Facial Palsy: Diagnostic and Therapeutic Management, An Issue of Otolaryngologic Clinics of North America, Volume 51-6

191 Pages·2018·22.093 MB·English

by  Teresa O, Nate Jowett, Tessa Hadlock

Facial Palsy: Diagnostic
and Therapeutic
Management
Editors
TERESA M. O
NATE JOWETT
TESSA A. HADLOCK
OTOLARYNGOLOGIC
CLINICS OF NORTH
AMERICA
www.oto.theclinics.com
Consulting Editor
SUJANA S. CHANDRASEKHAR
December 2018 • Volume 51 • Number 6

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FacialPalsy:DiagnosticandTherapeuticManagement
Contributors
CONSULTING EDITOR
SUJANAS.CHANDRASEKHAR,MD,FACS,FAAOHNS
PastPresident,AmericanAcademyofOtolaryngology–HeadandNeckSurgery,Partner,
ENT&AllergyAssociates,LLP,ClinicalProfessor,DepartmentofOtolaryngology–Head
andNeckSurgery,ZuckerSchoolofMedicineatHofstra-Northwell,Hempstead,New
York,USA;ClinicalAssociateProfessor,DepartmentofOtolaryngology–HeadandNeck
Surgery,IcahnSchoolofMedicineatMountSinai,NewYork,NewYork,USA
EDITORS
TERESAM.O,MD,MArch,FACS
Director,FacialNerveCenter,VascularBirthmarkInstituteofNewYork,Departmentof
Otolaryngology–HeadandNeckSurgery,ManhattanEye,Ear,andThroatHospital,Lenox
HillHospital,NewYork,NewYork,USA
NATEJOWETT,MD
AssistantProfessor,DepartmentofOtolaryngology,DivisionofFacialPlasticandRe-
constructiveSurgery,MassachusettsEyeandEar,HarvardMedicalSchool,Boston,
Massachusetts,USA
TESSAA.HADLOCK,MD
Chief,DivisionofFacialPlasticandReconstructiveSurgery,Professor,Departmentof
Otolaryngology–HeadandNeckSurgery,MassachusettsEyeandEar,HarvardMedical
School,Boston,Massachusetts,USA
AUTHORS
NICHOLASS.ANDRESEN,MD
DepartmentofOtolaryngology–HeadandNeckSurgery,JohnsHopkinsSchoolof
Medicine,Baltimore,Maryland,USA
BABAKAZIZZADEH,MD,FACS
AssociateClinicalProfessor,DivisionofHeadandNeckSurgery,DavidGeffenSchoolof
MedicineatUCLA,LosAngeles,California,USA;CenterforAdvancedFacialPlastic
Surgery,BeverlyHills,California,USA
JENNIFERBAIUNGO,PT,MS
PhysicalTherapist,FacialPlasticandReconstructiveSurgeryDepartment,Facial
NerveCenter,MassachusettsEyeandEar,FacialNerveCenter,Boston,Massachusetts,
USA
KOFIDEREKBOAHENE,MD
Professor,Otolaryngology–HeadandNeckSurgery,JohnsHopkinsSchoolofMedicine,
DepartmentofOtorhinolaryngology,TheJohnsHopkinsHospital,Baltimore,Maryland,USA

