Download PDF
CC BY 4.0 · Arq Neuropsiquiatr 2023; 81(11): 970-979
DOI: 10.1055/s-0043-1777003
Original Article

Post-parotidectomy facial nerve function: comparison between original and modified Sunnybrook Facial Grading Systems

Função do nervo facial pós-parotidectomia: comparação entre os Sistemas Sunnybrook de Graduação Facial original e modificado
Márcia Gonçalves e Silva Targino da Costa 
1   Hospital do Câncer I, Instituto Nacional de Câncer, Departamento de Fisioterapia, Rio de Janeiro RJ, Brazil.
,
Péricles de Andrade Maranhão-Filho 
2   Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Departamento de Neurologia, Rio de Janeiro RJ, Brazil.
,
Izabella Costa Santos 
3   Hospital do Câncer I, Instituto Nacional de Câncer, Departamento de Cirurgia de Cabeça e Pescoço, Rio de Janeiro RJ, Brazil.
,
Carolina Rocha Aquino González 
1   Hospital do Câncer I, Instituto Nacional de Câncer, Departamento de Fisioterapia, Rio de Janeiro RJ, Brazil.
,
Carlos Henrique Stohler de Almeida 
1   Hospital do Câncer I, Instituto Nacional de Câncer, Departamento de Fisioterapia, Rio de Janeiro RJ, Brazil.
,
Ronir Raggio Luiz 
4   Universidade Federal do Rio de Janeiro, Instituto de Estudos em Saúde Coletiva, Rio de Janeiro RJ, Brazil.
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background: Facial nerve dysfunction is the principal postoperative complication related to parotidectomy.

Objective: To test the hypothesis that the modified Sunnybrook Facial Grading System (mS-FGS) is superior to the original S-FGS in the assessment of facial nerve function following parotidectomy.

Methods: Prospective, longitudinal study evaluating patients with primary or metastatic parotid neoplasms undergoing parotidectomy with facial nerve-sparing between 2016 and 2020. The subjects were assessed twice, on the first postoperative day and at the first outpatient evaluation, 20-30 days post-surgery. Facial assessments were performed using the original and modified (plus showing the lower teeth) versions of the Sunnybrook System and documented by pictures and video recordings. Intra- and inter-rater agreements regarding the assessment of the new expression were analyzed.

Results: 101 patients were enrolled. In both steps, the results from the mS-FGS were significantly lower (p < 0.001). Subjects with a history of previous parotidectomy and those who underwent neck dissection had more severe facial nerve impairment. The mandibular marginal branch was the most frequently injured, affecting 68.3% of the patients on the first postoperative day and 52.5% on the first outpatient evaluation. Twenty patients (19.8%) presented an exclusive marginal mandibular branch lesion. The inter-rater agreement of the new expression assessment ranged from substantial to almost perfect. The intra-rater agreement was almost perfect (wk = 0.951).

Conclusion: The adoption of the Modified Sunnybrook System, which includes evaluation of the mandibular marginal branch, increases the accuracy of post-parotidectomy facial nerve dysfunction appraisal.

Resumo

Antecedentes: A disfunção do nervo facial é a principal complicação pós-operatória relacionada à parotidectomia.

Objetivo: Testar a hipótese de que o sistema Sunnybrook de graduação facial modificado (mS-FGS) é superior ao S-FGS original na avaliação da função do nervo facial após parotidectomia.

Métodos: Estudo longitudinal prospectivo avaliando o pós-operatório de pacientes com neoplasias parotídeas primárias ou metastáticas, submetidos à parotidectomia com preservação do nervo facial, entre 2016 e 2020. Os indivíduos foram avaliados duas vezes, no primeiro dia de pós-operatório e na primeira avaliação ambulatorial, 20-30 dias após a cirurgia. As avaliações faciais foram realizadas usando as versões original e modificada (que incluem mostrar os dentes inferiores) do sistema Sunnybrook e documentadas por fotos e vídeos. Foram adicionalmente analisadas as concordâncias intra e interexaminadoras da avaliação da nova expressão.

