Otolaryngology http://oto.sagepub.com/ -- Head and Neck Surgery
Contemporary Changes with the Use of Facial Nerve Monitoring in Chronic Ear Surgery Jinwei Hu, Terry R. Fleck, Jane Xu, Jeffrey V. Hsu and Helen X. Xu Otolaryngology -- Head and Neck Surgery 2014 151: 473 originally published online 3 June 2014 DOI: 10.1177/0194599814537223 The online version of this article can be found at: http://oto.sagepub.com/content/151/3/473
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Original Research—Otology and Neurotology
Contemporary Changes with the Use of Facial Nerve Monitoring in Chronic Ear Surgery
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(3) 473–477 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814537223 http://otojournal.org
Jinwei Hu, MD1, Terry R. Fleck, MD2, Jane Xu1, Jeffrey V. Hsu, MD3, and Helen X. Xu, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. There is a growing trend for the routine use of the facial nerve monitor (FNM) in chronic ear surgery. We aimed to examine current patterns in the use of FNMs in chronic ear surgery. Study Design. Descriptive design (survey). Setting. Academic health center. Methods. A 10-question survey was designed to identify level of training, scope of practice, specific otologic surgeries where monitoring was most used, and the opinion of respondents regarding the use of FNMs as standard of care for chronic and/or middle ear surgery. A randomized list of 2000 board-certified members of the American Academy of Otolaryngology—Head and Neck Surgery was generated. One thousand subjects received a mailed survey with a selfaddressed return envelope and 1000 subjects received an emailed survey through Surveymonkey.com. Results. There were 359 (36%) surveys returned by mail and 258 (26%) surveys returned electronically. Forty-three percent of respondents were in private practice, and 31% were fellowship trained in otology/neurotology. Sixty-five percent used a FNM in their training and 95% had regular access to a FNM. Revision mastoid surgery, cholesteatoma, canal wall down mastoidectomy, and facial recess approach were the settings where a FNM was most used. Forty-nine percent of respondents felt that a FNM should be used as the standard of care in chronic ear surgery; this represents an increase from 32% in a similar study done approximately 10 years ago. Conclusion. There is a growing trend for routine facial nerve monitoring in the setting of chronic ear surgery.
Introduction Iatrogenic facial weakness or paralysis is a serious complication in any ear surgery. Although the incidence of facial nerve injury is quite low for primary ear surgery (less than 1%),1 it can be as high as 4% to 10% in cases of surgical revision.2 Intraoperative facial nerve monitoring has been in use for nearly 2 decades.3 Its utility was first established in the surgical extirpation of retrocochlear lesions4,5 and has since proven beneficial with procedures involving the parotid gland.6,7 The role of intraoperative facial nerve monitor (FNM) use in chronic ear surgery has been less defined. A survey from Baylor University published 11 years ago highlighted FNM use in chronic ear surgery as being more prevalent in academic institutions and among younger otolaryngologists.8 Thirty-two percent of respondents in that survey felt that FNM use in chronic ear surgery should become standard of care.8 We surveyed 2000 general and otology/neurotology fellowshiptrained otolaryngologists in the United States with the aim to update information on the practice patterns of FNM use in chronic ear surgery.
Methods This was a survey-based descriptive study design. This study was reviewed and approved by the Institutional Review Board at Loma Linda University Medical Center. A 10-question survey was designed to identify level of training, scope of practice, familiarity with and access to a FNM, specific otologic surgeries where monitoring was most used, and if the respondents felt that facial nerve monitoring should be considered standard of care (see appendix 1 Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, USA 2 Kaiser Permanente Riverside Medical Center, Riverside, California, USA 3 Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
This article was presented at the Combined Otolaryngological Spring Meetings (COSM); April 18-22, 2012; San Diego, California.
Keywords facial nerve monitoring, chronic ear surgery Received September 17, 2013; revised April 23, 2014; accepted May 6, 2014.
Corresponding Author: Helen X. Xu, MD, Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Medical Center, 11234 Anderson Street, Room 2586A, Loma Linda, CA 92354, USA. Email: [email protected]
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at www.otojournal.org). A randomized list of 2000 boardcertified members of the American Academy of Otolaryngology—Head and Neck Surgery was generated. One thousand subjects received a mailed survey with a selfaddressed and stamped return envelope and 1000 subjects received an emailed survey through Surveymonkey.com. All analyses were performed using SAS (version 9.3; SAS Institute Inc) in consultation with the Loma Linda Statistics Department. Descriptive analyses are given as a number and percentage for each variable. Chi-square statistics were used to test the relationship between outcome variable and time from completing otolaryngology training and type of surgery. Multiple logistic regression procedure was used in the analysis to test the effect of time from completing otolaryngology training on using nerve monitoring for all chronic ear surgery after adjusting for type of surgery.
