Objective Facial Motion Analysis in Patients With Facial Nerve Dysfunction

Objectives/Hypothesis To objectively measure facial motion at various facial landmarks using a video‐computer interactive system. Study Design Clinical, prospective, non‐randomized. Methods A video‐computer interactive system, The Peak Motus Motion Measurement System, was used to study linear displacement at preselected facial landmarks in the normal and abnormal face. Subjects with normal facial function (n = 34) and patients with abnormal facial function (n = 26) from various etiologies were studied. The sites studied were marked with reflective beads. Of a larger repertoire of expressions, two expressions (eyes closed and closed‐lip smile) were studied in all subjects. The percent asymmetry in facial displacement between the sides of the face was calculated. The sensitivity of this measurement to facial dysfunction was evaluated. The presence of synkinesis was examined by quantifying the displacement at facial sites that were remote to the sites primarily involved in a given facial expression. Test–retest reliability of the percent asymmetry measurement was evaluated with the paired t test. Results The video‐computer interactive approach used accurately detected and quantified gross and subtle changes in facial function. The sensitivity of the percent asymmetry measurement was 95% (both expressions) for patients with apparent facial dysfunction (House‐Brackmann rating >I/VI). In patients with facial nerve dysfunction, displacement on the presumably normal side was significantly excessive in 27% to 35%, depending on the expression. With this interactive computer‐video system, synkinesis was detected in 58% of the pathologic subjects during the eyes closed or closed‐lip smile expressions. The paired t test indicated strong test–retest reliability (r = 0.73–0.99) of the percent asymmetry measurement. Conclusions The present report indicates that this approach to the assessment of facial motion is sensitive to facial dysfunction. This computer‐video interactive system is able to quantify synkinesis. A grading system for the magnitude of synkinesis, based on the magnitude of the displacement at remote facial sites, is proposed. The common occurrence of excessive facial motion on the presumably normal side of affected individuals indicates that patients with facial paralysis often overcompensate by exaggerating the normal side in an effort to move the affected side. This system is of value in the objective measurement of normal facial function and may prove a useful tool to quantify the outcomes of various medical and surgical treatments for facial nerve dysfunction.     

Masseteric-zygomatic nerve transfer for the management of eye closure-smile excursion synkinesis

ObjectiveThe purpose of this study is to illustrate the efficacy of masseteric-to-zygomatic nerve transfer to address eye closure-smile excursion synkinesis after facial nerve paralysis.BackgroundSynkinesis after facial nerve paralysis represents a wide range of facial movement disability. One manifestation is involuntary smiling with eye closure and a concomitant reduction of oral commissure movement with attempted smile (“frozen smile”) – arising as a result of aberrant fibers populating the zygomatic branch-muscle complex. This is a particularly difficult area to treat with conservative management. We propose a single-stage procedure to sever the dysfunctional zygomatic nerve and perform a masseteric-zygomatic nerve coaptation to recover a voluntary smile.MethodsWe present a case series of eight patients with eye closure/smile excursion synkinesis who underwent single-stage masseteric-zygomatic nerve transfer by a single surgeon. The surgical technique and indications for surgery were reviewed. Patients underwent facial movement analysis using Emotrics.ResultsWe analyzed the pre- and post- surgical photographic images of 8 patients with synkinesis (7 female, 1 male). Masseteric-facial nerve transfer was performed from 18 months to 22 years after the initial facial paralysis. Eyelid and brow positioning were more symmetric after surgery, with discrepancy between affected and unaffected side decreasing from 2.1 to 1.0 mm (p < .05) and 1.74 to 1.29 mm (p < .05), respectively. Symmetry of smile excursion postoperatively was also improved with commissure excursion discrepancy decreasing from 8.8 to 3.78 mm (p < .05). Discrepancy in the smile angle when comparing affected to unaffected side improved postoperatively from 10.3 to 5.2 degrees (p < .05). Improvement in oral commissure height was noted, but not statistically significant.ConclusionsThe masseteric-zygomatic nerve transfer is a useful technique for the treatment of eye closure/smile excursion synkinesis after failure of chemodenervation and/or physical therapy.     