Resultados: Cento e um pacientes foram incluídos. Em ambas as etapas, os resultados do mS-FGS foram significativamente menores (p < 0,001). Indivíduos com história de parotidectomia prévia e aqueles submetidos ao esvaziamento cervical apresentaram comprometimento mais grave do nervo facial. O ramo marginal mandibular foi o mais afetado, acometendo 68,3% dos pacientes no primeiro dia de pós-operatório e 52,5% na primeira avaliação ambulatorial. Vinte pacientes (19,8%) apresentaram lesão exclusiva do ramo marginal mandibular. A concordância interexaminadores da avaliação da nova expressão variou de substancial a quase perfeita. A concordância intraexaminador foi quase perfeita (wk = 0,951).

Conclusão: A adoção do sistema Sunnybrook modificado, que inclui a análise do ramo marginal mandibular, aumenta a precisão da avaliação da disfunção do nervo facial pós-parotidectomia.

Keywords

Parotid Neoplasms - Skin Neoplasms - Surgery - Facial Nerve Injuries - Patient Outcomes Assessment.

Palavras-chave

Neoplasias Parotídeas - Neoplasias Cutâneas - Cirurgia - Traumatismos do Nervo Facial - Avaliação de Resultados da Assistência ao Paciente.

Authors' Contributions

MGTSC: conceptualization, data curation; formal analysis; statistical analysis, writing – original draft, writing – review & editing; PAMF: conceptualization, writing – review & editing, ICS: conceptualization, formal analysis, writing – review & editing; CRAG: data curation; CHSA: data curation; RRL: methodology, formal analysis, statistical analysis; writing – review & editing, research coordinator.




