Julian M. Nedzelski

Development of a sensitive clinical facial grading system.

Clinicians require a reliable and valid method of evaluating facial function following facial nerve injury. This tool should be clinically relevant, easy to administer, provide a quantitative score for reporting purposes, and be sensitive enough to detect clinically important change over time or with treatment. The objectives of this study were to develop and validate a well-defined grading system that would address the above mentioned points. All essential information, including precise definitions for each item, is presented on one page (Fig. 1, see next page). The facial grading system (FGS) is based on the evaluation of resting symmetry, degree of excursion of facial muscles and degree of synkinesis associated with each voluntary movement. Different regions of the face are examined separately using five standard expressions. All items are graded on point scales and a cumulative composite score, tabulated.

Is no treatment good treatment in the management of acoustic neuromas in the elderly

Two hundred twenty-eight patients with acoustic neuromas were seen between 1974 and 1985. Twenty-eight received no surgical treatment. Five patients who had undergone previous partial excision were excluded. The mean age was 71 years. The mean expected survival was 14.3 years. The mean follow-up interval was 51 months (range 12 to 120 months). All patients underwent at least two CAT scans (mean = 4). Tumor size ranged from 4 mm to 30 mm. Three patients underwent insertion of ventricular-peritoneal shunt for hydrocephalus (mean 16 months after presentation) and two patients partial tumor removal (mean 30 months after presentation). Tumor growth was measured in each patient using CAT scanning. Monitoring by clinical examination and regular CAT scanning is possible, but in this study 20% of patients required surgical treatment within one third of their expected survival time. This suggests that an expectant attitude for this group of patients may be a debatable form of management.

Cerebrospinal fluid leaks and meningitis in acoustic neuroma surgery

Cerebrospinal fluid leaks and associated meningitis are the most common life-threatening complications of surgery for acoustic neuromas. This retrospective study reviews 319 patients who had surgery for 321 acoustic tumors at the Sunnybrook Health Sciences Center, University of Toronto, from April 1975 to March 1990. Cerebrospinal fluid leaks occurred after 13.4% of primary tumor operations. Surgical repair was required in 6.2% of all patients; 4.4% needed more than one operation. Meningitis occurred in 5.3% of all patients. These complications were more common in larger tumors and after the combined translabyrinthine middle fossa approach. Transnasopharyngeal eustachian tube obliteration was used to stop recurrent cerebrospinal fluid leaks in two patients.

Efficacy of feedback training in long-standing facial nerve paresis

An efficacious treatment has not been available to patients with aberrant regeneration of the facial nerve as a result of Bells palsy or after acoustic neuroma excision. This prospective controlled trial examines the efficacy of electromyographic feedback versus mirror feedback as treatment strategies for patients suffering from long‐standing (18 months minimum) facial nerve paresis. Twenty‐five patients were randomly assigned to electromyography with mirror feedback or mirror feedback alone. Seven rural patients who did not undergo treatment served as controls. At 0,6, and 12 months, facial motor function was objectively quantified by linear measurement of facial movement, visual assessment of voluntary movement, and electrical measurement of facial nerve response to maximal stimulation. Statistically significant improvements were noted in both electromyography and mirror‐feedback groups with respect to symmetry of voluntary movement (P < .03) and linear measurement of facial expression (P < .01). The positive results of this controlled trial demonstrate that feedback training in combination with a structured home rehabilitation program is a clinically efficacious treatment for patients with facial nerve paresis.

Pain after surgery for acoustic neuroma.

Postoperative pain after surgery in the cerebellopontine angle (CPA) is acknowledged to occur, but is rarely taken into account as a factor in the analysis of morbidity of such surgery. It is widely acknowledged that some patients, having undergone such surgery, particularly by means of the suboccipital approach, report significant postoperative pain and headache. This study was undertaken to determine the incidence and severity of pain after excision of acoustic neuromas and to establish whether this differed between the suboccipital and translabyrinthine routes. Ninety-one percent of all patients (n = 58), who had the suboccipital approach used for removal of their tumor, were surveyed. A smaller group (n = 40), MAtched for tumor size, age, and sex, but in whom the translabyrinthine approach was used, was similarly studied. A standard questionnaire, designed to detect and quantify postoperative pain, was administered to each patient. Of patients who underwent tumor excision by means of the suboccipital approach, 63.7% experienced significant local discomfort and headache, whereas this was notably absent in all those who had undergone translabyrinthine excision. In view of the significant morbidity noted to follow the suboccipital approach, several modifications of the surgical technique used were devised.

Intratemporal facial nerve schwannoma: a management dilemma.