Reconstruction of complex peripheral facial nerve defects by a combined approach using facial nerve interpositional graft and hypoglossal-facial jump nerve suture

Objectives/Hypothesis:

To describe a modified facial nerve reconstruction technique for complex defects of the facial fan after parotid surgery that avoids synkinesis between upper and lower face.

Study Design:

Retrospective case series.

Methods:

Patients who had undergone radical parotidectomy with a large defect of the facial fan, reconstruction of the upper face by facial nerve interpositional graft, and reconstruction of the lower face by hypoglossal‐facial nerve jump nerve suture were included in this series.

Results:

Four patients underwent the modified combined approach after tumor resection and prior to postoperative radiotherapy in three of the four cases. Surgery was combined with an upper lid weight implantation. Regeneration of the face was successful in all cases within 12 to 16 months. Most important, the separated reanimation of the upper and lower face circumvented synkinesis of the upper and lower face. This factor was essential for good functional results. Using the hypoglossal jump technique instead of a classical cross‐nerve suture technique prevented the sacrifice of ipsilateral tongue function.

Conclusions:

The presented method offers satisfactory results for facial reanimation and avoids synkinesis between the upper and lower face. Using the jump technique instead of a classic hypoglossal transfer as it was described originally for the combined approach avoids long‐term sequelae for the tongue. Laryngoscope, 121:2402–2405, 2011     

Facial-motion analysis with a video and computer system: a preliminary report

HYPOTHESIS: To investigate the feasibility of a video and computer-assisted system for evaluating the temporal and spatial aspects of facial motion during selected facial expressions in a pilot group of six normal adults. Evaluation of the diverse medical and surgical treatments for facial paralysis and paresis cannot occur until objective, reliable, and sensitive measures of the spatial and temporal aspects of facial function at specific facial landmarks are developed. METHODS: Facial motion at predetermined facial locations was assessed using a commercially available computer-interactive motion analysis system, which is based on videography principles. The displacement, velocity, and acceleration data were averaged across all trials and subjects. Time plots also were obtained for the left versus right side. RESULTS: The greatest mean maximum displacement (resultant vector) occurred during the eyebrow lift expression, reaching 1.2 cm in magnitude. The mean maximum velocity (resultant vector), which ranged from 4.5 to 8.5 cm/s for the dynamic facial expressions, was greatest for the eyes closed tight expression. The mean maximum acceleration (resultant vector), which ranged from 193 to 465 cm/s/s, was greatest for the eyebrow lift expression. Symmetrical time plots were obtained. The system documented synkinesis by revealing substantial left upper eyelid motion during the nose-wrinkle expression in an illustrative case with slight left facial dysfunction. CONCLUSION: This approach to facial motion analysis is feasible for the simultaneous, multiregional, spatial-temporal assessment of facial expressions. Because motion at relatively remote regions could be quantified, this approach is potentially useful for the evaluation of synkinesis.     

Individualized management of facial synkinesis based on facial function

Objectives: The researchers analyzed facial patterns in subjects with facial synkinesis after facial paralysis and evaluated the involved muscles to aid in the development of effective treatments for facial synkinesis.

Methods: A total of 142 subjects were included in the study, the primary measure for synkinesis was determined by video analysis involving the strongest combination of two muscle groups that contributed to facial expression. The secondary measure of synkinesis was the analysis of its severity using the SB grading system, while observing the number of facial synkinetic movements.

Results: The most common type of facial synkinesis was oral–ocular synkinesis (n?=?137). Other synkinesis such as ocular–oral, ocular–nasal, ocular–chin, ocular–stapedial, chin–ocular and chin–oral synkinesis continued to coexist together with oral–ocular synkinesis. The results of BTX-A treatment are assessed based on the number of facial synkinetic movements observed and the evaluation of initial facial function.

Conclusion: The effectiveness of botulinum toxin A (BTX-A) treatment should be considered on an individual basis, according to the initial state of facial function. A patient with mild facial synkinesis restricted to the oral–ocular area and with a high score on the Sunnybrook (SB) facial nerve grading system would be the best candidate for BTX-A treatment.     