Publication History

Received: 02 June 2023

Accepted: 06 September 2023

Article published online:
30 November 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Marchese-Ragona R, De Filippis C, Marioni G, Staffieri A. Treatment of complications of parotid gland surgery. Acta Otorhinolaryngol Ital 2005; 25 (03) 174-178
    PubMedSearch in Google Scholar
  • 2 Cannon CR, Replogle WH, Schenk MP. Facial nerve in parotidectomy: a topographical analysis. Laryngoscope 2004; 114 (11) 2034-2037
    CrossrefPubMedSearch in Google Scholar
  • 3 Tung B-K, Chu P-Y, Tai S-K. et al. Predictors and timing of recovery in patients with immediate facial nerve dysfunction after parotidectomy. Head Neck 2014; 36 (02) 247-251
    CrossrefPubMedSearch in Google Scholar
  • 4 Gaillard C, Périé S, Susini B, St Guily JL. Facial nerve dysfunction after parotidectomy: the role of local factors. Laryngoscope 2005; 115 (02) 287-291
    CrossrefPubMedSearch in Google Scholar
  • 5 Infante-Cossio P, Gonzalez-Cardero E, Garcia-Perla-Garcia A, Montes-Latorre E, Gutierrez-Perez JL, Prats-Golczer VE. Complications after superficial parotidectomy for pleomorphic adenoma. Med Oral Patol Oral Cir Bucal 2018; 23 (04) e485-e492
    CrossrefPubMedSearch in Google Scholar
  • 6 Nason RW, Binahmed A, Torchia MG, Thliversis J. Clinical observations of the anatomy and function of the marginal mandibular nerve. Int J Oral Maxillofac Surg 2007; 36 (08) 712-715
    CrossrefPubMedSearch in Google Scholar
  • 7 Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg 1996; 114 (03) 380-386
    CrossrefPubMedSearch in Google Scholar
  • 8 Fattah AY, Gurusinghe ADR, Gavilan J. et al; Sir Charles Bell Society. Facial nerve grading instruments: systematic review of the literature and suggestion for uniformity. Plast Reconstr Surg 2015; 135 (02) 569-579
    CrossrefPubMedSearch in Google Scholar
  • 9 Costa MGESTD, Maranhão-Filho PA, Santos IC, Luiz RR, Vincent MB. Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System. Arq Neuropsiquiatr 2019; 77 (07) 460-469 . Doi: 10.1590/0004-282. Doi: × 20190074
    CrossrefPubMedSearch in Google Scholar
  • 10 Bloom J, Lopez MJ, Rayi A. Anatomy, Head and Neck, Eye Levator Labii Superioris Muscle. In: StatPearls. StatPearls Publishing: Treasure Island (FL): 2022
    Search in Google Scholar
  • 11 Hu WL, Ross B, Nedzelski J. Reliability of the Sunnybrook Facial Grading System by novice users. J Otolaryngol 2001; 30 (04) 208-211
    CrossrefPubMedSearch in Google Scholar
  • 12 Kanerva M, Poussa T, Pitkäranta A. Sunnybrook and House-Brackmann Facial Grading Systems: intrarater repeatability and interrater agreement. Otolaryngol Head Neck Surg 2006; 135 (06) 865-871
    CrossrefPubMedSearch in Google Scholar
  • 13 Cabrol C, Elarouti L, Montava A-L. et al. Sunnybrook Facial Grading System: Intra-rater and Inter-rater Variabilities. Otol Neurotol 2021; 42 (07) 1089-1094
    CrossrefPubMedSearch in Google Scholar
  • 14 Robinson MW, Baiungo J. Facial Rehabilitation: Evaluation and Treatment Strategies for the Patient with Facial Palsy. Otolaryngol Clin North Am 2018; 51 (06) 1151-1167
    CrossrefPubMedSearch in Google Scholar
  • 15 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-174
    CrossrefPubMedSearch in Google Scholar
  • 16 Zhan KY, Khaja SF, Flack AB, Day TA. Benign Parotid Tumors. Otolaryngol Clin North Am 2016; 49 (02) 327-342
    CrossrefPubMedSearch in Google Scholar
  • 17 Parker ER. The influence of climate change on skin cancer incidence - A review of the evidence. Int J Womens Dermatol 2020; 7 (01) 17-27
    CrossrefPubMedSearch in Google Scholar
  • 18 Myers LL, Ahn C. Cutaneous squamous cell carcinoma metastasis to the parotid region lymph nodes. Laryngoscope 2019; 129 (07) 1579-1586
    CrossrefPubMedSearch in Google Scholar
  • 19 Cheriyan J, Wernberg J, Urquhart A. Head and neck melanoma. Surg Clin North Am 2014; 94 (05) 1091-1113, ix
    CrossrefPubMedSearch in Google Scholar
  • 20 Thom JJ, Moore EJ, Price DL, Kasperbauer JL, Starkman SJ, Olsen KD. The Role of Total Parotidectomy for Metastatic Cutaneous Squamous Cell Carcinoma and Malignant Melanoma. JAMA Otolaryngol Head Neck Surg 2014; 140 (06) 548-554
    CrossrefPubMedSearch in Google Scholar
  • 21 Asarkar A, Bundrick P, Nathan CO. When Should Parotidectomy and a Neck Dissection Be Performed in Cutaneous SCC of the Head and Neck?. Laryngoscope 2019; 129 (03) 535-536
    CrossrefPubMedSearch in Google Scholar