Copyright ©2018. Elsevier Inc. All rights reserved.
vi Contributors
GREGORYH.BORSCHEL,MD,FACS,FAAP
DivisionofPlasticandReconstructiveSurgery,TheHospitalforSickChildren,Toronto,
Ontario,Canada
PATRICKBYRNE,MD
Professor,Otolaryngology–HeadandNeckSurgery,JohnsHopkinsSchoolofMedicine,
Baltimore,Maryland,USA
MAURAK.COSETTI,MD
DepartmentofOtolaryngology–HeadandNeckSurgery,IcahnSchoolofMedicineat
MountSinai,NewYorkEyeandEarInfirmaryofMountSinai,NewYork,NewYork,USA
LEAHTHANF.DOMESHEK,MD
DivisionofPlasticandReconstructiveSurgery,TheHospitalforSickChildren,Toronto,
Ontario,Canada
JOSEPHR.DUSSELDORP,MBBS,MS,FRACS
SeniorLecturer,DepartmentofOtolaryngology–HeadandNeckSurgery,Massachusetts
EyeandEar,HarvardMedicalSchool,Boston,Massachusetts,USA;Departmentof
PlasticandReconstructiveSurgery,RoyalAustralasianCollegeofSurgeons,Universityof
Sydney,Sydney,Australia
AARONFAY,MD
MassachusettsEyeandEar,Boston,Massachusetts,USA
JULIAL.FRISENDA,MD
CenterforAdvancedFacialPlasticSurgery,BeverlyHills,California,USA
BRUCEJ.GANTZ,MD
ProfessorandChair,DepartmentofOtolaryngology–HeadandNeckSurgery,University
ofIowaHospitals&Clinics,IowaCity,Iowa,USA
TESSAA.HADLOCK,MD
Chief,DivisionofFacialPlasticandReconstructiveSurgery,Professor,Departmentof
Otolaryngology–HeadandNeckSurgery,MassachusettsEyeandEar,HarvardMedical
School,Boston,Massachusetts,USA
NATALIEHOMER,MD
DepartmentofOphthalmology,MassachusettsEyeandEar,HarvardMedicalSchool,
Boston,Massachusetts,USA
LISAE.ISHII,MD,MHS
Professor,Otolaryngology–HeadandNeckSurgery,JohnsHopkinsSchoolofMedicine,
Baltimore,Maryland,USA
MASARUISHII,MD,PhD
AssociateProfessor,Otolaryngology–HeadandNeckSurgery,JohnsHopkinsSchoolof
Medicine,Baltimore,Maryland,USA
ANDREWWILLIAMJOSEPH,MD,MPH
ClinicalLecturer,DepartmentofOtorhinolaryngology–HeadandNeckSurgery,Divisionof
FacialPlasticandReconstructiveSurgery,UniversityofMichiganMedicalSchool,Ann
Arbor,Michigan,USA
NATEJOWETT,MD
AssistantProfessor,DepartmentofOtolaryngology,DivisionofFacialPlasticandRe-
constructiveSurgery,MassachusettsEyeandEar,HarvardMedicalSchool,Boston,
Massachusetts,USA

Copyright ©2018. Elsevier Inc. All rights reserved.
Contributors vii
VIVIANKAUL,MD
DepartmentofOtolaryngology–HeadandNeckSurgery,IcahnSchoolofMedicineat
MountSinai,NewYorkEyeandEarInfirmaryofMountSinai,NewYork,NewYork,USA
JENNIFERC.KIM,MD
AssociateProfessor,DepartmentofOtorhinolaryngology–HeadandNeckSurgery,Divi-
sionofFacialPlasticandReconstructiveSurgery,UniversityofMichiganMedicalSchool,
AnnArbor,Michigan,USA
MARISSAPURCELLILAFER,MD
Resident,DepartmentofOtolaryngology–HeadandNeckSurgery,NewYorkUniversity,
NewYork,NewYork,USA
SURESHMOHAN,MD
DepartmentofOtolaryngology–HeadandNeckSurgery,MassachusettsEyeandEar,
HarvardMedicalSchool,Boston,Massachusetts,USA
JASONC.NELLIS,MD
Resident,Otolaryngology–HeadandNeckSurgery,JohnsHopkinsSchoolofMedicine,
Baltimore,Maryland,USA
TERESAM.O,MD,MArch,FACS
Director,FacialNerveCenter,VascularBirthmarkInstituteofNewYork,Departmentof
Otolaryngology–HeadandNeckSurgery,ManhattanEye,Ear,andThroatHospital,Lenox
HillHospital,NewYork,NewYork,USA
JAMESA.OWUSU,MD
DepartmentofHeadandNeckSurgery,Mid-AtlanaticPermanenteMedicalGroup,
McLean,Virginia,USA
ALICIAM.QUESNEL,MD
AssistantProfessor,DepartmentofOtolaryngology,Otology,Neurotology,and
SkullBaseSurgery,MassachusettsEyeandEar,HarvardMedicalSchool,Boston,
Massachusetts,USA
MARAWERNICKROBINSON,PT,MS,NCS
PhysicalTherapist,FacialPlasticandReconstructiveSurgeryDepartment,FacialNerve
Center,MassachusettsEyeandEar,Boston,Massachusetts,USA
FELIPESANTOS,MD
AssistantProfessor,DepartmentofOtolaryngology,Otology,Neurotology,and
SkullBaseSurgery,MassachusettsEyeandEar,HarvardMedicalSchool,Boston,
Massachusetts,USA
DANIELQ.SUN,MD
AssistantProfessor,DepartmentofOtolaryngology–HeadandNeckSurgery,Johns
HopkinsUniversitySchoolofMedicine,Baltimore,Maryland,USA
MARTINUSM.VANVEEN,MD
DepartmentofOtolaryngology–HeadandNeckSurgery,MassachusettsEyeandEar,
HarvardMedicalSchool,Boston,Massachusetts,USA;DepartmentofPlasticSurgery,
UniversityMedicalCenterGroningen,UniversityofGroningen,Groningen,The
Netherlands
RONALDM.ZUKER,MD,FRCS,FACS,FAAP
DivisionofPlasticandReconstructiveSurgery,TheHospitalforSickChildren,Toronto,
Ontario,Canada

