Comparative Study of Multimodal Therapy in Facial Palsy Patients.

Introduction In chronic facial palsy, synkinetic muscle overactivity and shortening causes muscle stiffness resulting in reduced movement and functional activity. This article studies the role of multimodal therapy in improving outcomes. Methods Seventy-five facial palsy patients completed facial rehabilitation before being successfully discharged by the facial therapy team. The cohort was divided into four subgroups depending on the time of initial attendance post-onset. The requirement for facial therapy, chemodenervation, or surgery was assessed with East Grinstead Grade of Stiffness (EGGS). Outcomes were measured using the Facial Grading Scale (FGS), Facial Disability Index, House-Brackmann scores, and the Facial Clinimetric Evaluation scale. Results FGS composite scores significantly improved posttherapy (mean-standard deviation, 60.13 ± 23.24 vs. 79.9 ± 13.01; confidence interval, -24.51 to -14.66, p < 0.0001). Analysis of FGS subsets showed that synkinesis also reduced significantly ( p < 0.0001). Increasingly, late clinical presentations were associated with patients requiring longer durations of chemodenervation treatment ( p < 0.01), more chemodenervation episodes ( p < 0.01), increased doses of botulinum toxin ( p < 0.001), and having higher EGGS score ( p < 0.001). Conclusions This study shows that multimodal facial rehabilitation in the management of facial palsy is effective, even in patients with chronically neglected synkinesis. In terms of the latency periods between facial palsy onset and treatment initiation, patients presenting later than 2 years were still responsive to multimodal treatment albeit to a lesser extent, which we postulate is due to increasing muscle contracture within their facial muscles.

Streamlining the Diagnosis of Atypical Facial Palsies: A 5-year Review of 805 Patients.

BACKGROUND: Currently, there are no definitive guidelines in the investigation and management of atypical facial palsies (AFPs). Our aim was to determine the etiology of AFPs presenting to a tertiary facial palsy center and to review the current spectrum of diagnostic and management approaches to these conditions. METHODS: A retrospective cohort analysis of attendees at the Queen Victoria Hospital multidisciplinary facial palsy clinic over a 5-year period from 2016 to 2020 was conducted. Demographic data were collated from the QVH Research and Governance team. Those presenting with classic Bell's palsy or Ramsay-Hunt syndrome were excluded. Anyone with atypical presentations (including multiple recurrences, focal neurological deficits, polycranial neuropathies, autoimmune conditions, hemifacial spasms, hearing/balance issues, weight loss, segmental facial palsies, and gradual onset presentations) were included under the AFP category. These patients were subjected to standard serological and radiological investigations and their follow-ups were reviewed. RESULTS: A total of 849 patients were identified, and 805 had actual facial palsy presentations. Of these, 172 patients had AFP. The majority of these patients had MRI imaging tests, which were useful, but the remaining serological tests were found to correlate more with symptom clusters and specific questions rather than with random tests for all AFPs. CONCLUSIONS: Although serological and radiological investigations help in the diagnosis of AFP, specific questions and presentations help streamline the diagnosis, without affecting its accuracy whilst reducing unnecessary tests and, thereby, cost and time. We present an algorithm organized by specific questions of presentations in those with AFPs.

The effect of template-based sequential (TBS) coding on an NHS plastic surgical practice.

INTRODUCTION: Clinical coding is often a mystery to us surgeons, but in actuality, it has a huge bearing on the financial sustainability of our services. Given the rapid innovations in plastic surgical procedures, clinical coders often struggle to decipher the extent of surgery. Meeting midway is the way forward here. METHODS: In a prospective audit over a six-month period, we analysed data from 2586 patients in our practice: a combination of general plastic surgery and specialist facial reanimation services. This involved comparing data from the first three months where coding was performed by clinical coders based on operating notes per se (phase I) and the subsequent three months when the operating surgeon filled in the OPCS 4.7 (version 2014) codes at the time of completing the operating notes; the clinical coders then vetted this information (phase II) as part of a sequential TBS coding system. RESULTS: In terms of outpatient income, there was a 3% increase in facial palsy income and 6% increase in general plastic services, but the most significant improvement was in terms of procedural income per case. General plastic surgery cases saw an increase of 49%, while facial palsy income increased by 58% over the same period. Greater insight into OPCS and HRG codes also allowed for the calculation of the actual tariffs for specific procedures. CONCLUSIONS: Having the operating surgeon as the primary coder, using a template, with subsequent vetting by the clinical coders, improves data capture, and this in turn increases income. Future recommendations include the use of proforma-based operating notes for workhorse procedures.