Keywords
facial nerve paralysis - facial recovery - grading scale
Introduction
Facial paralysis has a profound functional, cosmetic, and psychological impact on
affected patients. A variety of facial nerve grading systems have been described in
the literature. The most commonly used grading method is the House-Brackmann grading
scale that was adopted by the American Academy of Otolaryngology-Head and Neck Surgery
in 1985.[1] Other notable facial grading scales include the Sunnybrook, Yanagihara, Nottingham,
and Sydney.[2]
[3]
[4]
[5] The most commonly used facial nerve grading systems were designed to assess progressive
neural recovery with an anatomically intact facial nerve.[6] In their initial paper, House and Brackmann state that their facial nerve grading
scale was intended to assess facial nerve recovery of an intact nerve.[7] Patients who undergo surgical procedures for advanced lateral skull base tumors
that require facial nerve and adjacent musculature resection and cases of long-standing
facial nerve paralysis often require multiple static and mimetic procedures to optimize
cosmetic result and return of long-term function.[8]
[9] These can include the use of free muscle transfer, in conjunction with neural grafting,
oculoplastic techniques, and static soft tissue tightening procedures.
Existing facial recovery grading scales do not accurately assess this patient population.
Individuals in this population are often automatically assigned a House-Brackmann
score of 3 or 4.[6] This void prevents clinicians from properly describing and communicating facial
reanimation in this unique patient population.
Methods
The proposed facial recovery grading scale demonstrated in [Table 1] divides facial recovery assessment into three areas: the periorbital, midface, and
synkinesis. All three of these areas play a prominent role in determining functional
recovery and cosmetic results following facial reanimation. The scoring for each region
is based on a 0 to 2 point scale with 2 points indicating the best level of function
and zero indicating the worst level of function. For example, with regard to eye closure,
patients with corneal show are awarded 0 points and patients with complete eye closure
are awarded 2 points. The cumulative point total from the three areas of assessment
determine the patients' overall function and their letter grade. Grading patient overall
function ranges from A to F with A the best function and F the worst level of functioning
and cosmesis. Letter grades were chosen because they are an efficient means of communicating
patients' function because the vast majority of clinicians are familiar with the ABC
grading scale.
Table 1
Proposed facial recovery grading scale
|
Category
|
Score
|
Objective assessment
|
|
|
Periorbital
|
0
|
Corneal show
|
|
|
1
|
Scleral show
|
Point total
|
Grade
|
|
2
|
Complete closure
|
5–6
|
A
|
|
Midface
|
0
|
No movement
|
4
|
B
|
|
1
|
Minimal movement
|
3
|
C
|
|
2
|
Nasolabial pulling
|
2
|
D
|
|
Synkinesis
|
0
|
Severe
|
0–1
|
F
|
|
1
|
Minimal
|
|
|
2
|
No movement
|
|
Results
The three patients in this study underwent surgical resections that sacrificed the
facial nerve and adjacent musculature or developed long-standing paralysis of the
facial nerve. Each patient's facial recovery was graded utilizing the proposed facial
recovery grading system. Each patient has three pictures seen in [Figs. 1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9], one demonstrating resting tone, and two showing function in the periorbital and
midface regions.
Fig. 1 Patient 1 demonstrating resting tone.
Fig. 2 Patient 1 demonstrating complete eye closure. He would be awarded 2 points for this
level of function.
Fig. 3 Patient 1 demonstrating midface movement. He would be awarded 2 points for midface
movement and 1 point for mild of synkinesis. This man would be awarded a total of
5 points for grade A function.
Fig. 4 Patient 2 demonstrating resting tone.
Fig. 5 Patient 2 demonstrating complete eye closure. He would be awarded 2 points for this
level of function.
Fig. 6 Patient 2 demonstrating some midface movement with minimal synkinesis. One point
would be awarded for each area of assessment. He would be awarded a total of 4 points.
Fig. 7 Patient 3 demonstrating resting facial tone.
Fig. 8 Patient 3 demonstrating complete eye closure. She would be awarded 2 points.
Fig. 9 Patient 3 demonstrating no detectable midface movement earning no points and minimal
synkinesis earning 1 point. She would be awarded a total of 3 points for grade C function.