Results Two thousand anonymous questionnaires were sent to board-certified members of the American Academy of Otolaryngology—Head and Neck Surgery. There were 359 (36%) surveys returned by mail and 258 (26%) surveys returned electronically (total of 617, which was a 31% return rate). There were no statistically significant differences when comparing the mailed versus electronic responses (P = .764). In regard to practice demographics, 264 (43%) respondents were in private practice, and 345 (57%) respondents practiced in the academic setting. Almost one-third of respondents (31%) had been fellowship trained in otology/ neurotology. Among all the respondents, 85 (14%) had finished their fellowship training within the past 10 years. Four hundred (65%) respondents used a FNM in their residency or fellowship training, and virtually everyone had regular access to a FNM (95%). Fellowship-trained physicians in otology/neurotology demonstrated a significantly higher rate of using a FNM during their training as compared to nonfellowship-trained physicians (P \ .001) (Figure 1). Cholesteatoma, canal wall down mastoidectomy, primary or revision mastoid surgery, and facial recess approach were the settings where a FNM was most used (Figure 2). Three hundred thirty-three (57%) respondents stated that more than half of their chronic middle ear surgeries per month involve facial nerve monitoring (Table 1). Among these, fellowship-trained physicians in otology/neurotology had a significantly higher rate of using a FNM in chronic ear surgeries as compared to non-fellowship-trained physicians (P \ .001) (Figure 3). Those respondents who practiced in an academic setting were also more likely to use an intraoperative FNM. Thirty-one (5%) respondents experienced a formal complaint and/or lawsuit regarding facial nerve injury during a middle ear or mastoid surgery. In 76.9% of these cases, a FNM was not used during the procedure. There was no significant difference between fellowship-trained physicians and non-fellowship-trained physicians regarding facial nerve injury (P = .77). Fifty-two percent of respondents stated that these complaints and/or lawsuits prompted a change in their
Figure 1. Facial nerve monitor (FNM) usage during the residency or fellowship training. Fellowship-trained physicians demonstrated a significantly higher rate of using a FNM during their training as compared to non-fellowship-trained physicians (P \.001).
Figure 2. Types of chronic ear surgery and middle ear surgery during which a facial nerve monitor is used (total sample = 581).
routine toward the use of a FNM during middle ear and/or mastoid surgery. Of all respondents, 293 (49%) thought that a FNM should be used as the standard of care in all chronic ear surgery, which was a marked departure from the previously reported 32% in the reference study from Baylor University a decade ago. Those respondents who had finished their training within the past 10 years were nearly 2 times more likely to consistently use a FNM and felt that it should become standard of care (odds ratio = 1.89, P = .008). However, there were no statistically significant differences between fellowship-trained and non-fellowship-trained physicians in terms of their position on whether a FNM should be used as the standard of care in all chronic ear surgery (P = .09) (Figure 4).
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Table 1. Percentages of Chronic Middle Ear Surgeries Per Month Involving Facial Nerve Monitoring (FNM). Cases/Month Using FNM 0%-25% 26%-50% 51%-75% 76%-100% Total
No. of Respondents
% of Respondents
193 57 64 269 583
33.10 9.78 10.98 46.14 100.00
Figure 4. Fellowship-trained versus non-fellowship-trained physicians in terms of their position on whether a facial nerve monitor should be used as the standard of care in all chronic ear surgery (P = .09).
Figure 3. The pattern of facial nerve monitor (FNM) usage in chronic ear surgeries. Fellowship-trained physicians had a significantly higher rate of using a FNM in chronic ear surgery as compared to non-fellowship-trained physicians (P \.001).
