Otolaryngology Training in Uganda: The Mbarara University of Science and Technology Experience.

Sub-Saharan Africa has a high otolaryngologic disease burden exacerbated by an inadequate number of otolaryngologists. The Otolaryngology department at Mbarara University of Science & Technology in Uganda is addressing this problem by having created Uganda's second national residency training program in 2010. We chronicled an early period in the program's development by reporting surgical case quantity and complexity, as defined by "key indicator procedure" classification per the United States Accreditation Council for Graduate Medical Education, and interpreting it with respect to a timeline of significant events. Procedure complexity, but not total number per year, increased over the study period-KIPs increased from 3% in 2012 (6 of 175 total procedures) to 29% in 2016 (35 of 135 total procedures). During this period of complexity increase, operating room capacity expanded, faculty received advanced training and increased in number, and operative equipment improved.

A Facial Plastic and Reconstructive Surgery Training Module Using Surgical Simulation for Capacity Building.

OBJECTIVE: To introduce 3 novel intensive facial plastic and reconstructive surgery teaching modules for surgical capacity building using simulation in a low-middle income country. DESIGN: Prospective cohort study. SETTING: University-based medical center in Quito, Ecuador. PARTICIPANTS: First- and second-year otolaryngology residents in Quito, Ecuador. RESULTS: Residents participated in an intensive 3-day teaching program focused on microtia, nasoseptal abnormalities, and facial paralysis that included didactic lectures, simulation workshops, and live surgery. Residents underwent rigorous pre- and postmodule testing including written, oral, and practical examinations in each subject area. All participants completed anonymous feedback surveys with ratings on a Likert scale from 0 (very poor) to 10 (excellent). Nineteen residents completed both pre- and postmodule testing. The training module was successfully implemented and testing performance across all 3 subject areas significantly improved. Resident feedback was exceedingly positive, with average scores for each component ranging from 8.9 to 9.8, with highest scores given to the simulation workshops. The postmodule survey indicated that all residents found the course helpful and they desired additional courses covering more subject areas. CONCLUSIONS: Implementation of an intensive surgical training module combining didactics, surgical simulation, and live surgery resulted in the successful transfer of both skills and knowledge. While the long-term benefit of this program is yet to be determined, this model of training may prove to be a useful tool to help address surgical capacity building in the developing world.

Using Mobile Text and Media to Complement Teaching in a Facial Reconstruction Training Module in Haiti.

OBJECTIVES: (1) To describe electronic communication between global surgeons and trainees in a low-middle income country (LMIC) and to gauge appeal of the WhatsApp platform (2) To introduce a novel intensive ear reconstruction teaching module for surgical capacity building using simulation in a LMIC. DESIGN: Prospective cohort study. SETTING: University-based medical center in Haiti. PARTICIPANTS: Eleven otolaryngology trainees and faculty in Haiti. RESULTS: Three months prior to on-site arrival, a WhatsApp Messenger group was created for information-sharing and distribution of teaching materials. A surgical curriculum was created to incorporate didactics, cartilage framework simulation, and live surgery. During the intensive on-site week, WhatsApp was used to distribute materials and to recap learning points from each case, with pre- and postoperative surgical photographs circulated. Postmodule written, oral, and practical testing was conducted on the final day, and a postmodule survey was administered a month later. Post-tests scores were significantly improved from pretests scores. Initial scores on the written, oral, and practical tests averaged 24.6%. Postmodule scores averaged 86.9% (p < 0.001). Participants rated the use of WhatsApp to be highly important to their learning and requested further use of mobile health technology. CONCLUSIONS: WhatsApp Messenger technology complemented a reconstructive surgery education module in a LMIC. WhatsApp provides opportunities for premodule patient screening, real-time discussion, and postmodule review. Its usage was well-received by Haitian otolaryngology trainees and faculty. Our results suggest that the combination of didactic teaching, simulated surgery, and live surgery resulted in successful transfer of both skills and knowledge.

Head and Neck Cancer in Haiti: A Case Series from Hopital de L'Universite d'Etat d'Haiti.