Copyright ©2018. Elsevier Inc. All rights reserved.
FacialPalsy:DiagnosticandTherapeuticManagement
Contents
Foreword:You’reNeverFullyDressedWithoutaSmile xv
SujanaS.Chandrasekhar
Preface:FacialPalsy:DiagnosticandTherapeuticManagement xvii
TeresaM.O,NateJowett,andTessaA.Hadlock
TheImportanceandPsychologyofFacialExpression 1011
LisaE.Ishii,JasonC.Nellis,KofiDerekBoahene,PatrickByrne,andMasaruIshii
Facialexpressionisofcriticalimportanceininterpersonalinteractions.Thus,
patientswithimpairedfacialexpressionduetofacialparalysisexperience
impairedsocialinteractions.Numerousstudieshaveshownthatpatients
with facial paralysis and impaired facial expression suffer social conse-
quencesasdemonstratedbybeingratednegativelywithregardstoattrac-
tiveness, affect display, and other traits. This has been demonstrated
subjectively and objectively. Fortunately, reconstructive surgeries that
restoretheabilitytoexpressemotioncanrestorenormalcyinthesepatients.
AGeneralApproachtoFacialPalsy 1019
NateJowett
Managementoffacialpalsycanbedaunting.Thisarticlepresentsacon-
ceptualframeworkforclassificationandtherapeuticmanagementoffacial
palsy.
OutcomeTrackinginFacialPalsy 1033
JosephR.Dusseldorp,MartinusM.vanVeen,SureshMohan,and
TessaA.Hadlock
Outcome tracking in facial palsy is multimodal, consisting of patient-re-
ported outcome measures, clinician-graded scoring systems, objective
assessmenttools,andnoveltoolsforlaypersonandspontaneityassess-
ment. Patient-reported outcome measures are critical to understanding
burdenofdiseaseinfacialpalsyandeffectsofinterventionsfromthepa-
tientperspective.Clinician-gradedscoringsystemsareinherentlysubjec-
tiveandno1singlesystemsatisfiesallneeds.Objectiveassessmenttools
quantifyfacialmovementsbutcanbelaborious.Recentadvancesinfacial
recognition technology have enabled automated facial measurements.
Novel assessment tools analyze attributes such as spontaneous smile,
emotional expressivity, disfigurement, and attractiveness as determined
bylaypersons.
MedicalManagementofAcuteFacialParalysis 1051
TeresaM.O
Acute facial paralysis (FP) describes acute onset of partial or complete
weaknessofthefacial musclesinnervatedbythefacialnerve.AcuteFP