Factors affecting the effect of physical rehabilitation therapy for synkinesis as a sequela to facial nerve palsy

Objective

To investigate factors affecting the effect of physical rehabilitation therapy for synkinesis as a sequela to facial nerve palsy.

Early versus late gold weight implantation for rehabilitation of the paralyzed eyelid.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to evaluate the outcomes and complications associated with early gold weight implantation for management of the paralyzed eyelid. STUDY DESIGN: A retrospective review of clinical charts was conducted to analyze results and complications in patients who underwent gold weight implantation within 30 days of onset of facial nerve paralysis and to compare these outcomes with those of patients who received gold weights after a traditional waiting period. METHODS: The charts of 67 patients who underwent gold weight implantation during the time period of this study were reviewed. Patients were categorized into "early" or "late" groups based on whether gold weights were implanted before or after 30 days following onset of facial nerve paralysis. Etiology of facial nerve paralysis, degree of paralysis, timing of surgery, and outcomes of the procedure, including degree of lid closure and complication rates, were compared between the two groups. RESULTS: Of the 67 patients, 49.3% underwent gold weight implantation within 30 days of onset of paralysis and 50.7% received gold weights after 30 days. A total of 89.2% of all patients who underwent implantation in this study achieved satisfactory lid closure after the initial procedure. Both early and late implantation groups had statistically similar lid closure and complication rates. CONCLUSIONS: Implantation of gold weights within 30 days of paralysis is as effective for the management of paralytic lagophthalmos as delayed implantation and is not associated with higher complication rates. Early implantation of gold weights should be considered in all patients with paralytic lagophthalmos.     

Validation of the Synkinesis Assessment Questionnaire

OBJECTIVE: To validate the Synkinesis Assessment Questionnaire (SAQ), a newly developed patient-graded instrument to evaluate facial synkinesis. STUDY DESIGN: This was a prospective clinical questionnaire validation study. METHODS: A total of 65 patients with facial nerve disorders were recruited from the Facial Nerve Center. In 28 patients (group I), the SAQ, a preliminary 10-item instrument, was administered at the initial visit and repeated within 3 weeks without any medical or surgical intervention. In 37 patients (group II), the SAQ was administered before botulinum toxin therapy for facial synkinesis and again 2 weeks after Botox therapy. In addition, the instrument was administered to 20 healthy subjects without facial nerve dysfunction (group III). The reliability, validity, and responsiveness of the SAQ were assessed. RESULTS: Test-retest reliability for the SAQ was high (Spearman's rank correlation r = 0.876, P < .0001). Internal consistency of the instrument was assessed by calculating the Cronbach alpha value. This analysis supported the deletion of one item from the final SAQ. The Cronbach alpha for the final SAQ was 0.859. Construct validity analysis showed a statistically significant improvement in SAQ scores (P < .001) after successful administration of botulinum toxin for treatment of facial synkinesis. There was a highly statistically significant difference (P < .0001) in SAQ scores between normal subjects (group III) and patients with facial synkinesis (group II). CONCLUSIONS: The SAQ is a simple, patient-graded instrument designed to assess facial synkinesis. Instrument analysis suggests that it is a reliable and valid instrument for the assessment of facial synkinesis. The validated SAQ is the first dedicated instrument designed to assess facial synkinesis.     

Impact of early eyelid weight placement on the development of synkinesis and recovery in patients with idiopathic facial paralysis