This manuscript characterizes the demographics, presenting symptoms and risk factors of patients diagnosed with head and neck cancer at Hopital de L'Universite d'Etat d'Haiti (HUEH), Haiti's single largest healthcare facility. We conducted a prospective study of patients who presented to HUEH between January and March of 2016 with a lesion of the head or neck suspicious for cancer. All patients who met eligibility criteria received a biopsy, which was interpreted by a Haitian pathologist and when the specimen was available was confirmed by a team of pathologists from Stanford University. A total of 34 participants were identified. The biopsy-confirmed diagnoses were squamous cell carcinoma (n=7), benign (n=7), large cell lymphoma (n=2), ameloblastoma (n=2), pleomorphic adenoma (n=1), and adenocarcinoma (n=1). Fourteen patients were unavailable for biopsy. Patients with head and neck cancer had a mean age of 63.4 years, were majority male (62.5%), waited on average 10.9 months to seek medical attention, and most commonly presented with T-stage 3 or higher disease (87.5%). By characterizing patterns of head and neck cancer at HUEH we hope to facilitate efforts to improve early detection, diagnosis, and management of this important public health condition.

Otorhinolaryngology/Head and Neck Surgery in a low income country: The Haitian experience.

OBJECTIVE: Little is known regarding the diagnosis and management of pediatric surgical conditions of the head and neck in low-income countries. Haiti, the western hemisphere's poorest country, recently developed its first Otorhinolaryngology (ORL) department at the Hopital de L'Universite d'Etat d'Haiti (HUEH). This manuscript assesses the caseload at HUEH with a special emphasis on pediatric cases, with the aim of characterizing ORL related conditions and their treatments in low-income countries. METHODS: We conducted a retrospective chart review of surgical case logs at HUEH for the calendar year of 2014 and recorded patient age, diagnosis, and surgical intervention for all ORL surgeries. RESULTS: A total of 229 ORL surgeries were performed at HUEH during this time. The average age of the patient was 21.8 years and 54.2% of patients were 18 years or younger. The five most common diagnoses were tonsillar hypertrophy (23.6%), ingested foreign body (18%), mandibular fracture (9.2%), unspecified head or neck mass (6%), and thyroid goiter (4.8%). The five most common surgeries performed were tonsillectomy (23.6%), foreign body retrieval (17.9%), open reduction of mandibular fracture with direct skeletal fixation (6.9%), thyroidectomy (7.9%), and excision of unspecified mass. Trauma accounted for 33.6% of all ORL surgeries. CONCLUSIONS: Diseases related to the head and neck constitute a common yet underserved surgical problem. Strengthening ORL surgical capacity in Haiti should focus on improving capacity for the most common conditions including tonsillar disease, ingested foreign bodies, and facial trauma, as well as improving capacity for rarely performed surgeries, such as ear surgery, nose and sinus surgery, and cancer resections.

Barriers to Surgical Care and Health Outcomes: A Prospective Study on the Relation Between Wealth, Sex, and Postoperative Complications in the Republic of Congo.

BACKGROUND: Approximately thirty percent of the global burden of disease is comprised of surgical conditions. However, five billion people lack access to surgery, with complex factors acting as barriers. We examined whether patient demographics predict barriers to care, and the relation between these factors and postoperative complications in a prospective cohort. METHODS: Participants included people presenting to a global charity in Republic of Congo with a surgical condition between August 2013 and May 2014. The outcomes were self-reported barrier to care and postoperative complications documented by medical record. Logistic regression was used to adjust for covariates. RESULTS: Of 1237 patients in our study, 1190 (96.2 %) experienced a barrier to care and 126 (10.2 %) experienced a postoperative complication. The most frequently reported barrier was cost (73 %), followed by lack of provider (8.2 %). Greater wealth was associated with decreased odds of cost as a barrier (OR 0.72 [0.57, 0.90]). Greater wealth (OR 1.52 [1.03, 2.25]) and rural home location (OR 3.35 [1.16, 9.62]) were associated with increased odds of no surgeon being available. Cost as a barrier (OR 2.82 [1.02, 7.77]), female sex (OR 3.45 [1.62, 7.33]), and lack of surgeon (OR 5.62 [1.68, 18.77]) were associated with increased odds of postoperative complication. Patient wealth was not associated with odds of postoperative complication. CONCLUSIONS: Barriers to surgery were common in Republic of Congo. Patient wealth and home location may predict barriers to surgery. Addressing gender disparities, access to providers, and patient perception of barriers in addition to removal of barriers may help maximize patient health benefits.

Head and neck cancer in South Asia: Macroeconomic consequences and the role of the head and neck surgeon.