Discussion The current study is the largest survey investigation on this topic to date and reinforces the findings of the previous studies demonstrating a rise in the use of an intraoperative FNM during otologic surgery. In 1994, Roland and Meyerhoff9 surveyed the members of the American Otological and Neurotology Society; 4% of respondents believed that a FNM should be used for all tympanomastoid surgery, whereas a majority (95%) thought that it should be reserved for neurotologic procedures and those tympanomastoid operations with higher risks of facial nerve injury. Subsequently, a survey of the members of the American Academy of Otolaryngology—Head and Neck Surgery in 2002 demonstrated that 32% of all respondents thought that monitoring should be required for chronic ear surgery.8 In our study, the upward trend continued with regard to the
number of respondents who believe that FNM use should be considered standard of care in chronic ear surgery—now nearly half of all respondents compared to fewer than onethird 11 years ago.8 The shift seems to be most strongly associated with younger surgeons, as those who had completed their training within the past 10 years are nearly twice as likely to routinely use a FNM and feel that it should be the standard of care. From our study, a quarter of respondents use a FNM during resident teaching cases in order to help prevent iatrogenic facial nerve injury. However, Greenberg et al8 reported that 78% of all respondents believed that a FNM should be used when residents are actively involved in the procedure. In our opinion, the most likely explanations are familiarity, easier accessibility of a FNM (increased from 76%8 to 95% in the current study), cost-effectiveness of a FNM, and possible fear of a malpractice lawsuit. Additional contributors to the increased popularity of facial nerve monitoring among young surgeons may include greater experience with a FNM during training, more fear of facial nerve injury because they have less experience with ear surgery, and concerns that patients have greater awareness of facial nerve injury secondary to easier access to medical information from the Internet. The FNM is now routinely used in most cases involving retrocochlear pathology, and at least some parotid and chronic ear cases. Intraoperative monitoring of the facial nerve via electromyographic (EMG) activity of the facial muscles helps the surgeon identify the location of facial nerves, map the course of facial nerves, give an early warning signal of potential injury, and predict postoperative
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facial nerve function. When severe disease has eroded the bony covering of the facial nerve, a FNM can also help the surgeon in determining true disease from normal anatomy of the VII nerve.10 Although avoiding facial nerve injury mainly depends on a surgeon’s solid knowledge of facial nerve course, the monitor does help give an early warning signal of any potential injury. This is more important in complicated cases like cholesteatoma or chronic ear surgery, when a dehiscent facial nerve may be covered by granulation tissue. Facial nerve monitoring has added another dimension of safety to otologic and neurotologic surgery.11 The disadvantage of facial nerve monitoring in otologic surgery includes the added cost of surgery, potential risk of orbital injury from the needle placement in orbicularis oculi, and possible requirement for an audiologist for interpretation of the EMG in certain surgical centers. The 5 types of cases where respondents were most likely to use a FNM all involved drilling the mastoid bone, including cholesteatoma, canal wall down mastoidectomy, primary and revision mastoid surgeries, and facial recess approach. In addition, less invasive procedures such as a simple tympanoplasty or stapedectomy were much less likely to involve intraoperative FNM use. Our survey was also consistent with these earlier findings.8 It is always prudent to ascertain the cost-effectiveness of a procedure that places a cost burden on the health care delivery system. In this sense, intraoperative facial nerve monitoring has to be viewed from the standpoint of the following: (1) How effectively does it protect the patient from iatrogenic injury? (2) Is the cost burden that it places on the practitioner and/or the institution beyond any value that it might have for the patient? (3) Does it legally protect the practitioner in a manner that is measurably significant and does not prejudice the patient from harm? A few years ago, Wilson et al12 reviewed the cost-effectiveness of facial nerve monitoring and drew some interesting conclusions. They realized that CN VII injury was the second most common basis for litigation for the otologist and placed a punitive burden in the range of $250,000 to more than $1 million on the surgeon. More troubling were data that revealed that despite the use of high-quality surgical microscopes and related technical advances, the rate of such injuries was still nearly 4% with primary surgery and