The Dilator Naris Muscle as a Reporter of Facial Nerve Regeneration in a Rat Model.

OBJECTIVE: Many investigators study facial nerve regeneration using the rat whisker pad model, although widely standardized outcomes measures of facial nerve regeneration in the rodent have not yet been developed. The intrinsic whisker pad "sling" muscles producing whisker protraction, situated at the base of each individual whisker, are extremely small and difficult to study en bloc. Here, we compare the functional innervation of 2 potential reporter muscles for whisker pad innervation: the dilator naris (DN) and the levator labii superioris (LLS), to characterize facial nerve regeneration. METHODS: Motor supply of the DN and LLS was elucidated by measuring contraction force and compound muscle action potentials during stimulation of individual facial nerve branches, and by measuring whisking amplitude before and after DN distal tendon release. RESULTS: The pattern of DN innervation matched that of the intrinsic whisker pad musculature (ie, via the buccal and marginal mandibular branches of the facial nerve), whereas the LLS seemed to be innervated almost entirely by the zygomatic branch, whose primary target is the orbicularis oculi muscle. CONCLUSIONS: Although the LLS has been commonly used as a reporter muscle of whisker pad innervation, the present data show that its innervation pattern does not overlap substantially with the muscles producing whisker protraction. The DN muscle may serve as a more appropriate reporter for whisker pad innervation because it is innervated by the same facial nerve branches as the intrinsic whisker pad musculature, making structure/function correlations more accurate, and more relevant to investigators studying facial nerve regeneration.

Quality of life assessment in facial palsy: validation of the Dutch Facial Clinimetric Evaluation Scale.

This study aimed at validating an existing health-related quality of life questionnaire for patients with facial palsy for implementation in the Dutch language and culture. The Facial Clinimetric Evaluation Scale was translated into the Dutch language using a forward-backward translation method. A pilot test with the translated questionnaire was performed in 10 patients with facial palsy and 10 normal subjects. Finally, cross-cultural adaption was accomplished at our outpatient clinic for facial palsy. Analyses for internal consistency, test-retest reliability, construct validity and responsiveness were performed. Ninety-three patients completed the Dutch Facial Clinimetric Evaluation Scale, the Dutch Facial Disability Index, and the Dutch Short Form (36) Health Survey. Cronbach's α, representing internal consistency, was 0.800. Test-retest reliability was shown by an intraclass correlation coefficient of 0.737. Correlations with the House-Brackmann score, Sunnybrook score, Facial Disability Index physical function, and social/well-being function were -0.292, 0.570, 0.713, and 0.575, respectively. The SF-36 domains correlate best with the FaCE social function domain, with the strongest correlation between the both social function domains (r = 0.576). The FaCE score did statistically significantly increase in 35 patients receiving botulinum toxin type A (P = 0.042, Student t test). The domains 'facial comfort' and 'social function' improved statistically significantly as well (P = 0.022 and P = 0.046, respectively, Student t-test). The Dutch Facial Clinimetric Evaluation Scale shows good psychometric values and can be implemented in the management of Dutch-speaking patients with facial palsy in the Netherlands. Translation of the instrument into other languages may lead to widespread use, making evaluation and comparison possible among different providers.

'Everybody is watching me': A closer look at anxiety in people with facial palsy.

OBJECTIVES: Objectives were to evaluate the sociodemographic and disease-related factors, and coping style associated with social interaction and social appearance anxiety in people with unilateral facial palsy. METHODS: Medical data were extracted from electronic health records, and participants completed the Social Interaction Anxiety Scale (SIAS), Social Appearance Anxiety Scale (SAAS), and Coping Orientation to Problems Experienced inventory. Associations of SIAS and SAAS scores with sociodemographic and disease variables, and coping were assessed with multiple linear regression. RESULTS: Among 111 participants (mean age 58.6 years; 59% women), higher age and greater use of emotion-focused coping were associated with lower SIAS scores, whereas greater use of avoidant coping was associated with higher SIAS scores. Higher age, male sex, and greater use of emotion-focused coping were associated with lower SAAS scores, whereas greater use of avoidant coping was associated with higher SAAS scores. CONCLUSIONS: Healthcare providers should understand that women and younger people are more likely to have social appearance concerns and that this is not predicted by the objective severity of facial palsy.

Interpreting Quality-of-Life Questionnaires in Patients with Long-Standing Facial Palsy.