BACKGROUND: Head and neck cancer constitutes a substantial portion of the burden of disease in South Asia, and there is an undersupply of surgical capacity in this region. The purpose of this study was to estimate the economic welfare losses due to head and neck cancer in India, Pakistan, and Bangladesh in 2010. METHODS: We used publicly available estimates of head and neck cancer morbidity and mortality along with a concept termed the value of a statistical life to estimate economic welfare losses in the aforementioned countries in 2010. RESULTS: Economic losses because of head and neck cancer in India, Pakistan, and Bangladesh totaled $16.9 billion (2010 US dollars [USD]), equivalent to 0.26% of the region's economic output. Bangladesh, the poorest country, experienced the greatest proportional losses. CONCLUSION: The economic consequences of head and neck cancer in South Asia are significant, and building surgical capacity is essential to begin to address this burden. © 2016 Wiley Periodicals, Inc. Head Neck 38:1242-1247, 2016.

Head and neck cancer in South Asia: macroeconomic consequences and the role of surgery.

BACKGROUND: Head and neck cancer, for which the diagnosis and treatment are often surgical, comprises a substantial proportion of the burden of disease in South Asia. Further, estimates of surgical volume suggest this region faces a critical shortage of surgical capacity. We aimed to estimate the total economic welfare losses due to the morbidity and mortality of head and neck cancer in India, Pakistan, and Bangladesh for 1 year (2010). METHODS: We used publicly available estimates from the Institute for Health Metrics and Evaluation regarding the morbidity and mortality of head and neck cancer in India, Pakistan, and Bangladesh, along with an economic concept termed the value of a statistical life, to estimate total economic welfare losses due to head and neck cancer in the aforementioned countries in the year 2010. The counterfactual scenario is absence of disease. Sensitivity analyses were done with regard to how the value of a statistical life changes with income. FINDINGS: In 2010, the most conservative estimate of economic welfare losses due to head and neck cancer in the three studied countries is US$16·9 billion (2010 USD, PPP), equivalent to 0·26% of their combined gross domestic product (GDP). The welfare losses experienced by the population younger than 70 years of age accounted for US$15·2 billion (90% of the total losses). When adjusted for the size of their respective economies, Bangladesh, the poorest of the three countries, incurred the greatest loss (US$930 million), equivalent to 0·29% of its GDP. India and Pakistan experienced welfare losses of US$14·1 billion and US$1·9 billion, respectively. These figures are equivalent to 0·26% of the GDP for both countries. Oropharyngeal and hypopharyngeal cancer made up the largest share of the total burden at 39% (US$6·6 billion), followed closely by oral cavity cancer at 34% (US$5·7 billion). INTERPRETATION: The burden of non-communicable diseases, to which cancer contributes greatly, is growing at a rapid pace in South Asia. Head and neck cancer is a leading cause of cancer-related mortality in this region, and this study suggests that the associated economic welfare losses, estimated to be US$16·9 billion in 2010 alone, are substantial. A number of strategies are available to address this burden. Surgery, as part of a multidisciplinary approach that includes radiation therapy and chemotherapy, plays a central part in the diagnosis and treatment of head and neck cancer, and building surgical capacity, which offers large economies of scope and scale, can not only address the burden of head and neck cancer, but also create a platform for beginning to confront the rising tide of non-communicable diseases. FUNDING: None.

Global health-related publications in otolaryngology are increasing.

OBJECTIVES/HYPOTHESIS: Determine trends in global health-related publication in otolaryngology. STUDY DESIGN: A review of research databases. METHODS: A search of publications available on PubMed and nine additional databases was undertaken reviewing two time periods 10 years apart for the timeframes 1998 to 2002 (early time period) and 2008 to 2012 (recent time period) using specific search terms to identify global health-related publications in otolaryngology. Publications were examined for region of origin, subspecialty, type of publication, and evidence of international collaboration. χ and t test analyses were used to identify trends. RESULTS: In the 1998 to 2002 time period, a total of 26 publications met inclusion criteria for the study, with a mean of 5.2 ± 2.8 publications per year. In the 2008 to 2012 time period, a total of 61 publications met inclusion criteria, with a mean of 12.3 ± 5.6 publications per year. The 235% increase in global health-related publications identified between the two study periods was statistically significant (P = .02). The absolute number of publications in which collaboration occurred between countries increased from three in the early time period to nine the recent time period. CONCLUSIONS: There has been a significant increase in the volume of global health-related publications in English language otolaryngology journals over the past decade, providing strong evidence of the increasing trend of global health as an academic pursuit within the field of otolaryngology.

