is an easy fast technique for static restoration of the paralysed face and is a good alternative for patients that are not candidates for major reanimation surgery. The method also works in repositioning of neuromicrovascular gracilis flaps in case the fixation at the nasolabial fold has loosened.


 

TOPIC: Surgery for Facial Paralysis

Submitting Author: Sinikka Suominen

Title: Intraoral approach for facial reanimation

 

Introduction: In cases of permanent facial damage due to surgery or trauma, it is possible to restore the function of the muscles by either direct coaptation to a nearby donor nerve or by cross facial nerve grafting. However, the distance of a cross face graft makes the result slow and unpredictable.   The authors have used an intraoral approach in cross-facial nerve grafting, thus reducing the length of the graft to 12-14 cm. The benefit of this method is also that no additional facial scars will be created. The buccal branches of the facial nerves are readily available from an opening in the sulcus and the nerve tunnelled under the mucosa of the upper lip. The graft used was either the sural nerve or a vascularized  lateral femorocutaneous nerve. this can be combined with a masseter nerve transposition as a baby-sitter procedure.   6 cases will be presented with a follow-up of min 2 years, two had also masseter nerve transpositions. In t 4 patients regained partial facial function, and even function of the eye reappeared in three, confirmed by ENMG. The longer the duration of the facial paralysis, the less the result.   Conclusions: Reanimation through an intraoral approach is a simpler way to do cross-facial grafting.