April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Joseph & Kim

Long-standing flaccid facial paralysis present for greater than 2 years will result in ultrastructural changes within the distal facial nerve branches and within the dener- vated facial muscles, which may preclude dynamic reinnervation of the native facial musculature. However, these structures are generally preserved in patients who pre- sent less than 1 year from the time of onset, and up to 2 years in some cases. The goal of this article is to discuss management and rehabilitation strategies for patients who present with flaccid facial paralysis of less than 2 years’ duration.

EVALUATION AND INITIAL MANAGEMENT OF FACIAL PARALYSIS Management of Acute Facial Paralysis

All practitioners who work with patients with facial paralysis should be well-versed in the workup and management of acute facial paralysis. When these patients present acutely, the cause of facial weakness is often uncertain. Some patients may be referred with the diagnosis of Bell palsy before any meaningful evaluation. Others may have undergone unnecessarily extensive and costly workups. In 2013, the American Academy of Otolaryngology–Head and Neck Surgery developed the Bell palsy clinical practice guideline, which outlines many important topics in the clin- ical decision-making for these patients. 3 (See Teresa M. O’s article, “ Medical Management of Acute Facial Paralysis ,” in this issue.) Individualized Treatment Planning The management of facial paralysis should be individualized based on several patient- specific factors that are outlined here. During initial consultation, all new patients with flaccid facial paralysis undergo a thorough history and physical. The medical history interview of the patient should focus on the onset and characteristics of the paralysis (eg, acute complete, chronic progressive), associated symptoms (eg, hearing loss, tinnitus, dysphagia, diplopia), involved facial nerve branches, and whether any perceived recovery has begun to take place. Patients should specifically be ques- tioned about treatments that have been attempted (eg, oral steroids, electrical stimu- lation, surgery). Most important, patients’ individual perception of their facial disability and goals of care should be solicited. One of the most critical factors in treatment planning is determining the cause for facial paralysis. The cause can vary tremendously and includes traumatic (temporal bone fracture or traumatic transection); neoplastic (cerebellopontine angle tumor, facial nerve schwannoma, glomus tumors, salivary gland lesions); iatrogenic (inadver- tent facial nerve transection or facial nerve sacrifice); and inflammatory, infectious, and congenital causes. Understanding the natural course of disease associated with the various causes will aid in determination of an optimal treatment strategy. When planning treatments, it is extremely important to identify if other cranial nerves have been (or expected to become) affected by the disease process. Assessment of cranial nerves should be comprehensive, with a particular focus on assessment of the motor and sensory functions of the trigeminal nerve, as well as the motor functions of the contralateral (unaffected) facial nerve, glossopharyngeal nerve, spinal accessory nerve, and hypoglossal nerve. This evaluation is critical because nerve substitution procedures are among the mainstays of flaccid facial paralysis treatment when the duration of paralysis is less than 2 years. Assessment of Affected Facial Zones Physical examination of patients with facial paralysis should proceed in a systematic manner. The authors find it helpful to assess the affected branches of the facial nerve

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