Injuries to the facial nerve during surgeries of the head, ear, and face lead to the undesirable cosmetic result of a facial droop, dissatisfied patients, and potential malpractice claims. Monitoring the facial nerve during surgery may help, but only if done consistently well.
That lack of standard references as a resource for facial nerve monitoring was the impetus behind creating best practice guidelines compiled by a multidisciplinary group of experts representing more than a century of combined monitoring experience, including Professor of Anesthesiology and Neurosurgery Christoph N. Seubert, MD, PhD. The “Best Practices in Facial Nerve Monitoring” guidelines were published by The Laryngoscope as a supplement, which is more than 40 print pages, with additional online supplementary content, six tables, and 27 figures. It will appear in the journal’s April 2021 print edition.
The supplement describes critical steps in the technical set-up of facial nerve monitoring and provides a basis for interpreting and troubleshooting signals. With a standardized approach to ensure that no detail is overlooked and complications are avoided, patient safety and outcomes will be improved. Additionally, the operative team’s satisfaction in their work will be enhanced, costs will be reduced, and the possibility of lawsuits minimized.
“I hope this allows people to come up with a system that consistently delivers high-quality care,” Dr. Seubert said.
Work on the supplement spanned nearly five years and included help from our department’s Communications and Publishing Office, as the text underwent numerous rounds of revisions, additions, and fine-tuning. One of the challenges of distilling such a large quantity of learning was identifying the best means of dissemination.
“It’s a body of knowledge that was looking for a format,” Dr. Seubert said, noting that synthesizing clinical knowledge can take a variety of forms, ranging from a review paper to a textbook. “This topic was in between in size; part of the struggle was pouring this into form.”
Another challenge was that facial nerve function monitoring is viewed in a variety of ways, contributing to the non-standardized approach. Some just look for the presence of a monitor and if the device is present, they consider the work high quality; if it is not present, they do not consider it high quality.
Others consider facial nerve monitoring an essential tool for safely performing surgeries, but even among those with that view, there is a wide range of interest groups with little overlap, such as ear, nose, and throat surgeons, neurosurgeons, and monitoring companies.
That range of people from many different walks of clinical life is reflected in the supplement’s author list, which comprises a neurotological surgeon, a neurologist at an academic medical center, a neuromonitoring expert who is among the world’s leading authorities in the field, an anesthesiologist, a technologist from a monitoring company who is heavily involved in education, and an expert who has a history as a monitoring technologist and has held executive roles with monitoring companies.
With such a diverse field, presenting the information in one cohesive text was vital.
“We hope the audience includes everyone who comes into contact with that monitor and wonders how to best use it,” Dr. Seubert said. That list includes everyone in an ear, nose, and throat or neurosurgical operating room, such as surgeons, neurologists, trainees, anesthesiologists, operating room nurses, and technologists. “We have tried to include material for everyone on that list, including a neurologist who gets presented with just the data as part of interpreting a more complex monitoring setup.”
Furthermore, the supplement goes well beyond enumerating best practices by explaining the context in which the practices are applied and offering didactic examples in the form of case histories and pitfalls. Given the broad audience, the supplement includes a substantial amount of detail on surgical anatomy to create a shared set of facts around which to have conversations.
“Our hope is that this multipronged approach serves to engage the full spectrum of the intended audience, not just the one or two people in a given operating room who have ultimate responsibility for monitoring successfully,” Dr. Seubert said.
Dr. Seubert originally became involved in the project through connections with his coauthors in the niche field of intraoperative neuropsychological monitoring. All coauthors are members of the American Society of Neurophysiological Monitoring (ASNM), where Dr. Seubert has served as a board member and participated in educational activities throughout his career.
The first author, Jack M. Kartush, MD, FASNM, a longtime neurotological surgeon at the Michigan Ear Institute, was the founding president of the ASNM, while another coauthor, Charles D. Yingling, PhD, DABNM, of the Department of Otolaryngology and Head and Neck Surgery at Stanford University and a private practice group called Golden Gate Neuromonitoring, visited UF as a consultant to teach transcranial motor-evoked potentials for clinical use. The other authors are Kent S. Rice, MS, CNIM, DABNM, R.EPT, of the medical monitoring and device company NuVasive; Robert E. Minahan, MD, ABPN, of the Department of Neurology at Georgetown University; and Gene K. Balzer, PhD, FASNM, FAAA, of Real Time Neuromonitoring Associates.
The authors are pioneers in the field of neuromonitoring, and many devoted their careers to the specialty. With many at or nearing retirement age, bringing the safety technology to patient care in a seminal work represents a way to pass their knowledge to the next generation.
“A first-hand history carries a particular value,” Dr. Seubert said.