Case 1: A 53-year-old man underwent a right parotidectomy and radiation therapy outside
of the LUMC health care system for adenoid cystic carcinoma. He subsequently developed
a recurrence. When he presented to LUMC, his facial nerve was intact and symmetric.
This man underwent a right preauricular-infratemporal fossa approach for right radical
parotidectomy with ipsilateral selective neck dissection. He was reconstructed with
an anterolateral thigh free flap and medial antebrachial nerve graft. The only additional
surgical procedure he underwent was debulking of his free flap 3 months postoperatively.
The photographs here are ∼ 26 months following his initial surgery. Additionally he
did not require any botulinum toxin injections or physical therapy. He would be awarded
a total of 5 points: 2 points for complete eye closure, 2 points for nasolabial pull,
and 1 point for minimal synkinesis.
Case 2: A 64-year-old man underwent a right parotidectomy with facial nerve preservation
outside the LUMC health care system for adenoid cystic carcinoma with disease at the
stylomastoid foramen and around the facial nerve. When he presented at Loyola he had
complete right facial paralysis. He underwent a preauricular-infratemporal fossa approach
for radical parotidectomy and selective neck dissection. This defect was reconstructed
with a right serratus free flap, right sural nerve graft, and had a 1.4-g platinum
weight placed. Additionally this patient underwent postoperative radiation therapy
at LUMC. The images are ∼ 18 months from his initial surgery. He did not undergo any
botulinum toxin injections or physical therapy. This patient would be awarded a total
of 4 points for grade B function: 2 points for complete eye closure, 1 point for mild
midface movement, and 1 point for minimal synkinesis.
Case 3: A 74-year-old woman underwent right translabyrinthine craniotomy in 2006 for
an 2.2-cm acoustic neuroma that was noted intraoperatively to be adherent to the facial
nerve. This patient had slight right-sided synkinesis with intact facial function
following this initial surgery. She developed a recurrent 2.5-cm acoustic neuroma
and underwent right transcochlear craniotomy in 2010. She underwent canthoplasty with
right gold weight placement shortly after surgery for right-sided facial paralysis
House-Brackmann VI/VI. After she failed to demonstrate gains in facial function 9
months following surgery, she underwent right parotidectomy with facial nerve exposure,
facial nerve decompression lateral to the geniculate, and a split hypoglossal to facial
nerve anastomosis. At the time of the pictures she was ∼ 16 months out from her 12–7
anastomosis and had not undergone any additional surgeries, physical therapy, or botulinum
toxin injection. She would be awarded a total of 3 points corresponding to grade C
function: 2 points for complete eye closure, 0 points for midface movement, and 1
point for minimal synkinesis.
Discussion
All three patients in this study underwent operative procedures that required resection
of the facial nerve and adjacent musculature or developed long-standing facial nerve
paralysis following a surgical procedure. Each patient underwent facial reanimation
techniques and could not have had their facial recovery assessed with the grading
scales currently available in the literature. Each was graded based on three aspects:
the periorbital region, midface region, and the presence of synkinesis. Each aspect
has a point range with 0 indicating the worst level of functioning and 2 demonstrating
the best level of functioning. Summing the point values from each area of evaluation
yields a point total that corresponded to a letter grade of functioning. The usefulness
of the presented grading scales was demonstrated in evaluating three patients who
underwent various static and mimetic facial reanimation procedures. The ideal facial
recovery grading scale for patients who have undergone static and mimetic facial reanimation
should have several characteristics. It should be applicable to this unique patient
population, easy to use in a busy clinical setting, accurately describe a patient's
facial recovery, and demonstrate interobserver reliability. The proposed facial recovery
grading scale is applicable to this population, easy to use, and allows clinicians
to accurately describe facial recovery. A future area of investigation would be a
study to determine interobserver reliability utilizing this grading scale. Patients
who lack an intact facial nerve should not have their facial function described in
relation to the House-Brackmann scale because it was not designed for use in this
patient population.
Conclusion
The proposed facial nerve grading scale provides a means of grading facial recovery
for a unique population of patients. The facial nerve grading scales most frequently
cited in the literature rely on an intact facial nerve. The grading scale proposed
in this article allows for a concise method for regional evaluation of patient facial
recovery in patients who have undergone both static and mimetic facial reanimation.
