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Melanie Cole (Host):  Welcome to the UAB Med Cast. I’m Melanie Cole and today, we’re discussing facial nerve disorders and injuries. Joining me in this panel are Dr. Hari Jeyarajan. He’s an Assistant Professor and Head and Neck Surgeon in the Department of Otolaryngology, Dr. Rene Myers. He’s an Assistant Professor and Craniofacial Plastic Surgeon and Dr. Benjamin Greene. He’s an Assistant Professor and an Otolaryngologist and they’re all with UAB Medicine. Dr. Greene, I’d like to start with you. Tell us a little bit about the prevalence of facial nerve disorders and injuries. What are the most common that you see?

Benjamin Greene, MD (Guest):  The most common facial nerve disorders that I see are related to Bell’s Palsy or idiopathic sudden onset facial nerve paralysis. It’s something that happens suddenly which is in the name of it and is usually a complete one sided facial nerve paralysis. Kind of a drooping face. Most people are familiar with a Bell’s Palsy or something like that and that is by far the most common cause of facial paralysis. It’s about 60 to even 70% of all causes of unilateral facial nerve paralysis. So, that’s the majority of what I see. But we also see a fair number of facial nerve palsies due to injury whether or not it’s a stab injury, a gunshot, or a crush injury where people fracture one of the hardest bones in the body, the temporal bone and can cause pinching of the nerve inside of the bone. But also, we see a lot due to cancer especially living in the southern states; skin cancers can go to the area of the parotid gland and cause facial nerve paralysis whether or not that’s being resected from surgery or the cancer itself hurting the nerve. And so all of those things are the most common types of unilateral facial nerve paralysis.

Rene Myers, MD (Guest):  And I would echo that what Dr. Greene said and then also say that on the pediatric side, we also see a fair number of parents who bring their infants in with what’s called a congenital unilateral lower lip paralysis which can be somewhat disconcerting if a child is trying to smile and their lower lip on one side is not moving. Generally, it’s a pretty benign thing and we con generally talk them through that entire process. With some people requesting treatment when the infants are a little bit older and then of course, also on the pediatric side, there are some congenital forms of both unilateral and bilateral facial paralysis including something called Moebius Syndrome where they can have significant dysfunction of the Cranial Nerve VII which is a fairly rare syndrome but it’s definitely something that we see and can follow as well.

Host:  Well thank you for that answer gentlemen. And Dr. Jeyarajan, tell us about the clinic at UAB. Tell us about your comprehensive approach that integrates the most cutting edge therapies for facial nerve disorders spanning from rehab to medical management to surgical repair.

Harishanker Jeyarajan, MD (Guest):  At UAB, we’ve established a multidisciplinary facial nerve clinic and essentially what that means is we know that facial nerve disorders include the range of different problems from pure paralysis to partial function to abnormal function. And there are various methods to treat these and the importance of this clinic is to sort of bring the strengths of multiple different training specialties together to see these patients. And so, we try and use a combination of surgeons, physiotherapists, and nurse practitioners to sort of see the patients and address the patients in what we call a multi-model manner. The clinic itself is set up in the ENT clinic and the reason that is is probably because as ENT surgeons and head and neck surgeons, we often cause a lot of the problems that we see due to the fact that we have to treat these cancers that quite often involve the nerves and a lot of our adult patients are patients that present either from trauma or as De. Greene mentioned before complications of skin cancer and even complications of brain surgeries and brain tumors, simple skull based tumors.

And so, we sort of sit in a really good position to sort of see these patients and treat them in the clinic. The clinic runs twice a month. We do one full day. Operate on a Monday and we see – we have one full day of clinic and we have a second half day of clinic. Usually the clinic consists of Ben Greene. Ben Greene is always there. We have an APP that’s there with him. And we have a speech pathologist who has been specially trained in the management of – the use of facial nerve physiotherapy to manage these patients. I try to make it there as well and we have access to a lot of other subspecialists often that don’t need to be there at the clinic at the time but if we need them to come in and see them for a specific reason they can come and see them as well.

When we see these patients, we do an initial assessment and all patients receive a standard set of photographs and also have a standard video taken at each appointment. The reason we do this is having an objective standardized approach allows us to both objectively assess the patient and allows them also to objectively see what problems that they are having and it allows us to – by doing it at every appointment, it allows us to follow their progress with whatever treatment that we implement.

Most patients will start off when we see them, depending on what problems they have, all patients also get assessed using a standardized survey. There are a number of different systems out there that we use to score patients and to also establish how facial nerve dysfunction is affecting their quality of life. The most common objective measure that is used across the country and across the world and the one that we use is called the Sunnybrook System. And each patient gets scored, has standardized photography and standardized videography done and then we then ask them a series of questions to assess how this is affecting their quality of life.