Copyright ©2018. Elsevier Inc. All rights reserved.
x Contents
occurswithinafewhourstodays.Thedifferentialdiagnosisisbroad;how-
ever, the most common cause is viral-associated Bell Palsy. A compre-
hensive history and physical examination are essential in arriving at a
diagnosis.MedicaltreatmentforacuteFPdependsonthespecificdiag-
nosis;however,corticosteroidsandantiviralmedicationsarethecorner-
stoneoftherapy.Lackofrecoveryafter4monthsshouldpromptfurther
diagnosticworkup.
SurgicalManagementofAcuteFacialPalsy 1077
DanielQ.Sun,NicholasS.Andresen,andBruceJ.Gantz
Bell palsy and traumatic facial nerve injury are two common causes of
acute facial palsy. Most patients with Bell palsy recover favorably with
medical therapy alone. However, those with complete paralysis (House-
Brackmann6/6),greaterthan90%degenerationonelectroneurography,
andabsentelectromyographyactivitymaybenefitfromsurgical decom-
pression via amiddle cranial fossa(MCF) approach.Patients withacute
facialpalsyfromtraumatictemporalbonefracturewhomeetthesesame
criteriamaybecandidatesfordecompressionviaanMCFortranslabyrin-
thineapproachbasedonhearingstatus.
ManagementofFlaccidFacialParalysisofLessThanTwoYears’Duration 1093
AndrewWilliamJosephandJenniferC.Kim
Flaccidfacialparalysisresultsindisfiguringfacialchanges.Thetreatment
offlaccidfacialparalysisiscomplexandtreatmentapproachesshouldbe
determined based on duration and the causes of paralysis, status and
accessibility ofthe affectedfacial nerve,medical comorbidities, and pa-
tient-specific goals. Although primary nerve repair is the preferred treat-
ment strategy when possible, nerve substitution procedures are the
mainstay of treatment for patients with flaccid facial paralysis of less
than2yearsduration.
ManagementofLong-StandingFlaccidFacialPalsy:PeriocularConsiderations 1107
NatalieHomerandAaronFay
Ineffectiveeyelidclosurecanposeaseriousriskofinjurytotheocularsur-
faceandeye.Incasesofeyelidparesis,systematicexaminationoftheeye
and ocular adnexa will direct appropriate interventions. Specifically, 4
distinct periorbital regions should be independently assessed: eyebrow,
upper eyelid, ocular surface, and lower eyelid. Corneal exposure can
lead to dehydration, thinning, scarring, infection, perforation, and blind-
ness. Long-term sequelae following facial nerve palsy may also include
epiphora,gustatorylacrimation,andsynkinesis.
ManagementofLong-StandingFlaccidFacialPalsy:Midface/Smile:Locoregional
MuscleTransfer 1119
JamesA.OwusuandKofiDerekBoahene
Masseter and temporalis muscle transfer is an effective technique for
restoringfacialsymmetryandcommissureexcursioninflaccidfacialparal-
ysis.Adherencetotheprinciplesandbiomechanicsofmuscletransferis
essentialforachievingoptimalresults.Muscletransferhastheadvantage

Copyright ©2018. Elsevier Inc. All rights reserved.
Contents xi
ofbeingsinglestagedwithfastrecoveryoffunction.Itisparticularlyuseful
inpatientswithlowlifeexpectancyormultiplecomorbiditieswhereamore
complex,multiplestageproceduremaybedetrimental.
FreeGracilisTransferandStaticFacialSuspensionforMidfacialReanimationin
Long-StandingFlaccidFacialPalsy 1129
NateJowettandTessaA.Hadlock
Videocontentaccompaniesthisarticleathttps://www.oto.theclinics.
com/.
Thisarticle presentsanapproachto reanimation ofthe midface inlong-
standing flaccid facial palsy by means of functional free gracilis transfer
andstaticfacialsuspension.
ManagementofLong-StandingFlaccidFacialPalsy:StaticApproachestothe
Brow,Midface,andLowerLip 1141
MarissaPurcelliLaferandTeresaM.O
Chronic flaccid facial paralysis (FFP>2 years) may be approached with
staticanddynamictechniques.Ahorizontalzonalassessmentevaluates
theupper,middle,andlowerthirdsoftheface.Surgeryistailoredtoanin-
dividual’sdeficits,goals,andhealthstatus.Whiledynamicreanimationis
the gold standard for rehabilitation, there are cases in which static ap-
proachesaremoreappropriateormaybeusedasanadjuncttodynamic
techniques.ThisarticlefocusesonthesurgicalmanagementofFFPpri-
marilyusingstaticapproachestotheindividualzonesofthefacetocreate
restingsymmetry.
FacialRehabilitation:EvaluationandTreatmentStrategiesforthePatientwith
FacialPalsy 1151
MaraWernickRobinsonandJenniferBaiungo
Videocontentaccompaniesthisarticleathttp://oto.theclinics.com/.
Thisarticledescribesthemostwidelyusedclinician-gradedandpatient-
reportedoutcomemeasures,anddescribesfacialrehabilitationstrategies
for acute and chronic facial palsy, and rehabilitation following dynamic
facial reanimation surgery. The multimodality rehabilitation of the facial
palsy patient is determined by the extent of facial nerve injury, specific
functionaldeficits,thepresenceofsynkinesis,andthepatient’sindividual
goals. Appropriate intervention, including patient education, soft tissue
mobilization, neuromuscular reeducation, and chemodenervation, de-
creasesfacialtensionandimprovesfacialmusclemotorcontrol,physical
function,facialexpression,andqualityoflife.
SurgicalManagementofPostparalysisFacialPalsyandSynkinesis 1169
BabakAzizzadehandJuliaL.Frisenda
Videocontentaccompaniesthisarticleathttp://www.oto.theclinics.
com/.
Modifiedselectiveneurectomyofthedistalbranchesofthebuccal,zygo-
matic, and cervical branches of the facial nerve in addition to platysmal