Ovine model for auricular reconstruction: porous polyethylene implants.

OBJECTIVES: We developed a large animal model for auricular reconstruction with engineered cartilage frameworks and evaluated the performance of porous polyethylene auricular implants in this model. METHODS: Eighteen high-density porous polyethylene auricular frameworks were implanted subcutaneously in the infra-auricular areas of 9 sheep. The implants were harvested 17 weeks later for gross and histologic examination. The perioperative and postoperative courses were carefully documented. RESULTS: Five implants became exposed, and 2 implants needed to be removed at 7 weeks. Additionally, 1 infected implant was removed at 2 weeks. Seromas developed in 2 implants because of drain failures and were drained successfully during the first postoperative week. There were no other surgical site complications. The remaining 10 implants had an acceptable cosmetic appearance at 17 weeks. CONCLUSIONS: The perioperative complication rate in the ovine porous polyethylene auricular implant model was higher than that reported for auricular reconstructions in humans. The implant exposures were likely caused by ischemia and excessive stress on the thin overlying skin, because vascularized flap coverage was not used. The histologic findings were comparable to the results reported for other animal models. This large animal model is appropriate for auricular reconstruction experiments, including engineered constructs.

Objective outcomes analysis following microvascular gracilis transfer for facial reanimation: a review of 10 years' experience.

IMPORTANCE Objective assessment of smile outcome after microvascular free gracilis transfer is challenging, and quantification of smile outcomes in the literature is inconsistent. OBJECTIVE To report objective excursion and symmetry outcomes from a series of free gracilis cases and investigate the predictive value of intraoperative measurements on final outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical chart review was undertaken of all patients who underwent microvascular free gracilis transfer for smile at our institution over the past 10 years. MAIN OUTCOMES AND MEASURES Outcome measures included the following: smile excursion, angle of smile with respect to the vertical midline, and facial symmetry during repose and with smile. Measurements were obtained using an automated tool for assessment of facial landmarks (FACE-Gram). An exhaustive set of intraoperative parameters including degree of recoil of the gracilis muscle following harvest, the degree to which the muscle foreshortened during stimulation of the obturator nerve, final stretched length of the inset muscle, surgeon assessment of neurorrhaphy and pulse pressure, ischemia time, number of sutures used during neurorrhaphy, nerve used to innervate the flap, and surgeon assessment of oral commissure overcorrection were recorded and placed into a linear regression model to investigate correlations with smile. RESULTS From March 2003 to March 2013, 154 microvascular free gracilis transfers were performed for facial reanimation at our institution, 14 (9%) of which were deemed failures. Of the remaining 140 flaps, 127 fulfilled inclusion criteria and constituted the study cohort. Smile excursion, angle excursion, and symmetry of the oral commissure at repose and with smile all improved following gracilis free flap (P < .05). Associations between selected outcomes measures and intraoperative gracilis measurements were identified. CONCLUSIONS AND RELEVANCE Facial reanimation using free gracilis transfer results in quantifiable improvements in oral commissure excursion and facial symmetry both at rest and with smiling. Associations between contractility and internal recoil of the flap and final outcome were identified. LEVEL OF EVIDENCE 4

A comparison of facial nerve grading systems.

PURPOSE: This study aimed to compare a computerized tool to standard objective clinical scales for global and zone-specific assessment of facial nerve function. METHODS: This was a retrospective review of 77 patients with facial paralysis who underwent facial videography. Videos were independently scored by 3 facial nerve specialists using the House-Brackmann Scales (HBI and HBII). Digital scoring was performed with Facogram software. Scores were recorded and compared using intraclass and Pearson (r) correlations. RESULTS: Interobserver correlation was high with HBII, with overall scores in excellent agreement (intraclass correlation range, 0.78-0.95; P ≤ 0.0001). There were strong correlations between Facogram and HBII (r ≥ 0.67, P ≤ 0.0001) and strong intraobserver correlations between HBI and HBII (r ≥ 0.71, P ≤ 0.0001). The HBII required more clinician time [mean (SD), 72 (21) seconds per case], compared with Facogram, which did not require any clinician time. CONCLUSIONS: An automated, zone-specific facial analysis tool can eliminate clinician subjectivity and allow standardized assessment of facial paralysis.

