Marc H. Hohman

Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center

To evaluate the range and incidence of facial palsy etiologies in cases presenting to a tertiary facial nerve center, and to review the broad and evolving spectrum of diagnostic and management approaches to the condition.

Objective Outcomes Analysis Following Microvascular Gracilis Transfer for Facial Reanimation: A Review of 10 Years’ Experience

IMPORTANCE Objective assessment of smile outcome after microvascular free gracilis transfer is challenging, and quantification of smile outcomes in the literature is inconsistent. OBJECTIVE To report objective excursion and symmetry outcomes from a series of free gracilis cases and investigate the predictive value of intraoperative measurements on final outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical chart review was undertaken of all patients who underwent microvascular free gracilis transfer for smile at our institution over the past 10 years. MAIN OUTCOMES AND MEASURES Outcome measures included the following: smile excursion, angle of smile with respect to the vertical midline, and facial symmetry during repose and with smile. Measurements were obtained using an automated tool for assessment of facial landmarks (FACE-Gram). An exhaustive set of intraoperative parameters including degree of recoil of the gracilis muscle following harvest, the degree to which the muscle foreshortened during stimulation of the obturator nerve, final stretched length of the inset muscle, surgeon assessment of neurorrhaphy and pulse pressure, ischemia time, number of sutures used during neurorrhaphy, nerve used to innervate the flap, and surgeon assessment of oral commissure overcorrection were recorded and placed into a linear regression model to investigate correlations with smile. RESULTS From March 2003 to March 2013, 154 microvascular free gracilis transfers were performed for facial reanimation at our institution, 14 (9%) of which were deemed failures. Of the remaining 140 flaps, 127 fulfilled inclusion criteria and constituted the study cohort. Smile excursion, angle excursion, and symmetry of the oral commissure at repose and with smile all improved following gracilis free flap (P < .05). Associations between selected outcomes measures and intraoperative gracilis measurements were identified. CONCLUSIONS AND RELEVANCE Facial reanimation using free gracilis transfer results in quantifiable improvements in oral commissure excursion and facial symmetry both at rest and with smiling. Associations between contractility and internal recoil of the flap and final outcome were identified. LEVEL OF EVIDENCE 4

Prospective comparison of handheld pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children

OBJECTIVES To compare pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children and to determine if a significant difference exists in sensitivity and specificity based on patient age and/or experience of the examiner. METHODS A prospective study of 102 patients, or 201 ears, enrolled over a 1-year period in a tertiary medical center. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for staff and resident-performed pneumatic otoscopy, staff and resident-performed binocular microscopy, and tympanometry. Tympanometry data were stratified for age. A kappa correlation was used to compare each tool to myringotomy result (gold standard) and to compare staff versus resident. RESULTS Binocular microscopy by staff pediatric otolaryngologist was the most sensitive, 88.0% (95% CI 81.4-94.7), and specific, 89% (95% CI 83.1-94.9). Resident binocular microscopy revealed a sensitivity of 81.5% (95% CI 73.6-89.5) and specificity 78.9% (95% CI 71.2-86.6). Staff was more sensitive and specific than resident at pneumatic otoscopy, sensitivity 67.9% (95% CI 57.6-78.3) and specificity 81.4% (95% CI 73.8-88.9) versus 57.7% (95% CI 46.7-68.7) and 78.4% (95% CI 70.4-86.4). Tympanometry had a much lower specificity for ages 5-12 months than for older children. CONCLUSIONS Binocular microscopy by staff pediatric otolaryngologist revealed the best sensitivity and specificity. Pneumatic otoscopy even performed by an inexperienced examiner is more sensitive and specific than tympanometry. The tympanometer is less specific in children under 1 year of age.

Health-related quality of life in 794 patients with a peripheral facial palsy using the FaCE Scale: a retrospective cohort study.

To describe the health‐related quality of life of patients visiting a tertiary referral centre for facial palsy, and to analyse factors associated with health‐related quality of life, using the FaCE Scale instrument.

Two-step highly selective neurectomy for refractory periocular synkinesis.