ballooned to almost 10% in revision surgery.1,2 Wilson and colleagues strongly favored the use of intraoperative facial nerve monitoring in all patients undergoing middle ear and mastoid surgery, adding about $222.73 to $528.00 to the total cost. This additional cost is offset by the overall reduction in costs associated with the management of facial paralysis.12 In addition, they showed that in terms of the qualityadjusted life year index (QALY), the use of facial nerve monitoring had the highest effect and lowest cost when measured in all patients undergoing middle ear and mastoid surgery.12 Our study demonstrated that 5% of respondents have had a formal complaint and/or lawsuit regarding facial nerve injury during chronic ear surgery. Among these, a FNM had
been used only one-fifth of the time. Furthermore, greater than half of the respondents felt that these complaints and/ or lawsuits changed their indications for use of a FNM during chronic ear surgery. A survey of FNM use in parotid gland surgery showed that surgeons who employed monitoring in their practice were 20.8% less likely to have instances of lawsuits because of facial nerve injury.7 From a legal standpoint, the law and medical professions appear to have a stark lack of consensus regarding the use of a FNM for otologic procedures. In a recent commentary, Ruhl et al,13 after surveying the malpractice landscape in otology, suggested that facial nerve injury (38%) is one of the most common alleged injuries and the routine use of a FNM should be adopted in ear and mastoid surgery. However, they also recognized the opinion from the legal literature that states that the use of this technique may ‘‘serve only to increase the time and cost of surgeries.’’14 The contrarian opinion also holds that such monitoring is cost-effective.12,15 Based on survey comments from our respondents, there seems to be a strong sentiment against the idea of standard use of a FNM for chronic ear surgery. The main arguments against the idea are that there is no substitute for fundamental knowledge of the temporal bone anatomy and reliance on an adjunctive tool is risky.10,11 Many respondents also dislike the legal implications of making the FNM ‘‘standard of care.’’ The comments on the opposing side agree that it is no replacement for knowledge of temporal bone anatomy and surgical skills, however, they argue that using a FNM can add another level of safety and its cost-benefit ratio is in favor of regular use.12,15 The routine use of a FNM during otologic surgery still remains controversial. The overall response rate (31%) was within the expected range from previous survey studies. It is interesting that we noted a higher return rate from the hard copy (36%) when compared to the electronic version (26%). There was also an unexplained and higher-than-expected return from those practicing in the academic setting. There were no significant differences when comparing the mailed versus electronic responses. Kaplowitz et al16 compared the web and mail survey response rates and revealed that the mail response rate (31%, n = 2594) was significantly higher than the email response rate (25%, n = 4440), likely due to age difference and web access rate. The response rates of our study are comparable to the above study but with fewer participants. Further research examining possible demographic differences in compliance with mail and web survey requests is desirable.
Conclusion There is a growing trend for routine intraoperative facial nerve monitoring in the setting of chronic ear surgery as compared to previous studies. This was especially noted with surgeons who completed their training within the past 10 years. A strong sentiment remains against the use of a FNM or the implications of FNM use being considered standard of care.
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Acknowledgments The authors thank Khaled Bahjri, MD, MPH, and Salem Dehom, MPH, for their assistance with the statistical analysis.
Author Contributions Jinwei Hu, analysis and interpretation of data, drafting the article, revision of article; Terry R. Fleck, design, acquisition of data, analysis and interpretation of data, revision of article; Jane Xu, analysis of data, drafting the article, revision of article; Jeffrey V. Hsu, analysis of data, drafting the article, revision of article; Helen X. Xu, substantial contributions to conception and design; analysis and interpretation of data; final approval of the version to be published.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
Supplemental Material Additional supporting information may be found at www.otojournal .org/supplemental
References 1. May M. The Facial Nerve. New York, NY: Thieme; 1986. 2. Wiet RJ. Iatrogenic facial paralysis. Otolaryng Clin N Am. 1982;15:773-780. 3. Silverstein H, Smouha EE, Jones R. Routine intraoperative facial nerve monitoring during otologic surgery. Am J Otol. 1988;9:269-275. 4. Benecke JE Jr, Calder HB, Chadwick G. Facial nerve monitoring during acoustic neuroma removal. Laryngoscope. 1987;97: 697-700.