Surgical site infections after gracilis free flap reconstruction for facial paralysis.

Compared with other free tissue transfer procedures, the gracilis free muscle transfer (GFMT) for facial reanimation is unique in that the recipient site is typically uninvolved by malignancy or infection. In this study, the authors examined the incidence, bacteriology, and outcomes of surgical site infection (SSI) after gracilis free muscle transfer for facial reanimation. From 2003 to 2011, 105 patients underwent 107 GFMT operations, with 6 SSIs. All cases of infection occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperatively. None of the patients who received ampicillin-sulbactam developed an SSI. Surgical site cultures grew oral flora, including α-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium and Neisseria species, and coagulase-negative staphylococci. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. These data may have implications for the optimal perioperative antibiotic choice in facial reanimation cases. Further study is needed to determine the ideal antibiotic regimen for this category of free flap surgeries.

Color Doppler ultrasound: effective monitoring of the buried free flap in facial reanimation.

OBJECTIVE: The gracilis muscle free flap has become a reliable means for smile reanimation for patients with facial paralysis. Because it is a buried flap, it presents a postoperative monitoring challenge. We sought to evaluate our experience with color Doppler ultrasound in the monitoring of gracilis free flap viability in the immediate postoperative setting. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary medical center. METHODS: Patients with facial paralysis treated with gracilis muscle free flap for smile reanimation performed between March 2009 and November 2010 were evaluated by color Doppler ultrasound and included in the study. Our experience with the use of the color Doppler ultrasound to monitor the gracilis muscle flap is presented. RESULTS: Forty-six patients were identified. In all cases, color Doppler ultrasound was used postoperatively to assess flow through the vascular pedicle. Outcomes included an early flap survival rate of 100%, with no instances of equivocal or absent flow on either the arterial or venous side. Color Doppler ultrasound provided important objective information regarding muscle perfusion postoperatively in several instances of equivocal postoperative perfusion of the flap. CONCLUSION: Color Doppler ultrasound is a safe, noninvasive method that can be performed serially to evaluate a buried free flap. We have had success in verifying normal arterial and venous flow through the pedicle using this method of monitoring of the gracilis muscle free flap during facial reanimation, and in 3 instances, it eliminated the need for wound exploration to verify appropriate muscle perfusion.

Facial reanimation of patients with neurofibromatosis type 2.

BACKGROUND: Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome defined by bilateral vestibular schwannomas. Facial paralysis, from either tumor growth or surgical intervention, is a devastating complication of this disorder and can contribute to disfigurement and corneal keratopathy. Historically, physicians have not attempted to treat facial paralysis in these patients. OBJECTIVE: To review our clinical experience with free gracilis muscle transfer for the purpose of facial reanimation in patients with NF2. METHODS: Five patients with NF2 and complete unilateral facial paralysis were referred to the facial nerve center at our institution. Charts and operative reports were reviewed; treatment details and functional outcomes are reported. RESULTS: Patients were treated between 2006 and 2009. Three patients were men and 2 were women. The age of presentation of debilitating facial paralysis ranged from 12 to 50 years. All patients were treated with a single-stage free gracilis muscle transfer for smile reanimation. Each obturator nerve of the gracilis was coapted to the masseteric branch of the trigeminal nerve. Measurement of oral commissure excursions at rest and with smile preoperatively and postoperatively revealed an improved and nearly symmetric smile in all cases. CONCLUSION: Management of facial paralysis is often times overlooked when defining a care plan for NF2 patients who typically have multiple brain and spine tumors. The paralyzed smile may be treated successfully with single-stage free gracilis muscle transfer in the motivated patient.

Platysmectomy: an effective intervention for facial synkinesis and hypertonicity.

OBJECTIVES: To describe a procedure to permanently address platysmal synkinesis and hypertonicity and to report changes in quality of life associated with platysmectomy using the Facial Clinimetric Evaluation instrument. METHODS: Chemodenervation significantly relieves platysmal synkinesis in almost all patients with significant face and neck synkinesis associated with dynamic facial expressions. We recently began to offer platysmectomy as part of a permanent solution to chronic superficial torticollis-like neck symptoms. For a 10-month period, 24 patients underwent the procedure, and preoperative and postoperative Facial Clinimetric Evaluation data were obtained from 21 patients (88%). RESULTS: In 19 patients, platysmectomy was performed using local anesthesia without sedation. In the remaining 5 patients, platysmectomy was performed using general anesthesia concurrent with free gracilis transfer for smile reanimation. No intraoperative or postoperative complications occurred. Overall, the patients' quality of life significantly improved after platysmectomy (P = .02). CONCLUSION: Platysmectomy is straightforward and seems effective in treating neck synkinesis associated with chronic hypertonic platysmal activity.