PurposeDetermine the impact of upper eyelid weight placement at 3 months post onset of idiopathic facial paralysis (IFP) on the recovery of facial function in patients with lagophthalmos.MethodsThis is a retrospective review of patients with incomplete recovery of IFP—defined as a Sunnybrook Facial Grading Scale (FGS) score of less than 100, 3 months after onset. Only patients with FGS and Facial Clinimetric Evaluation (FaCE) scores recorded at 3 and 12 months were included. Patients were categorized into 3 groups: Group A, lagophthalmos with eyelid weight placement; Group B, lagophthalmos without eyelid weight placement; Group C, complete eye closure (CEC) without eyelid weight placement. The eye comfort domain and composite score of the FaCE questionnaire were analyzed. Voluntary eye closure, synkinesis with eye closure, overall synkinesis and the composite score of the FGS were also analyzed. Paired two-tailed t-test was used to evaluate the data comparing the 3 and 12 month FaCE and FGS scores within and between the 3 groups.ResultsThe change in composite FGS score significantly increased from month 3 to month 12 in Group A as compared to Group B (37 vs 4.25, P = 0.01). While Group A had significantly lower eye comfort (−12.5, P = 0.01), voluntary eye closure (−1.75, P = 0.05) and overall FGS scores (−28.75, P = 0.04) at 3 months compared to those in Group C, there were no differences between these two groups at 12 month follow-up.ConclusionsFor patients with lagophthalmos at 3 months, early eyelid weight placement may lead to improved facial function at 12 months.     

Comparison of postoperative facial nerve outcomes between translabyrinthine and retrosigmoid approaches in matched-pair patients

OBJECTIVES/HYPOTHESIS: The objective was to assess whether the translabyrinthine approach for acoustic tumor removal offers better postoperative facial nerve function compared with the retrosigmoid approach. STUDY DESIGN: Retrospective case review from a tertiary otology referral center. METHODS: Patients who had undergone either retrosigmoid or translabyrinthine approach for removal of acoustic neuroma from January 1, 1980, to December 31, 1999, were included in the study. Two groups of patients were created, one containing retrosigmoid cases and the other, translabyrinthine. Attempts were made to match each retrosigmoid case to a translabyrinthine case with regard to tumor size, patient age, and date of operation. This matching served to eliminate these variables from influencing postoperative facial nerve outcomes. From an initial pool of 450 patients, 35 pairs of patients were matched for the study. Facial nerve functions were reported at immediate, 3-month, and 1-year postoperative periods. RESULTS: Patient demographics demonstrated that matched patients had almost identical tumor size, patient age, and date of operation. Comparisons of postoperative facial nerve functions between the matched groups revealed that retrosigmoid approach carried 2.86 times higher risk of facial nerve dysfunction during the immediate postoperative period. However, by 1 year, the facial nerve outcomes were similar between the two groups. CONCLUSION: Compared with the translabyrinthine approach, retrosigmoid approach carries a higher risk of postoperative facial nerve dysfunction during the immediate postoperative period. However, long-term facial nerve outcomes are identical between the two approaches.     

Grading facial nerve function: why a new grading system, the MoReSS, should be proposed.

OBJECTIVE: To compare the interobserver variability of a new grading system to the currently recommended House-Brackmann Grading Scale. STUDY DESIGN: Prospective case-control study. SETTING: Tertiary referral center. PATIENTS: All patients with a facial nerve paresis/paralysis (whatever the cause). INTERVENTION: All patients were evaluated for their facial nerve function by three observers, independently, using both the new system and the House-Brackmann Grading Scale. MAIN OUTCOME MEASURE: The level of agreement between the three observers using both scales. RESULTS: With the movement, rest, secondary defects, and subjective scoring grading scale, a higher percentage of agreement between the observers was noticed than with the House-Brackmann Grading Scale. CONCLUSION: The movement, rest, secondary defects, and subjective scoring grading system is more useful for grading facial nerve dysfunction in clinical practice than the House-Brackmann Grading Scale.     