5. Silverstein H, Rosenberg SI, Flanzer J, et al. Intraoperative facial nerve monitoring in acoustic neuroma surgery. Am J Otol. 1993;14:524-532. 6. Witt RL. Facial nerve monitoring in parotid surgery: the standard of care? Otolaryngol Head Neck Surg. 1998;119:468-470. 7. Lowry TR, Gal TJ, Brennan JA. Patterns of use of facial nerve monitoring during parotid gland surgery. Otolaryngol Head Neck Surg. 2005;133:313-318. 8. Greenberg JS, Manolidis S, Stewart MG, et al. Facial nerve monitoring in chronic ear surgery: US practice patterns. Otolaryngol Head Neck Surg. 2002;126:108-114. 9. Roland PS, Meyerhoff WL. Intraoperative electrophysiological monitoring of the facial nerve: is it standard of practice? Am J Otolaryngol. 1994;15:267-270. 10. Weber PC. Iatrogenic complications from chronic ear surgery. Otolaryng Clin N Am. 2005;38:711-722. 11. Silverstein H, Rosenberg S. Intraoperative facial nerve monitoring. Otolaryng Clin N Am. 1991;24:709-725. 12. Wilson L, Lin E, Lalwani A. Cost-effectiveness of intraoperative facial nerve monitoring in middle ear or mastoid surgery. Laryngoscope. 2003;113:1736-1745. 13. Ruhl DS, Hong SS, Littlefield PD. Lessons learned in otologic surgery: 30 years of malpractice cases in the United States. Otol Neurotol. 2013;34:1173-1179. 14. Goldsmith LS. Medical Malpractice: Guide to Medical Issues. New York, NY: Matthew Bender and Company; 1986. 15. Heman-Ackah SE, Gupta S, Lalwani AK. Is facial nerve integrity monitoring of value in chronic ear surgery? Laryngoscope. 2013;123:2-3. 16. Kaplowitz MD, Hadlock TD, Levine R. A comparison of web and mail survey response rates. Public Opinion Quarterly. 2004;68:94-101.
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Contemporary Changes with the Use of Facial Nerve Monitoring in Chronic Ear Surgery Jinwei Hu, Terry R. Fleck, Jane Xu, Jeffrey V. Hsu and Helen X. Xu Otolaryngology -- Head and Neck Surgery 2014 151: 473 originally published online 3 June 2014 DOI: 10.1177/0194599814537223 The online version of this article can be found at: http://oto.sagepub.com/content/151/3/473
Published by: http://www.sagepublications.com
On behalf of:
American Academy of Otolaryngology- Head and Neck Surgery
Additional services and information for Otolaryngology -- Head and Neck Surgery can be found at: Email Alerts: http://oto.sagepub.com/cgi/alerts Subscriptions: http://oto.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Sep 2, 2014 OnlineFirst Version of Record - Jun 3, 2014 What is This?
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Original Research—Otology and Neurotology
Contemporary Changes with the Use of Facial Nerve Monitoring in Chronic Ear Surgery
Otolaryngology– Head and Neck Surgery 2014, Vol. 151(3) 473–477 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814537223 http://otojournal.org
Jinwei Hu, MD1, Terry R. Fleck, MD2, Jane Xu1, Jeffrey V. Hsu, MD3, and Helen X. Xu, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objective. There is a growing trend for the routine use of the facial nerve monitor (FNM) in chronic ear surgery. We aimed to examine current patterns in the use of FNMs in chronic ear surgery. Study Design. Descriptive design (survey). Setting. Academic health center. Methods. A 10-question survey was designed to identify level of training, scope of practice, specific otologic surgeries where monitoring was most used, and the opinion of respondents regarding the use of FNMs as standard of care for chronic and/or middle ear surgery. A randomized list of 2000 board-certified members of the American Academy of Otolaryngology—Head and Neck Surgery was generated. One thousand subjects received a mailed survey with a selfaddressed return envelope and 1000 subjects received an emailed survey through Surveymonkey.com. Results. There were 359 (36%) surveys returned by mail and 258 (26%) surveys returned electronically. Forty-three percent of respondents were in private practice, and 31% were fellowship trained in otology/neurotology. Sixty-five percent used a FNM in their training and 95% had regular access to a FNM. Revision mastoid surgery, cholesteatoma, canal wall down mastoidectomy, and facial recess approach were the settings where a FNM was most used. Forty-nine percent of respondents felt that a FNM should be used as the standard of care in chronic ear surgery; this represents an increase from 32% in a similar study done approximately 10 years ago. Conclusion. There is a growing trend for routine facial nerve monitoring in the setting of chronic ear surgery.
