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Dynamic Reanimation for Facial Paralysis Workup

  • Author: Steven M Parnes, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jan 20, 2016
 

Laboratory Studies

Electrophysiologic testing is very useful in predicting recovery of neural functioning and determining motor endplate function. Electroneurography (ENoG) is useful in the acute period after facial paralysis. Within 5-14 days after injury, an ENoG study determines the percent of denervation. If 90% degeneration of the nerve is present, the prognosis for return of function is quite poor. In situations of smaller percent degeneration, the patient should be observed for 12-24 months for any return of facial nerve function.

Electromyography (EMG) is a beneficial examination 2 weeks after injury and beyond. The examination may show polyphasic action potentials of the examined muscle, which indicated active neural input and a good prognosis for eventual return of function. Fibrillations indicate denervation with intact motor endplates, which portends a poor prognosis for recovery of function without surgical intervention. Electrical silence, seen in the setting of prolonged facial paralysis, signifies that the motor endplates are no longer viable, and, therefore, nerve transposition procedures would ultimately fail.

If any doubt exists, a muscle biopsy always can be performed to observe for any surviving motor endplates. This procedure helps determine the appropriate techniques, such as nerve procedures, musculofascial transpositions, or static techniques.

 
 
Contributor Information and Disclosures
Author

Steven M Parnes, MD Head, Professor, Department of Otolaryngology-Head and Neck Surgery, Albany Medical College

Steven M Parnes, MD is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, The Triological Society, American Medical Association, Association for Research in Otolaryngology, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Coauthor(s)

Anna Butrymowicz, MD Resident Physician, Division of Otolaryngology-Head and Neck Surgery, Albany Medical Center

Anna Butrymowicz, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American College of Surgeons, American Heart Association, Triological Society, New York State Society of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Jennifer P Porter, MD Assistant Professor, Department of Otorhinolaryngology, Division of Communicative Science, Chevy Chase Facial Plastic Surgery

Jennifer P Porter, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Texas Medical Association

Disclosure: Nothing to disclose.

References
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Superior view of the intracranial, meatal, labyrinthine, and tympanic segments of the facial nerve; anterior inferior cerebellar artery (AICa), cochlea (C), chorda tympani (CT), external auditory canal (EAC), geniculate ganglion (GG), greater petrosal nerve (GPN), and labyrinthine artery (La).
Terminal branches of the facial nerve, demonstrating its variability; buccal (B), mandibular (M), temporal (T), and zygomatic (Z).
Greater auricular nerve located superficial to the sternocleidomastoid, perpendicular to a line drawn between the mastoid and the angle of the mandible.
Sural nerve located just lateral to the saphenous vein and medial and posterior to the lateral malleolus of the ankle.
Nerve crossover using the proximal trunk of the hypoglossal nerve to the distal trunk of the facial nerve.
The temporalis muscle transfer; nasolabial incision (A), scalp incision incorporated with facelift incision behind the ear (B), superimposed incisions over the temporalis muscle indicating a harvest of the middle portion of the temporalis muscle (C), incision of the temporalis muscle superiorly, separating the periosteum from the skull base (D), transfer of the temporalis muscle in a subcutaneous plane, but superficial to the muscular aponeurotic system (E), and insertion of the temporalis muscle into the orbicularis oris muscle with an overcorrected position (F).
Intraoral approach harvests the masseter muscle for transfer. Incision is made along the gingival sulcus (A). One muscle is exposed; curved scissors are used to transect the muscle in the midportion (B). Two slips of muscle are attached to the dermal layers of the skin for overcorrection of the smile (C).
Gold implant technique for upper eyelid closure. Incision is made several centimeters above the upper eyelid (A). With a sharp instrument, the tarsal plate is identified (B). The gold implant is sutured in place, straddling the tarsal plate and slightly posterior to it (C). Lateral view is showing the position of the gold implant in the upper eyelid (D).
Lateral tarsal strip procedure for ectropion of the lower lid. A lateral canthotomy incision is shown (A). Division of the lateral aspect of the lower lid into an anterior musculocutaneous layer and posterior tarsal conjunctival layer is shown (B). Tarsal strip is grasped with skin hook (C). Tarsal strip is positioned inside the lateral rim of the orbit, which has been exposed (D). Tarsal strip is sutured to periosteum inside of lateral orbital rim (E). Excess skin is excised and wound closed (F).
(A) Right facial paralysis after injury to facial nerve within the mastoid. (B) Two years after direct anastomosis, patient in repose with good symmetry. (C) Excellent eye closure and mobility of the mouth with slight asymmetry.
(A) Patient has facial paralysis after temporal bone resection. Interpositional graft is used. The patient has incomplete eye closure. (B) Gold implant is placed over tarsal plate. (C) One week postoperatively, patient demonstrates effective eye closure.
(A) Patient is demonstrating total left facial paralysis after excision of glomus tumor. (B) One year after intraoral masseter muscle transfer, the patient is in repose with good symmetry. (C) Patient is demonstrating a symmetric smile but with incomplete eye closure. (D) Patient 2 years after lateral tarsal strip procedure of lower eyelid.
(A) Patient sustained a chain saw injury to the face with severance of the buccal branch. (B) Two years after repair of the laceration without facial nerve repair, patient demonstrates excellent recovery of function.
(A) Patient has right facial paralysis after resection of acoustic neuroma and loss of facial nerve. (B) One year after hypoglossal-to-facial crossover, patient demonstrates a symmetric smile. (C) Patient exhibits excellent eye closure without mass movement.
(A) Patient has left facial paralysis after resection of glomus jugulare that involved the facial nerve. (B) Patient had temporalis muscle fascia transfer. Note the overcorrection and Steri-strips applied to maintain position. (C) One year after surgery, patient is in repose with excellent symmetry. (D) Patient is attempting to smile with minimal movement and slight asymmetry.
Facial reanimation treatment algorithm.
 
 
 
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