Free gracilis transfer for smile in children: the Massachusetts Eye and Ear Infirmary Experience in excursion and quality-of-life changes.

BACKGROUND: Free muscle transfer for facial reanimation has become the standard of care in recent decades and is now the cornerstone intervention for dynamic smile reanimation. We sought to quantify smile excursion and quality-of-life (QOL) changes in our pediatric free gracilis recipients following reanimation. METHODS: We quantified gracilis muscle excursion in 17 pediatric patients undergoing 19 consecutive pediatric free gracilis transplantation operations, using our validated SMILE program, as an objective measure of functional outcome. These were compared against excursion measured the same way in a cohort of 17 adults with 19 free gracilis operations. In addition, we prospectively evaluated QOL outcomes in these children using the Facial Clinimetric Evaluation (FaCE) instrument. RESULTS: The mean gracilis excursion in our pediatric free gracilis recipients was 8.8 mm ± 5.0 mm, which matched adult results, but with fewer complete failures of less than 2-mm excursion, with 2 (11%) and 4 (21%), respectively. Quality-of-life measures indicated statistically significant improvements following dynamic smile reanimation (P = .01). CONCLUSIONS: Dynamic facial reanimation using free gracilis transfer in children has an acceptable success rate, yields improved commissure excursion, and improves QOL in the pediatric population. It should be considered first-line therapy for children with lack of a meaningful smile secondary to facial paralysis.

Surgical treatment of the periocular complex and improvement of quality of life in patients with facial paralysis.

OBJECTIVE: A devastating sequela of facial paralysis is the inability to close the eye. The resulting loss of corneal protection can potentially lead to severe consequences. Eyelid weight placement, lower eyelid suspension, and brow ptosis correction are frequently performed to protect the eye. We sought to measure and report the change in quality of life (QOL) after surgical treatment of the periocular complex, using the validated Facial Clinimetric Evaluation (FaCE) QOL instrument. METHODS: From March 2009 to May 2010, 49 patients presenting to the Facial Nerve Center with paralytic lagophthalmos requiring intervention were treated with static periocular reanimation. Thirty-seven of the patients completed preoperative and postoperative FaCE surveys. RESULTS: Overall QOL, measured by the FaCE instrument, significantly improved following static periocular treatment. Mean FaCE scores increased from 44.1 to 52.7 (P < .001). Patients also reported a significant decrease in the amount of time their eye felt dry, irritated, or scratchy (P < .001). The amount of artificial tears and/or ointment also significantly decreased (P = .03). There were 2 cases of localized cellulitis with 1 eyelid weight extrusion. CONCLUSIONS: We report the first series of postoperative QOL changes following static periocular treatment for paralytic lagophthalmos. Patients report a notable improvement in periocular comfort and overall QOL.

Good correlation between original and modified House Brackmann facial grading systems.

OBJECTIVES/HYPOTHESIS: Subjective scales of facial function were plagued with reporting variations until the House-Brackmann scale was described in 1985. Despite its utility, weaknesses were identified, including noninclusion of synkinesis phenomena and insensitivity to segmental weakness. Therefore, the scale was recently revised to address these weaknesses. The objective of this investigation was to determine agreement between the original and the updated House-Brackmann scales. STUDY DESIGN: Prospective clinical trial. METHODS: Fifty consecutive new facial paralysis patients underwent standardized facial videography while performing facial movements. Video clips were scored by three independent facial nerve clinicians. The time it took to produce a score for each method was tracked. Interobserver correlations were calculated, and comparisons were made between scores by using the original and modified House-Brackmann scales. RESULTS: : Interobserver correlation was high for both House-Brackmann scales. Overall scores were in excellent agreement (difference of 0.1 ± 0.5, no statistical difference), although the modified scale took substantially longer to calculate (120 seconds ± 20 seconds vs. 30 seconds ± 10 seconds, P < .001). CONCLUSIONS: We found substantial grading correlation between the original and the newly modified House-Brackmann scales. Because of specific zonal and synkinesis scoring, the modified scale took longer to score.