Introduction Iatrogenic facial weakness or paralysis is a serious complication in any ear surgery. Although the incidence of facial nerve injury is quite low for primary ear surgery (less than 1%),1 it can be as high as 4% to 10% in cases of surgical revision.2 Intraoperative facial nerve monitoring has been in use for nearly 2 decades.3 Its utility was first established in the surgical extirpation of retrocochlear lesions4,5 and has since proven beneficial with procedures involving the parotid gland.6,7 The role of intraoperative facial nerve monitor (FNM) use in chronic ear surgery has been less defined. A survey from Baylor University published 11 years ago highlighted FNM use in chronic ear surgery as being more prevalent in academic institutions and among younger otolaryngologists.8 Thirty-two percent of respondents in that survey felt that FNM use in chronic ear surgery should become standard of care.8 We surveyed 2000 general and otology/neurotology fellowshiptrained otolaryngologists in the United States with the aim to update information on the practice patterns of FNM use in chronic ear surgery.
Methods This was a survey-based descriptive study design. This study was reviewed and approved by the Institutional Review Board at Loma Linda University Medical Center. A 10-question survey was designed to identify level of training, scope of practice, familiarity with and access to a FNM, specific otologic surgeries where monitoring was most used, and if the respondents felt that facial nerve monitoring should be considered standard of care (see appendix 1 Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, USA 2 Kaiser Permanente Riverside Medical Center, Riverside, California, USA 3 Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
This article was presented at the Combined Otolaryngological Spring Meetings (COSM); April 18-22, 2012; San Diego, California.
Keywords facial nerve monitoring, chronic ear surgery Received September 17, 2013; revised April 23, 2014; accepted May 6, 2014.
Corresponding Author: Helen X. Xu, MD, Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Medical Center, 11234 Anderson Street, Room 2586A, Loma Linda, CA 92354, USA. Email: [email protected]
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at www.otojournal.org). A randomized list of 2000 boardcertified members of the American Academy of Otolaryngology—Head and Neck Surgery was generated. One thousand subjects received a mailed survey with a selfaddressed and stamped return envelope and 1000 subjects received an emailed survey through Surveymonkey.com. All analyses were performed using SAS (version 9.3; SAS Institute Inc) in consultation with the Loma Linda Statistics Department. Descriptive analyses are given as a number and percentage for each variable. Chi-square statistics were used to test the relationship between outcome variable and time from completing otolaryngology training and type of surgery. Multiple logistic regression procedure was used in the analysis to test the effect of time from completing otolaryngology training on using nerve monitoring for all chronic ear surgery after adjusting for type of surgery.
Results Two thousand anonymous questionnaires were sent to board-certified members of the American Academy of Otolaryngology—Head and Neck Surgery. There were 359 (36%) surveys returned by mail and 258 (26%) surveys returned electronically (total of 617, which was a 31% return rate). There were no statistically significant differences when comparing the mailed versus electronic responses (P = .764). In regard to practice demographics, 264 (43%) respondents were in private practice, and 345 (57%) respondents practiced in the academic setting. Almost one-third of respondents (31%) had been fellowship trained in otology/ neurotology. Among all the respondents, 85 (14%) had finished their fellowship training within the past 10 years. Four hundred (65%) respondents used a FNM in their residency or fellowship training, and virtually everyone had regular access to a FNM (95%). Fellowship-trained physicians in otology/neurotology demonstrated a significantly higher rate of using a FNM during their training as compared to nonfellowship-trained physicians (P \ .001) (Figure 1). Cholesteatoma, canal wall down mastoidectomy, primary or revision mastoid surgery, and facial recess approach were the settings where a FNM was most used (Figure 2). Three hundred thirty-three (57%) respondents stated that more than half of their chronic middle ear surgeries per month involve facial nerve monitoring (Table 1). Among these, fellowship-trained physicians in otology/neurotology had a significantly higher rate of using a FNM in chronic ear surgeries as compared to non-fellowship-trained physicians (P \ .001) (Figure 3). Those respondents who practiced in an academic setting were also more likely to use an intraoperative FNM. Thirty-one (5%) respondents experienced a formal complaint and/or lawsuit regarding facial nerve injury during a middle ear or mastoid surgery. In 76.9% of these cases, a FNM was not used during the procedure. There was no significant difference between fellowship-trained physicians and non-fellowship-trained physicians regarding facial nerve injury (P = .77). Fifty-two percent of respondents stated that these complaints and/or lawsuits prompted a change in their
Figure 1. Facial nerve monitor (FNM) usage during the residency or fellowship training. Fellowship-trained physicians demonstrated a significantly higher rate of using a FNM during their training as compared to non-fellowship-trained physicians (P \.001).