And based on the disorder that they have, we then implement a treatment strategy that incorporates usually a combination of physiotherapy, what we call chemical denervation particularly for the patients that are having what we call facial nerve dysfunction rather than just paralysis and then we discuss surgical treatment options depending on what type of dysfunction and what type of problems or symptoms the patient is exhibiting. There’s many different options when it comes to surgery. We divide them broadly into what we call static options and dynamic options. Dynamic options really involve either trying to get the nerve to start working on its own again so through the use of nerve graft or we try and get the nerve to work by hooking it up or connecting it to another nerve, so that’s called [00:07:26] nerve transposition. Sometimes the patient doesn’t even have the muscles to create facial movement and in those situations, a dynamic approach would involve taking another muscle something the Dr. Myers alluded to before, [00:07:40] muscle flap and using that to try and drive the face to make a smile.

And there are a lot of other static procedures that we offer really trying to position the face in a better position at rest. It becomes quite complex but in general, we use a range of these different techniques to try and suit the problem that the patient presents with and suit the outcomes that the patients are trying to achieve.

Dr. Myers:  You know one of the biggest things in terms of doing multidisciplinary and hearing from both the plastic surgery standpoint, the ENT standpoint, the physical therapist standpoint; all of those things of everything that we all have contributed is really paled in comparison of what the patient has to say about what their experience with facial paralysis is like and what their goals are in terms of what their ultimate reconstruction would be. For example, some of the more elderly patients that have some facial nerve dysfunction or paralysis might opt for less surgery versus a younger patient who has more life to live might opt for a more extensive operation if it meant that their life or the way that they can present their face to the world could be improved because people make a lot of assumptions about other people based on what their face looks like and if half of your face doesn’t work or if your entire face doesn’t work; then other people you interact with will misread the emotionality that person has or doesn’t have in a given situation. Oftentimes they are described as being – looking like they are mean because they are not smiling properly. And that can really affect somebody’s social standing and how they can interact with the world at large. It really is a big deal for them.

So, getting down to what they really want fixed whether it’s something as simple as my eye gets really dry, I need to have that fixed all the way up to I need a spontaneous smile because I can’t interact with people the way that I want to.

Host:  Dr. Myers, I’d like you to expand for us a little bit as even a slight amount as you are saying of facial asymmetry or weakness can have a huge affect in a person’s quality of life and due to the sensitivity of these disorders and the intricate nature of what you do; tell us about some of the latest advances whether it’s robotics, minimally invasive technology that could allow surgeons to access hard to reach areas. So, give us a little bit of a rundown on what you do.

Dr. Myers:  Certainly. Discovery of neuromodulation in terms of using whether it’s Botox or Dysport or any of the other botulinum toxins that are available on the market to target certain muscle groups to help with things like synkinesis where people’s muscles are firing at inappropriate times for example because sometimes it can be a very bothersome thing to patients. As we’ve continued to learn more about facial nerve dysfunction and how we can put nerves back together, transfer nerves or transfer entire muscles using microscopes and very intricate microsurgical techniques to put those things all together in a very staged and planned out operation that can several times in the operating room to get that accomplished over the course of a year or two to have an outcome at the end that everybody can be happy with.

Dr. Greene:  And I’d like to add to what Dr. Myers was saying about just having the surgery or after having treatment having a good team involving facial therapists, APP support, great photographers is really helpful to getting the patients back to the best that they can be. So, just the three of us come in and do these large surgeries, transferring muscles, transferring nerves what have you; but without the therapy, without the training, without the retraining and without the discussions with the patients about neuromodulation and chemo denervation or just how to use these new muscles it doesn’t work nearly as well as when you have the multidisciplinary team approach that we’ve developed here to make sure that they get the therapy that they need to get the muscles and the nerve groups working as well as they can be.

Host:  And Dr. Greene would you expand just a little bit when you are saying all of this multidisciplinary multimodal approach; what have you guys learned from generous research on the subject plus all of this practical experience that you’re going over with us today and this multimodal approach. What else have you learned that makes your program stand apart and is so unique in the country?

Dr. Greene:  What I learned is that everybody at some level was doing some type of facial nerve repair before we started this and it just – it was not as coordinated as it could have been. And so, by developing the facial nerve clinic; we put everything together and are standardizing the approach so that every patient gets very good treatment the same way with similar people. And I also learned that there’s a lot I don’t know. And there’s a lot that Dr. Myers as a plastic surgeon sees differently than I do and the same thing with Dr. Jeyarajan. We see things and look at things in a little different way, not totally different but just a little bit where it helps having different eyes and different ideas to help each patient. We also have oculoplastic surgery involved where they specialize in plastic surgery around the eyelids and eyes and one of the most important parts of managing facial nerve paralysis is making sure that they eye can close appropriately because in early Bell’s Palsy and facial nerve paralysis, the facial nerve is responsible for closing the eye and when the eye can’t close it can get dried out, they can get abrasions and infections of the eye where over time can result in decreased vision, irritation and even blindness.

And so having people that are very specialized with eyelid surgery onboard is very important for the patients and just seeing how great the oculoplastic surgeons are at doing their job and doing what they love, seeing how great Dr. Myers and the Plastic Surgery Department is at helping us out and getting these things done and having partners like Dr. Jeyarajan, they are just incredible surgeons. It’s been kind of enlightening to me to show me what else is out there, what other ideas are out there. And really, really has been kind of inspiring to see what more we can do for patients and what more we can offer for the whole southeast region.