Long-term functional outcome in facial nerve graft by fibrin glue in the temporal bone and cerebellopontine angle

The aim of this study was to evaluate the functional outcome of facial nerve repair with fibrin glue in end-to-end anastomosis and intermediate nerve graft. Thirty-six patients undergoing facial nerve repair by end–to-end anastomosis or facial nerve grafting using exclusively fibrin glue between 1986 and 1999 were included in this retrospective study. The population comprised ten vestibular schwannomas (28%), nine temporal bone fractures (25%), seven facial nerve schwannomas (19%), four facial nerve hemangiomas (11%), two iatrogenic facial nerve interruptions (6%) and four miscellaneous facial nerve lesions (11%). Data were reviewed concerning etiology, location of the nerve interruption, type of repair and postoperative facial function according to the repaired facial nerve recovery scale (A: normal; B: independent movements of eyelid and mouth; C: strong closure of eyelids and mouth; D: incomplete eyelid closure; E: minimal movement; F: no movement). Eleven patients (31%) underwent end-to-end nerve anastomosis and 25 (69%) underwent intermediate facial nerve grafting. The mean follow-up period was 50 months (range: 3–95). Among patients followed-up more than 18 months (n=20), a score of B or C was obtained in 16 patients (80%), a score D in 2 cases (10%) and a score E in 2 cases (10%). The type of repair and the site of interruption did not influence the results. Fibrin glue is a simple, rapid and efficient means of facial nerve repair. In case of intraoperative facial nerve interruption, this type of repair can be attempted in any location at the time of the tumor removal.     

Mona Lisa syndrome: solving the enigma of the Gioconda smile

The Mona Lisa smile is presented as a possible example of facial muscle contracture that develops after Bell's palsy when the facial nerve has undergone partial wallerian degeneration and has regenerated. The accompanying synkinesis would explain many of the known facts surrounding the painting and is a classic example of Leonardo da Vinci as the compulsive anatomist who combined art and science.     

Functional assessments of the rodent facial nerve: a synkinesis model

Objectives/Hypothesis: Rodent whisker movement has been used as a tool, after facial nerve manipulation, to quantify functional recovery. We have recently established a method to study functional correlates of aberrant regeneration of the facial nerve. Our objective was to establish normative parameters for both spontaneous and induced whisking and blinking behavior in a large group of normal rats. Study Design: Prospective animal study. Methods: Eighty animals underwent quantitative facial movement testing to measure simultaneous vibrissal movement and ocular closure for each side independently. Right and left C‐1 whisker positions were continuously recorded for 5‐minute sessions, and changes in infrared detection corresponding to eye closure were continuously recorded. Whisking and blinking were elicited by delivery of olfactory stimuli (10 s scented airflows) and corneal air puffs. Whisks were counted and analyzed, and eye closures were counted. Results: Whisking amplitude, velocity, and acceleration were consistent with literature values. Air puff delivery elicited an ipsilateral blink 99% of the time, a contralateral blink 18% of the time, and changes in or initiation of bilateral whisking 70% of the time. Olfactory stimulus delivery prompted a change in whisking behavior 83% of the time, and eye closure 20% of the time. Conclusions: This study establishes normative data for assessing cranial nerve VII‐controlled facial movement in four separate facial regions. We demonstrate the capability and tendency of animals to move their orbicularis oculi muscles independently of and simultaneously with their midfacial muscles. This model provides an excellent tool for the study of aberrant regeneration after facial nerve injury in the rodent.     

Facial nerve dysfunction after parotidectomy: the role of local factors

OBJECTIVES/HYPOTHESIS: The objective was to analyze the incidence and factors associated with facial nerve dysfunction after conservative parotidectomy with facial nerve dissection. STUDY DESIGN: A retrospective unicentric study in a tertiary care center with prospective record of studied factors. METHODS: Over a 10-year period, 131 patients with normal facial nerve function underwent a superficial or total conservative parotidectomy with nerve dissection performed by one surgeon for primary benign or malignant tumors. Facial nerve function was assessed on the first postoperative day and at 1 month and 6 months after the parotidectomy. Extent of surgery, histopathological findings, tumor size, close contact of tumor with facial nerve, and sex and age of the patient were reviewed. These variables were studied in a chi2 statistical univariate and stratified analysis to determine their association with postoperative facial nerve dysfunction. RESULTS: Incidence of postoperative facial nerve dysfunction was 42.7% on the first postoperative day, 30.7% at 1 month after the parotidectomy, and 0% at 6 months after the parotidectomy. The most common dysfunction was paresis in a single nerve branch (48.2%), in particular, the marginal mandibular branch. Total parotidectomy was associated with a significantly higher incidence of facial nerve dysfunction during the first postoperative period (60.5% at day 1 and 44.7% at month 1) than superficial parotidectomy (18.2% at day 1 and 10.9% at month 1) (P < .001). In patients with total parotidectomy, close contact of the tumor with the facial nerve was found to have statistical causal relation with facial nerve weakness. In patients with superficial parotidectomy, inflammatory conditions were found as factors that increased postoperative facial nerve dysfunction. CONCLUSION: In the study series of conservative parotidectomies with facial nerve dissection, only extent of surgery and particular local conditions of nerve dissection, especially the close contact of tumor with facial nerve and inflammatory conditions, were found to be associated with postoperative facial nerve dysfunction.     