Objective(s): To interpret change in quality-of-life scores in facial palsy patients by calculating the smallest detectable change (SDC) and minimal important change (MIC) for the Facial Disability Index (FDI), Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Materials and Methods: The SDC, for individuals and groups, was calculated using previously collected test-retest data (2-week interval). The MIC (predictive modeling method) was calculated in a second similar facial palsy population using two measurements (1-1.5-year interval) and an anchor question assessing perceived change. Results: SDCindividual of FaCE was 17.6 and SAQ was 28.2. SDCgroup of FaCE was 2.9 and SAQ was 4.6 (n = 62). Baseline FaCE and SAQ scores were 43.3 (interquartile range [IQR]: 35.8;55.0) and 51.1 (IQR: 32.2;60.0), respectively. MIC for important improvement of FDI physical/social function, FaCE total, and SAQ total were 4.4, 0.4, 0.7, and 2.8, respectively (n = 88). MIC for deterioration was 8.2, -1.8, -8.5, and 0.6, respectively. Baseline scores were 70.0 (IQR: 60.0;80.0), 76.0 (68.0;88.0), 55.0 (IQR: 40.0;61.7), and 26.7 (IQR: 22.2;35.6), respectively. Number of participants reporting important change for the different questionnaires ranged from 3 to 23 per subscale. Conclusion: Interpreting change scores of the FDI, FaCE, and SAQ is appropriate for groups, but for individual patients it is limited by a substantial SDC.

Quality of life before and after different treatment modalities in peripheral facial palsy: A systematic review.

OBJECTIVES: A systematic review was conducted to investigate the effect of peripheral facial palsy (PFP) on the quality of life (QoL). Secondly, we investigated if different treatment modalities influence the QoL of patients with PFP. METHODS: A multidatabase systematic literature search was performed using the following databases: PubMed, Embase, MEDLINE, and The Cochrane Library from the earliest date of each database up to August 2015. The inclusion criteria were either prospective and/or retrospective cohort trials and/or case series measurement of QoL before and after treatment, patients with PFP (irrespective of etiology), and various treatment modalities (medication, physical therapy, botulinum toxin injections, and several types of surgical procedures). Two authors rated the methodological quality of the included studies independently using the Newcastle-Ottawa Quality Assessment Scale for nonrandomized studies. RESULTS: Two hundred fifty-eight studies were found, of which 14 studies met the inclusion criteria. Most studies were assessed to be of fair to good methodological quality. The Cohen's κ (between author r.e.l. and s.p.) was 0.68. Eight different questionnaires were used to measure QoL, of which the Facial Clinimetric Evaluation scale was used most frequent. After different modalities, all studies showed significant improvements in terms of QoL. CONCLUSIONS: This study found significant improvement when measuring QoL before and after different treatment modalities in patients with peripheral facial palsy. Future research should focus on patients with PFP due to the same etiology and use of valid QoL instruments for outcome measures. Laryngoscope, 127:1044-1051, 2017.

Assessing psychological distress in patients with facial paralysis using the Hospital Anxiety and Depression Scale.

OBJECTIVES: Anxiety and depression are seen among patients with facial paralysis (FP), but less is known about the exact prevalence. The aim of the current study is to assess the prevalence of anxiety and depressive disorders in the FP population and to investigate possible differences between patients with left- and right-sided FP. METHODS: Fifty-nine patients with FP and 59 healthy individuals were included in this study between March and December of 2014. The Hospital Anxiety and Depression Scale was used to assess the prevalence of anxiety and depression among these groups. RESULTS: The mean age of the patients and controls was 56 ± 15 and 40 ± 16 years, respectively. Twenty-eight patients had left-sided FP, 30 patients had right-sided FP, and one patient had bilateral FP. In the patient group, approximately 30% had anxiety and 25% had a depressive disorder. Compared with the control group, significantly more patients presented with mild anxiety (p = 0.031), mild depression (p = 0.047), and moderate depression (p = 0.006). No significant differences were found in terms of the prevalence of anxiety between left- and right-sided FP. However, significantly more patients with left-sided FP had mild depression (p = 0.018) than those with right-sided FP. CONCLUSION: This study found a significant difference in anxiety and depression between patients with FP and healthy controls. No clinically significant difference was noted in the prevalence of anxiety or depression between patients with left- and right-sided FP.

Synkinesis assessment in facial palsy: validation of the Dutch Synkinesis Assessment Questionnaire.

