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. 2023 Nov;81(11):970-979.
doi: 10.1055/s-0043-1777003. Epub 2023 Nov 30.

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

Márcia Gonçalves E Silva Targino da Costa  1 , Péricles de Andrade Maranhão-Filho  2 , Izabella Costa Santos  3 , Carolina Rocha Aquino González  1 , Carlos Henrique Stohler de Almeida  1 , Ronir Raggio Luiz  4
Affiliations

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

Márcia Gonçalves E Silva Targino da Costa et al. Arq Neuropsiquiatr. 2023 Nov.

Abstract
in English, Portuguese

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.

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.

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Conflict of interest statement

There is no conflict of interest to declare.

Figures

Figure 1
Figure 1
Degree of voluntary movement of each expression assessed on POD 20-30.
Figure 2
Figure 2
Graphic representation of the statistically significant results in comparison of S-FGS and mS-FGS with clinical-surgical variables (POD 20-30).
Figure 3
Figure 3
Examples of exclusive MMB dysfunction post parotidectomy (POD 20-30). A Patient 1: 54-year-old man after superficial parotidectomy due to a Warthin Tumor. The first 5 images correspond to expressions evaluated by the S-FGS. The sixth picture (highlighted) shows the new expression introduced in mS-FGS. B Patient 2: 49-year-old man after more aggressive surgery: resection of retroauricular skin cancer plus superficial parotidectomy, neck dissection (levels II and III) and reconstruction with SCAIF flap, due to squamous cell carcinoma. The pictures present the same expressions, also identifying the corresponding predominant branches of the facial nerve under test. The patient had mild OO paresis but a DLI/DAO palsy.
See this image and copyright information in PMC

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