  • 22 Liu Z, Wang B, Yang L. A modified method for minimizing damage to the marginal mandibular branch (MMB) during partial superficial parotidectomy(PSP): A retrospective study. J Craniomaxillofac Surg 2022; 50 (08) 637-642
    CrossrefPubMedSearch in Google Scholar
  • 23 Dulguerov P, Marchal F, Lehmann W. Postparotidectomy facial nerve paralysis: possible etiologic factors and results with routine facial nerve monitoring. Laryngoscope 1999; 109 (05) 754-762
    CrossrefPubMedSearch in Google Scholar
  • 24 Haginomori S-I, Wada S-I, Ichihara T, Terada T, Kawata R. A new electroneurography as a prognostic tool for marginal mandibular nerve paralysis after parotid gland surgery: A preliminary evaluation. Auris Nasus Larynx 2017; 44 (05) 602-606
    CrossrefPubMedSearch in Google Scholar
  • 25 Musani MA, Zafar A, Suhail Z, Malik S, Mirza D. Facial nerve morbidity following surgery for benign parotid tumours. J Coll Physicians Surg Pak 2014; 24 (08) 569-572
    PubMedSearch in Google Scholar
  • 26 Hwang SY, Brett RH. An audit of parotidectomy in Singapore: a review of 31 cases. Med J Malaysia 2003; 58 (02) 273-278
    PubMedSearch in Google Scholar
  • 27 Raslan A, Volk GF, Möller M, Stark V, Eckhardt N, Guntinas-Lichius O. High variability of facial muscle innervation by facial nerve branches: A prospective electrostimulation study. Laryngoscope 2017; 127 (06) 1288-1295
    CrossrefPubMedSearch in Google Scholar
  • 28 Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E. Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 2006; 116 (04) 534-540
    CrossrefPubMedSearch in Google Scholar
  • 29 Witt RL, Nicolai P. Recurrent Benign Salivary Gland Neoplasms. Adv Otorhinolaryngol 2016; 78: 63-70
    CrossrefPubMedSearch in Google Scholar
  • 30 Sajisevi M. Indications for Facial Nerve Monitoring During Parotidectomy. Otolaryngol Clin North Am 2021; 54 (03) 489-496
    CrossrefPubMedSearch in Google Scholar
  • 31 Murthy SP, Paderno A, Balasubramanian D. Management of the marginal mandibular nerve during and after neck dissection. Curr Opin Otolaryngol Head Neck Surg 2019; 27 (02) 104-109
    CrossrefPubMedSearch in Google Scholar
  • 32 Chiesa Estomba C, Sistiaga Suárez J, González-García J, Larruscain-Sarasola E, Thomas Arrizabalaga I, Altuna Mariezcurrena X. Marginal mandibular nerve injury during neck dissection of level IIa, and the influence of different types of dissection: diathermy versus cold knife. Otolaryngol Pol 2018; 72 (04) 21-25
    CrossrefPubMedSearch in Google Scholar
  • 33 Bron LP, O'Brien CJ. Facial nerve function after parotidectomy. Arch Otolaryngol Head Neck Surg 1997; 123 (10) 1091-1096
    CrossrefPubMedSearch in Google Scholar
  • 34 Eviston TJ, Yabe TE, Gupta R, Ebrahimi A, Clark JR. Parotidectomy: surgery in evolution. ANZ J Surg 2016; 86 (03) 193-199
    CrossrefPubMedSearch in Google Scholar
  • 35 John Delphine A, Samuel VM, Gaikwad P, Sharma SL, Thomas CT. Inter- and Intra-rater Reliability of Modified House-Brackmann and Sunnybrook Facial Nerve Grading Systems in Post Parotidectomy Patients. Indian J Otolaryngol Head Neck Surg 2023; 75 (01) 100-108
    CrossrefPubMedSearch in Google Scholar
  • 36 van Veen MM, Bruins TE, Artan M, Werker PMN, Dijkstra PU. Learning curve using the Sunnybrook Facial Grading System in assessing facial palsy: An observational study in 100 patients. Clin Otolaryngol 2020; 45 (05) 823-826
    CrossrefPubMedSearch in Google Scholar
  • 37 Tan JR, Coulson S, Keep M. Face-to-Face Versus Video Assessment of Facial Paralysis: Implications for Telemedicine. J Med Internet Res 2019; 21 (04) e11109
    CrossrefPubMedSearch in Google Scholar
  • 38 Swendseid B, Li S, Thuener J. et al. Incidence of facial nerve sacrifice in parotidectomy for primary and metastatic malignancies. Oral Oncol 2017; 73: 43-47
    CrossrefPubMedSearch in Google Scholar
  • 39 Yesensky J, Solis RN, Bewley A. Facial Nerve Sacrifice During Parotidectomy for Metastatic Cutaneous Squamous Cell Carcinoma. OTO Open 2021; 5 (01) X21996627
    CrossrefPubMedSearch in Google Scholar
  • 40 Poutoglidis A, Paraskevas GK, Lazaridis N. et al. Extratemporal facial nerve branching patterns: systematic review of 1497 cases. J Laryngol Otol 2022; 136 (12) 1170-1176
    CrossrefPubMedSearch in Google Scholar
  • 41 Nada Y, Sasaki K, Nozaki M, Soejima K. Congenital partial absence of the facial muscles. Br J Plast Surg 1998; 51 (02) 138-141
    CrossrefPubMedSearch in Google Scholar