The objective of this study is to validate an existing health-related quality of life questionnaire for patients with synkinesis in facial palsy for implementation in the Dutch language and culture. The Synkinesis Assessment Questionnaire was translated into the Dutch language using a forward-backward translation method. A pilot test with the translated questionnaire was performed in 10 patients with facial palsy and 10 normal subjects. Finally, cross-cultural adaption was accomplished at our outpatient clinic for facial palsy. Analyses for internal consistency, test-retest reliability, and construct validity were performed. Sixty-six patients completed the Dutch Synkinesis Assessment Questionnaire and the Dutch Facial Disability Index. Cronbach's α, representing internal consistency, was 0.80. Test-retest reliability was 0.53 (Spearman's correlation coefficient, P < 0.01). Correlations with the House-Brackmann score, Sunnybrook score, Facial Disability Index physical function, and social/well-being function were -0.29, 0.20, -0.29, and -0.32, respectively. Correlation with the Sunnybrook synkinesis subscore was 0.50 (Spearman's correlation coefficient). The Dutch Synkinesis Assessment Questionnaire shows good psychometric values and can be implemented in the management of Dutch-speaking patients with facial palsy and synkinesis in the Netherlands. Translation of the instrument into other languages may lead to widespread use, making evaluation, and comparison possible among different providers.

Rat whisker movement after facial nerve lesion: evidence for autonomic contraction of skeletal muscle.

Vibrissal whisking is often employed to track facial nerve regeneration in rats; however, we have observed similar degrees of whisking recovery after facial nerve transection with or without repair. We hypothesized that the source of non-facial nerve-mediated whisker movement after chronic denervation was from autonomic, cholinergic axons traveling within the infraorbital branch of the trigeminal nerve (ION). Rats underwent unilateral facial nerve transection with repair (N=7) or resection without repair (N=11). Post-operative whisking amplitude was measured weekly across 10weeks, and during intraoperative stimulation of the ION and facial nerves at ⩾18weeks. Whisking was also measured after subsequent ION transection (N=6) or pharmacologic blocking of the autonomic ganglia using hexamethonium (N=3), and after snout cooling intended to elicit a vasodilation reflex (N=3). Whisking recovered more quickly and with greater amplitude in rats that underwent facial nerve repair compared to resection (P<0.05), but individual rats overlapped in whisking amplitude across both groups. In the resected rats, non-facial-nerve-mediated whisking was elicited by electrical stimulation of the ION, temporarily diminished following hexamethonium injection, abolished by transection of the ION, and rapidly and significantly (P<0.05) increased by snout cooling. Moreover, fibrillation-related whisker movements decreased in all rats during the initial recovery period (indicative of reinnervation), but re-appeared in the resected rats after undergoing ION transection (indicative of motor denervation). Cholinergic, parasympathetic axons traveling within the ION innervate whisker pad vasculature, and immunohistochemistry for vasoactive intestinal peptide revealed these axons branching extensively over whisker pad muscles and contacting neuromuscular junctions after facial nerve resection. This study provides the first behavioral and anatomical evidence of spontaneous autonomic innervation of skeletal muscle after motor nerve lesion, which not only has implications for interpreting facial nerve reinnervation results, but also calls into question whether autonomic-mediated innervation of striated muscle occurs naturally in other forms of neuropathy.

Whisking recovery after automated mechanical stimulation during facial nerve regeneration.

IMPORTANCE Recovery from facial nerve transection is typically poor, but daily mechanical stimulation of the face in rats has been reported to remarkably enhance functional recovery after facial nerve transection and suture repair. This phenomenon needs additional investigation because of its important clinical implications. OBJECTIVE To determine whether automated mechanical stimulation of the whisker pad improves whisking recovery after facial nerve transection and repair in a rat model. DESIGN AND SETTING Sixty-one rats underwent unilateral facial nerve transection and suture repair and were randomized into 8 groups. Six groups received daily automated whisker or whisker pad mechanical stimulation including 0.5-, 1.5-, and 8.0-Hz patterns. Two control groups received restraint without stimulation. Treatment started on postoperative day 8, occurred 5 days per week, and lasted throughout 15 weeks of recovery. Whisking amplitude, velocity, and acceleration were quantified weekly for 15 weeks. INTERVENTIONS Unilateral facial nerve transection, suture repair, and, for 6 groups, daily automated whisker or whisker pad mechanical stimulation. MAIN OUTCOMES AND MEASURES Quantification of whisking amplitude, velocity, and acceleration. RESULTS Rats receiving the low frequencies of stimulation of the whiskers or whisker pad did not demonstrate enhanced whisking recovery, and rats receiving stimulation at 8.0 Hz showed significantly worse whisking recovery compared with controls and previously published groups receiving lower dose manual stimulation. CONCLUSIONS AND RELEVANCE Although daily manual whisker pad stimulation has been shown to enhance whisking recovery, rats in this study did not demonstrate improved whisking recovery after automated mechanical stimulation across a wide range of driving frequencies. Moreover, faster stimulation (8.0 Hz) was actually detrimental to recovery. Further work is needed to understand the relationship between stimulation patterns and the physiologic mechanisms underlying improved or worsened functional outcomes after facial nerve transection and repair.