Copyright ©2018. Elsevier Inc. All rights reserved.
xii Contents
myotomyisaneffectivesurgicalprocedureforthetreatmentofpostfacial
paralysissynkinesis.Successofthisproceduredependsonidentification
of the peripheral facial nerve branches, preservation of zygomatic and
marginalmandibularbranchesthatinnervatekeysmilemuscles,andabla-
tion of buccal and cervical branches that cause lateral and/or inferior
excursionoftheoralcommissure.Resultsarelong-lasting;objectiveim-
provements in electronic clinician-graded facial function scale score,
House-Brackmannscore,anddecreasedbotulinumtoxin-Arequirements
havebeenobserved.
EvaluationandManagementofFacialNerveSchwannoma 1179
AliciaM.QuesnelandFelipeSantos
Facialnerveschwannomasarebenignperipheralnervesheathtumorsthat
arisefromSchwanncells,andmostcommonlypresentwithfacialparesis
and/orhearingloss.ComputedtomographyandMRIarecriticaltodiag-
nosis. Management decisions are based on tumor size, facial function,
and hearing status. Observation is usually the best option in patients
withgoodfacialfunction.Forpatientswithpoorfacialfunction,theauthors
favorsurgicalresectionwithfacialreanimation.Thereisgrowingevidence
to support radiation treatment in patients with progressively worsening
moderatefacialparesisandgrowingtumors.
ManagementofVestibularSchwannoma(IncludingNF2):FacialNerve
Considerations 1193
VivianKaulandMauraK.Cosetti
Current consensus on optimal treatment of vestibular schwannoma
remainspoorlyestablished;treatmentoptionsincludeobservation,stereo-
tacticradiosurgery,microsurgicalresection,medicaltherapy,oracombi-
nation of these. Treatment should be individualized and incorporate the
multitude of patient- and tumor-specific characteristics known to affect
outcome.Treatmentparadigmsforsporadicandneurofibromatosistype
2–related tumors are distinct and decision-making in neurofibromatosis
type2isuniquelychallenging.Inallcases,treatmentshouldmaximizetu-
morcontrolandminimizefunctionaldeficit.
ManagementofBilateralFacialPalsy 1213
LeahthanF.Domeshek,RonaldM.Zuker,andGregoryH.Borschel
Bilateralfacial paralysisisarareentitythatoccurs inboth pediatric and
adultpatientsandcanhavecongenitaloracquiredcauses.Whenparalysis
doesnotresolvewithconservativeormedicalmanagement,surgicalinter-
ventionmaybeindicated.Thisarticlepresentstheauthors’preferredtech-
nique for facial reanimation in patients with bilateral congenital facial
paralysis.Specifically,astagedbilateralsegmentalgracilistransfertoipsi-
lateralnervetomasseterisdiscussed.

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