Synkinetic Brow Dysfunction: Diagnosis and Treatment Algorithm.

Importance: The diagnosis and management of brow dysfunction in patients with postfacial paralysis with synkinesis can be perplexing and challenging for the treating physician. Objective: To describe a novel diagnostic and treatment algorithm for brow dysfunction in patients with postfacial paralysis with synkinesis. Design: Surgical pearls-description of novel surgical technique. Setting: A private practice. Participants: Patients who underwent the operation.

An International Collaborative Standardizing Patient-Centered Outcome Measures in Pediatric Facial Palsy.

IMPORTANCE: Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population. OBJECTIVE: To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives. DESIGN, SETTING, AND PARTICIPANTS: A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016. MAIN OUTCOMES AND MEASURES: The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention. RESULTS: The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy-reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy. CONCLUSIONS AND RELEVANCE: This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy. LEVEL OF EVIDENCE: NA.

Physical therapy for facial nerve palsy: applications for the physician.

PURPOSE OF REVIEW: The aim of this study was to describe the current state of physical therapy for facial nerve palsy, the evidence basis for these interventions and how therapy can be integrated with other medical and surgical interventions for facial nerve palsy, as it applies to ophthalmologists, oculoplastic surgeons and other specialists. RECENT FINDINGS: Many studies indicate that physical therapy is effective for the rehabilitation of patients with facial nerve palsy and can be used synergistically with interventions administered by physicians, such as targeted botulinum toxin injections. The field is limited by a relative paucity of high-quality randomized controlled trials. Alternative therapies including Brief Electrical Stimulation continue to be studied; however, they lack a scientific rationale and, anecdotally, appear to cause more problems in cases of incomplete facial nerve recovery. SUMMARY: Physical therapy, specifically neuromuscular retraining, is a useful intervention for treating facial nerve palsy. Care for these patients is best delivered in a multidisciplinary setting in which physical therapy and medical or surgical interventions can be closely integrated. Further study aimed at standardizing physical therapy and optimizing the integration of this with other treatments for facial nerve palsy are needed.

Botulinum Toxin in the Treatment of Facial Paralysis.

This article reviews the current literature supporting the use of botulinum toxin in producing symmetric facial features and reducing unwanted, involuntary movements. Methods, protocols, and adverse events are discussed. Additionally, the authors suggest that using botulinum toxin A therapy in postparalytic facial synkinesis can provide long-term results when used in conjunction with other treatment modalities.

Treating Buccinator With Botulinum Toxin in Patients With Facial Synkinesis: A Previously Overlooked Target.

OBJECTIVE: Synkinesis after facial nerve injury produces functional and cosmetic concerns for patients. The purpose of this study was to review the authors' experience of treating buccinator synkinesis with botulinum toxin. METHODS: This was a retrospective medical records review. All patients seen at the University of Wisconsin Neuromuscular Retraining Clinic who were treated with botulinum injections to the buccinator muscle were included. After a period of neuromuscular retraining lasting 6 to 12 months, botulinum injections were administered to the anterior, middle, and/or posterior aspect of buccinator by the senior author via an intraoral approach. The sites and dosage of the injections depended substantially on input from the therapist overseeing the patient's neuromuscular retraining therapy. Data on patient age, gender, indication for treatment, location and dose of botulinum administration, and outcome were collected. The Synkinesis Assessment Questionnaire (SAQ) was used as a patient-reported outcome measure. Descriptive statistics were computed for all recorded variables. RESULTS: A total of 42 patients with synkinesis involving the buccinator were treated. Female-to-male ratio was 9:1, and follow up ranged from 5 months to 18 years. The indications for treatment included significant retraction and immobility of the affected oral commissure at rest and during volitional and spontaneous facial expressions, difficulty manipulating food during mastication, and biting the inside of the affected cheek. Mean total dose of botulinum administered to buccinator per session was 2.0 units (range, 0.6-2.5 units). SAQ scores improved from a mean of 66.6 preinjection to 45.0 postinjection. In general, patient satisfaction with the procedure was high, and there were no serious complications. CONCLUSIONS: To the authors' knowledge, this is the first report of a cohort of patients with buccinator synkinesis treated with botulinum toxin. This treatment has become a valuable adjunct in the comprehensive management of patients with facial synkinesis.