Functional recovery after facial nerve cable grafting in a rodent model.

IMPORTANCE: Cable grafting is widely considered to be the preferred alternative to primary repair of the injured facial nerve; however, quantitative comparison of the 2 techniques has not been previously undertaken in a rodent model. OBJECTIVE: To establish functional recovery parameters after interposition autografting in a rodent facial nerve model. DESIGN, SETTING, AND PARTICIPANTS: Prospective randomized animal study at a tertiary care facial nerve center using 16 female Wistar Hannover rats. INTERVENTION: The experimental group received reversed autograft reconstruction of a 20-mm neural gap, and the control group received facial nerve transection and primary repair. MAIN OUTCOME AND MEASURE: Whisker excursion was measured weekly for 70 postoperative days using laser micrometers. RESULTS: The control group exhibited the most rapid recovery, with substantial return of whisker movement occurring during the third postoperative week. The experimental group demonstrated return of function beginning in the fourth postoperative week, eventually achieving a degree of function comparable to that of the control group by the sixth postoperative week (P = .68). CONCLUSIONS AND RELEVANCE: Recovery of facial function after cable grafting seems to be slower than, but eventually similar to, recovery after primary neurorrhaphy in a rodent model. In the present study we have established a benchmark for recovery of whisker movement across a 20-mm rodent facial nerve gap, which will be used for comparison of different facial nerve gap bridging materials in future studies. LEVEL OF EVIDENCE: NA.

Facial nerve repair: fibrin adhesive coaptation versus epineurial suture repair in a rodent model.

OBJECTIVES/HYPOTHESIS: Repair of the transected facial nerve has traditionally been accomplished with microsurgical neurorrhaphy; however, fibrin adhesive coaptation (FAC) of peripheral nerves has become increasingly popular over the past decade. We compared functional recovery following suture neurorrhaphy to FAC in a rodent facial nerve model. STUDY DESIGN: Prospective, randomized animal study. METHODS: Sixteen rats underwent transection and repair of the facial nerve proximal to the pes anserinus. Eight animals underwent epineurial suture (ES) neurorrhaphy, and eight underwent repair with fibrin adhesive (FA). Surgical times were documented for all procedures. Whisking function was analyzed on a weekly basis for both groups across 15 weeks of recovery. RESULTS: Rats experienced whisking recovery consistent in time course and degree with prior studies of rodent facial nerve transection and repair. There were no significant differences in whisking amplitude, velocity, or acceleration between suture and FA groups. However, the neurorrhaphy time with FA was 70% shorter than for ES (P < 0.05). CONCLUSION: Although we found no difference in whisking recovery between suture and FA repair of the main trunk of the rat facial nerve, the significantly shorter operative time for FA repair makes this technique an attractive option. The relative advantages of both techniques are discussed.

Computer-assisted assessment of ocular synkinesis: a comparison of methods.

OBJECTIVES/HYPOTHESIS: To define an objective, easy to perform, rapid method for the assessment of ocular synkinesis by employing both the Facial Assessment by Computer Evaluation software and a modification of the Glasgow Facial Palsy Scale. STUDY DESIGN: Retrospective study. METHODS: Fifty normal subjects and 50 patients with known ocular synkinesis were studied. Measurements of ocular synkinesis were made using the semiautomated Facial Assessment by Computer Evaluation software, and a modification of the automated Glasgow Facial Palsy program. RESULTS: The mean resting vertical palpebral fissure width of a normal eye was 10.17 mm (standard deviation [SD], 1.63 mm), and the degree of eye closure during smile was on average 21.56% (SD, 13.38%). Synkinetic eyes had a statistically significantly smaller resting palpebral fissure width on average (8.99 mm; SD, 1.61 mm; P < .001, t test), and a statistically significantly greater degree of narrowing during smiling (32.65%; SD, 13.68%; P < .001, t test). Using a modified synkinesis-determining application of the Glasgow Facial Palsy Scale did not consistently correlate with the Facial Assessment by Computer Evaluation program or clinical observations of eye closure during smiling (R = 0.251, Pearson correlation) and puckering (R = 0.253, Pearson correlation). CONCLUSIONS: The Facial Assessment by Computer Evaluation program yields rapid, consistent, palpebral fissure width measurements, and when combined with a subjective self-assessment questionnaire yields a comprehensive measure of ocular synkinesis. Our modified application of the Glasgow Facial Palsy Scale did not appear to be a reliable method for quantitative ocular synkinesis assessment.