Objective: To report the findings in patients with facial nerve schwannoma in whom surgery was elected at onset versus patients treated expectantly. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Twenty-four patients with a mean age of 44 years (range, 18-65 yr) were followed for an average of 6 years (range, 1-19 yr). Intervention: Eleven patients underwent complete tumor excision and 13 patients were enrolled in ongoing monitoring only. Main Outcome Measures: Facial nerve function and hearing acuity were noted at the time of initial and last visits. Magnetic resonance imaging was used to determine tumor growth in those individuals treated expectantly and as a means of excluding tumor recurrence/persistence in those treated surgically. Results: Of the 11 patients who underwent tumor removal, the facial nerve was spared in 7. Eight had varying degrees of facial nerve dysfunction initially. In this group (mean follow-up, 8 yr), six patients had unchanged nerve function, four had improved nerve function, and one had worsened. No long-term recurrence was noted. Of the 13 patients followed expectantly, three had facial weakness initially. During the follow-up interval (mean, 5 yr), facial function remained unchanged for eight and worsened in five. During this interval, 4 of the 13 patients demonstrated tumor growth and 3 have recently undergone tumor removal. Conclusion: Facial nerve schwannomas are extremely slow growing and frequently present without facial dysfunction. It is possible to surgically remove these tumors while sparing the nerve; as a result, postoperative function is correspondingly better. Finally, the decision on how to treat these patients should be individualized and based on initial facial function, growth rate, surgical experience, and informed patient consent.

Reliability of the Sunnybrook Facial Grading System by novice users.

OBJECTIVES To evaluate the intrarater and inter-rater reliability of the Sunnybrook Facial Grading System (SFGS) by novice users. DESIGN Prospective interval study using one measurement instrument. SETTING Tertiary teaching hospital (Sunnybrook & Womens College Health Science Centre). METHODS Twenty-two patients with a wide spectrum of facial dysfunction recorded on videotapes were rated using the SFGS by eight novice observers independently in two different sittings separated by 3 weeks. The order of patients was randomized for the second sitting. Intraclass correlation coefficients were calculated for component scores and for total scores within and between raters. RESULTS The intrarater reliability coefficients for the eight raters ranged from .838 to .929. This largely overlaps with the data obtained in previous studies with expert raters. The inter-rater reliability for all eight raters at time 1 was .982 and for time 2 was .970. This is higher than what was previously obtained with expert raters. CONCLUSION The SFGS is as reliable when applied by novice users as by expert users.

Sunnybrook facial grading system: Reliability and criteria for grading†

In clinical research, which is distinctly quantitative and rigidly fixed to a written protocol, the need for precision is great, especially when multicenter trials are planned. The Sunnybrook Facial Grading System (SB) is a well‐established tool for assessing facial movement outcomes; however, some ambiguities do arise. The purpose of this study was to construct specific grading criteria and to test the intra‐rater and inter‐rater reliability before and after the use of these criteria. The hypothesis was that even in naïve observers, specific criteria improve reliability.

Early-deafened adult cochlear implant users: assessment of outcomes.

OBJECTIVE To determine whether adults deafened in the prelingual and perilingual stages of speech development realize objective and subjective benefits from cochlear implantation. METHOD Retrospective analysis of the open-set speech recognition and subjective data such as use and quality of life. RESULTS Between 1989 and 1999, 198 deafened adults underwent cochlear implantation at Sunnybrook and Womens College Health Sciences Centre. Of these, 44 patients were deafened pre- or perilingually. These subjects were implanted with a Nucleus 22, Nucleus 24 (Cochlear Corporation, Denver, Colorado, USA), or Clarion (Advanced Bionics Corporation, Sylmar, California, USA) device. The average age at implantation was 34 years (range 14-62 years). Significant differences in speech perception, as measured by a composite score of open-set word, phoneme, and sentence recognition, were found among groups who differed by type of education and communication training received in childhood. CONCLUSION By and large, open-set speech recognition in prelingually and perilingually deafened adults is inferior to that achieved in postlingually deafened adults and varies according to the type of communication training they received. However, cochlear implants have significantly improved the overall communication skills and quality of life in all subgroups of patients.

Acoustic neuroma surgery: the results of long-term hearing preservation.

Objective To report the long-term outcome hearing results following acoustic neuroma surgery. To determine whether changes, if any, in the thresholds of the operated ear are mirrored in the contralateral unoperated side. In addition, to identify predictive factors, if any, that may predispose individuals to hearing loss in the operated ear in the late post-operative period. Study Design Retrospective patient chart review Setting University Tertiary Referral Centre Patients From 1978 to 1997, one hundred and twenty six patients with small acoustic neuromas (less than 2cm as measured within in the cerebellopontine angle) underwent excision via the suboccipital (retrosigmoid) approach with the patient in the prone position. Hearing preservation was successful in 43 patients (34.1%). The audiometric data of thirty patients with a minimum follow-up interval of 36 months was analyzed. The mean follow-up period was 113.4 months (range 36-264, SD=57.8) and the mean age at surgery was 47.3 years (range 32 to 64, SD = 7.3). Outcome Measures Speech Reception Thresholds (SRT), Speech Discrimination Scores (SDS) and Pure-tone Audiometry (PTA, 0.5, 1 & 2 kHz) were noted on the operated and unoperated ears. The AAO Classification according to the Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma was used to assess hearing serviceability. Results Subsequent to including corresponding changes in the unoperated ear, the means of the SRT and PTA in the operated ear between the early and late post-operative periods were statistically significantly different (p=0.0012 & 0.034 respectively). Twelve (40%) patients demonstrated significant deterioration in hearing thresholds over time. Pre-operatively, 96.7% of patients had serviceable hearing (Class A & B). This falls to 76.6% in the early post-operative period and to 56.7% in the late post-operative period. Conclusion Our study highlights the finding that over time a significant number of individuals realize a greater ongoing hearing loss in the post tumour excision ear than the contralateral ear.