Dr. Myers:  I agree 100% Ben and I would also say that being able to – especially these big operations, the really complicated things where we are doing microvascular surgery, you are transferring free functional muscles and doing nerve transfers, all of those things; from a surgeon’s standpoint, once can go into those things and do it by themselves but how much more comfortable do we feel having two other microvascularly trained surgeons around during those things. I would say, way more comfortable. Because if for whatever reason, I’m struggling with something with one of the residents, that’s very simple; either yourself or Hari will scrub in and we make it all work. And it’s a lovely orchestra of surgery that winds up happening because there is very experience people who have all done these things a lot and the particular flaps that we do, especially the Gracilis muscle flap; we do those things all the time for things like lower extremity reconstruction which are not quite as delicate an endeavor as facial reanimation but being able to do those things constantly all the time helps inform us about reconstruction of a smile and doing it up in somebody’s face where it’s a little more difficult than doing it in somebody’s leg.

Host:  Dr. Jeyarajan, tell us a little bit about what you’ve seen and then I want to give all of you gentlemen a chance to say a last thought on this particular topic. Dr. Jeyarajan why don’t you start. Tell us a little bit about your outcomes and do you have any clinical trials you’d like to mention?

Dr. Jeyarajan:  In the clinic so far, we’ve seen just over about 200 patients, I think. The most common cause of facial nerve dysfunction by far is that that’s been due to Bell’s Palsy or idiopathic facial nerve paralysis as Dr. Greene alluded to before. And then we’ve had a fair amount due to surgery and a fair amount due to trauma. Most of these patients particularly ones that have had Bell’s Palsy have been managed nonsurgically. The vast majority of them have been able to be managed through a combination of specialized facial nerve physiotherapy, what we call chemical denervation or Botox injections that helps to sort of adjust the unwanted movements that can sometimes happen as the face starts working again. And so far, for those patients, we’ve noticed a significant improvement in both objective measures so that means using what we sort of talked about before, the Sunnybrook scoring system, we’ve seen a significant improvement in their objective facial nerve function and we’ve also seen a significant improvement in their standardized quality of life scores and that basically says that patients themselves are feeling a lot happier and a lot better and that’s without even requiring surgery.

With regards to our facial reanimation techniques, we’ve had relatively good outcomes so far with our reinnervation but also with reinnervation it takes a lot of time to actually see the nerves come back and that’s something that’s really important when you see these patients is that a lot of these patients that have required nerve sacrifice due to tumors or traumas or brain surgeries; when we do these surgeries, the nerves take time to recuperate and regrow along the nerve graft that we put down and so that takes months to really happen and so we’re still waiting to sort of see what the long term outcomes of those nerve grafts have been.

With regards to our general physiotherapy for our facial nerve dysfunction patients; we’ve had excellent outcomes. And that’s based on both objective measures and also the subjective quality of life scores that we’ve been looking at.

With regards to where we go from here, we just submitted a publication going over how we’ve come about starting the clinic, setting it up and looking at our initial outcomes. I feel that the next endeavor really is to really explore our long term outcomes with our dynamic reanimation techniques and that’s probably the next place that we’re going to be really focusing on and hopefully assessing long term outcomes regarding that.

Dr. Greene:  That’s exactly right. The most interesting thing for me about doing the facial nerve clinic and seeing the facial nerve patients is just how happy people are to be listened to and actually get treatment. Some of the patients have had Bell’s Palsy and the sequelae of a partially healed Bell’s Palsy for 20 years or more. And were told years ago that there was nothing more that can be done. And that’s just not true anymore. Because we can take care of folks that have had all kinds of facial nerve problems. I mean it has never happened that somebody has come to me with a facial nerve problem and I said there’s nothing we can do. Because there’s always something that we can do to help people. And it’s just – it’s very satisfying when you can tell people that you can help them when they’ve been looking for something for a long, long time.

Host:  So, well put and Dr. Myers, I’d like the last word to be for you. Please tell other providers when you feel that it’s important that they refer to this amazing clinic at UAB Medicine and any exciting advances, what you see on the horizon happening for facial nerve disorders and injuries.

Dr. Myers:  I would say that it’s interesting. For upper extremity, some of the plastic surgeons around the country including some of us at UAB are starting to get into what’s called targeted muscle reinnervation which hasn’t been worked out significantly within the head and neck area but that’s certainly some place where things could potentially go in the future trying to actually reinnervate individual muscles within the face. As far as who should be referred to us, certainly we’re always available. It’s very easy to get ahold of us at UAB and any provider that simply wants to have a conversation with us if they have questions about a particular patient, we’re more than happy to talk to them on the phone and equally willing to see people in the clinic that need to be seen in the clinic.

And really, any sort of whether it is idiopathic, traumatic, congenital or anything else that provides a facial asymmetry or a dysfunction in somebody’s facial musculature; we are absolutely 100% ready to see those things and be able to hopefully provide something to improve those people’s lives.

Host:  What great information. Gentlemen, thank you so much for coming on today and collaborating and sharing with us your incredible expertise for other providers about the clinic at UAB Medicine. Thank you so much. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.