面神经鼓乳段定位及术中面瘫预防

目的:根据颞骨解剖结合中耳手术体会,探讨面神经走行定位,避免中耳手术中面神经损伤.方法:用30侧颞骨标本,模拟面神经减压术的手术步骤暴露面神经鼓乳段,确定面神经走行,用易见且恒定的标志进行面神经定位.结果:面神经水平段位于水平半规管与镫骨之间达匙突前上;垂直段位于鼓室后壁,垂直段后缘延长线与水平半规管后1/3相交,夹角为(117.04±2.42)°,其深度位于水平半规管及鼓环平面以下;外膝位于水平半规管前下方.水平半规管中点至面神经最短距离为(1.97±0.53)mm,砧骨短脚至面神经最短距离为(1.03±0.29)mm,匙突至面神经最短距离为(0.93±0.25)mm,镫骨头至面神经最短距离为(1.18±0.42)mm,前庭窗平面鼓沟至面神经的距离为(3.08±0.28)mm,圆窗平面鼓沟与面神经的距离为(2.13±0.34)mm.结论:水平半规管凸、砧骨短脚、镫骨、鼓环及匙突,是面神经鼓乳段理想的定位标志.熟悉面神经走行,可提高中耳手术安全性.     

Bell's palsy: diagnosis, management and results of treatment

A series of 100 consecutive cases of idiopathic Bell's palsy treated by facial nerve decompression are presented. These procedures were accomplished without injury to the facial nerve, hearing or balance and without the production of a mastoid cavity. One hundred percent normal facial function was the result in 22 patients with normal excitability subjected to facial nerve decompression. Sixty-eight patients who had surgery after loss of nerve excitability obtained an average of 80 percent return of function with varying degrees of synkinesis in most cases. The decision regarding the nature and timing of treatment should be a subjective one, made after a careful analysis of the available facts and each patient's own circumstance. The availability of a promptly accomplished and precisely performed facial nerve decompression allows every patient to have a minimal risk of permanent facial deformity.     

面瘫后口眼联带运动的肌电图研究及临床意义

目的探讨面瘫后口眼联带运动的电生理实质。方法对41例已有临床口眼联动现象的周围性面瘫患者做了肌电图检查,同心针电极放置在降口角肌内记录,嘱患者做眨眼和闭目动作,观察降口角肌肌电信号的变化,健、患侧对比分析,探讨联动现象的电生理实质。结果在做眨眼或闭目运动时,所有患者患侧降口角肌内均能记录到异常的联动电位,呈两种特征,闭目时为一种连续的、波幅较低的随意动作电位样的冲动,眨眼时表现为一种与眼睑运动同步的持续(30～350)毫秒的多相电位。在做健侧降口角肌检查时,发现8例患者肌电图异常,其中健侧有周围性面瘫病史的2例引出了异常联动电信号,另有6例引出了纤颤电位,这6例曾经历过健侧面部的针灸或小针刀治疗,其余健侧肌电图正常的33例健侧面部均无疾病、手术或有创治疗史。结论①面瘫后口眼联带运动的病理生理基础是神经错向再生,本应支配眼轮匝肌的面神经纤维与支配降口角肌的神经纤维产生了联系。②面部针灸、小针刀有可能损伤颅外段面神经分支或末梢。