INTRODUCTION Botulinum toxin type A (BTA) has become a gold standard of treatment for facial synkinesis, and now is an integral part of the treatment paradigm for patients with this sequela. In our center, we routinely treat 30 patients per week with botulinum toxin. Addressing synkinesis via a multidisciplinary approach, we begin with physical therapy and later add chemodenervation to the regimen. Injections of BTA (onabotulinumtoxinA, Botox Cosmetic, Allergan Inc, Irvine, CA) are repeated every 3 to 6 months, if they offer symptom relief. Repeated BTA treatments can lead to decreased effectiveness through the well-described phenomenon of antibody development. Once BTA has lost its effectiveness, despite increased doses, we advance to type B botulinum toxin (BTB) (rimabotulinumtoxinB, Myobloc, Solstice Neurosciences LLC, Louisville, KY). We currently treat 390 patients with BTA injections; only 10 are receiving BTB. The same loss of effectiveness that occurs with BTA can occur with BTB; historically, these patients have continued their physical therapy but experience worsening of synkinesis symptoms in the absence of chemodenervation. To address this problem in the periocular area, we have refined the decades-old technique of selective neurectomy. Traditionally, the procedure did not identify specific nerve branches responsible for the synkinesis symptoms, resulting in either unsatisfactory relief, worsening of facial weakness, or a combination of both. Therefore, we resolved to avoid these problems through precise titration of the neurectomy. To this end, the procedure was divided into two steps: 1) Facial nerve dissection is done under general anesthesia; 2) The patient is awakened and recovered, and then the neurectomy is performed, achieving the exact degree of orbicularis oculi weakening required to decrease ocular synkinesis while avoiding lagophthalmos.

Epidemiology of iatrogenic facial nerve injury: A decade of experience

To determine the procedure‐specific incidence, risk factors, and injury patterns in patients with iatrogenic facial nerve injury as seen at a tertiary care facial nerve center.

A comparison of facial nerve grading systems.

Purpose This study aimed to compare a computerized tool to standard objective clinical scales for global and zone-specific assessment of facial nerve function. Methods This was a retrospective review of 77 patients with facial paralysis who underwent facial videography. Videos were independently scored by 3 facial nerve specialists using the House-Brackmann Scales (HBI and HBII). Digital scoring was performed with Facogram software. Scores were recorded and compared using intraclass and Pearson (r) correlations. Results Interobserver correlation was high with HBII, with overall scores in excellent agreement (intraclass correlation range, 0.78–0.95; P ⩽ 0.0001). There were strong correlations between Facogram and HBII (r ≥ 0.67, P ⩽ 0.0001) and strong intraobserver correlations between HBI and HBII (r ≥ 0.71, P ⩽ 0.0001). The HBII required more clinician time [mean (SD), 72 (21) seconds per case], compared with Facogram, which did not require any clinician time. Conclusions An automated, zone-specific facial analysis tool can eliminate clinician subjectivity and allow standardized assessment of facial paralysis.

Electrical Stimulation of Eye Blink in Individuals with Acute Facial Palsy: Progress toward a Bionic Blink.

Background: Elicitation of eye closure and other movements via electrical stimulation may provide effective treatment for facial paralysis. The authors performed a human feasibility study to determine whether transcutaneous neural stimulation can elicit a blink in individuals with acute facial palsy and to obtain feedback from participants regarding the tolerability of surface electrical stimulation for daily blink restoration. Methods: Forty individuals with acute unilateral facial paralysis, HB grades 4 through 6, were prospectively studied between 6 and 60 days of onset. Unilateral stimulation of zygomatic facial nerve branches to elicit eye blink was achieved with brief bipolar, charge-balanced pulse trains, delivered transcutaneously by adhesive electrode placement; results were recorded on a high-speed video camera. The relationship between stimulation parameters and cutaneous sensation was analyzed using the Wong-Baker Faces Pain Rating Scale. Results: Complete eye closure was achieved in 55 percent of participants using stimulation parameters reported as tolerable. In those individuals, initial eye twitch was observed at an average current of 4.6 mA (±1.7; average pulse width of 0.7 ms, 100 to 150 Hz), with complete closure requiring a mean of 7.2 mA (±2.6). Conclusions: Transcutaneous facial nerve stimulation may artificially elicit eye blink in a majority of patients with acute facial paralysis. Although individuals varied widely in their reported degrees of discomfort from blink-eliciting stimulation, most of them indicated that such stimulation would be tolerable if it could restore eye closure. These patients would therefore benefit from a biomimetic device to facilitate eye closure until the recovery process is complete. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Determining the threshold for asymmetry detection in facial expressions

To quantify the threshold for human perception of asymmetry for eyebrow elevation, eye closure, and smile, and to ascertain whether asymmetry detection thresholds and perceived severity of asymmetry differ in distinct facial zones.

Facial nerve repair: fibrin adhesive coaptation versus epineurial suture repair in a rodent model

Repair of the transected facial nerve has traditionally been accomplished with microsurgical neurorrhaphy; however, fibrin adhesive coaptation (FAC) of peripheral nerves has become increasingly popular over the past decade. We compared functional recovery following suture neurorrhaphy to FAC in a rodent facial nerve model.