Figure 2. Types of chronic ear surgery and middle ear surgery during which a facial nerve monitor is used (total sample = 581).
routine toward the use of a FNM during middle ear and/or mastoid surgery. Of all respondents, 293 (49%) thought that a FNM should be used as the standard of care in all chronic ear surgery, which was a marked departure from the previously reported 32% in the reference study from Baylor University a decade ago. Those respondents who had finished their training within the past 10 years were nearly 2 times more likely to consistently use a FNM and felt that it should become standard of care (odds ratio = 1.89, P = .008). However, there were no statistically significant differences between fellowship-trained and non-fellowship-trained physicians in terms of their position on whether a FNM should be used as the standard of care in all chronic ear surgery (P = .09) (Figure 4).
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Table 1. Percentages of Chronic Middle Ear Surgeries Per Month Involving Facial Nerve Monitoring (FNM). Cases/Month Using FNM 0%-25% 26%-50% 51%-75% 76%-100% Total
No. of Respondents
% of Respondents
193 57 64 269 583
33.10 9.78 10.98 46.14 100.00
Figure 4. Fellowship-trained versus non-fellowship-trained physicians in terms of their position on whether a facial nerve monitor should be used as the standard of care in all chronic ear surgery (P = .09).
Figure 3. The pattern of facial nerve monitor (FNM) usage in chronic ear surgeries. Fellowship-trained physicians had a significantly higher rate of using a FNM in chronic ear surgery as compared to non-fellowship-trained physicians (P \.001).
Discussion The current study is the largest survey investigation on this topic to date and reinforces the findings of the previous studies demonstrating a rise in the use of an intraoperative FNM during otologic surgery. In 1994, Roland and Meyerhoff9 surveyed the members of the American Otological and Neurotology Society; 4% of respondents believed that a FNM should be used for all tympanomastoid surgery, whereas a majority (95%) thought that it should be reserved for neurotologic procedures and those tympanomastoid operations with higher risks of facial nerve injury. Subsequently, a survey of the members of the American Academy of Otolaryngology—Head and Neck Surgery in 2002 demonstrated that 32% of all respondents thought that monitoring should be required for chronic ear surgery.8 In our study, the upward trend continued with regard to the
number of respondents who believe that FNM use should be considered standard of care in chronic ear surgery—now nearly half of all respondents compared to fewer than onethird 11 years ago.8 The shift seems to be most strongly associated with younger surgeons, as those who had completed their training within the past 10 years are nearly twice as likely to routinely use a FNM and feel that it should be the standard of care. From our study, a quarter of respondents use a FNM during resident teaching cases in order to help prevent iatrogenic facial nerve injury. However, Greenberg et al8 reported that 78% of all respondents believed that a FNM should be used when residents are actively involved in the procedure. In our opinion, the most likely explanations are familiarity, easier accessibility of a FNM (increased from 76%8 to 95% in the current study), cost-effectiveness of a FNM, and possible fear of a malpractice lawsuit. Additional contributors to the increased popularity of facial nerve monitoring among young surgeons may include greater experience with a FNM during training, more fear of facial nerve injury because they have less experience with ear surgery, and concerns that patients have greater awareness of facial nerve injury secondary to easier access to medical information from the Internet. The FNM is now routinely used in most cases involving retrocochlear pathology, and at least some parotid and chronic ear cases. Intraoperative monitoring of the facial nerve via electromyographic (EMG) activity of the facial muscles helps the surgeon identify the location of facial nerves, map the course of facial nerves, give an early warning signal of potential injury, and predict postoperative
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facial nerve function. When severe disease has eroded the bony covering of the facial nerve, a FNM can also help the surgeon in determining true disease from normal anatomy of the VII nerve.10 Although avoiding facial nerve injury mainly depends on a surgeon’s solid knowledge of facial nerve course, the monitor does help give an early warning signal of any potential injury. This is more important in complicated cases like cholesteatoma or chronic ear surgery, when a dehiscent facial nerve may be covered by granulation tissue. Facial nerve monitoring has added another dimension of safety to otologic and neurotologic surgery.11 The disadvantage of facial nerve monitoring in otologic surgery includes the added cost of surgery, potential risk of orbital injury from the needle placement in orbicularis oculi, and possible requirement for an audiologist for interpretation of the EMG in certain surgical centers. The 5 types of cases where respondents were most likely to use a FNM all involved drilling the mastoid bone, including cholesteatoma, canal wall down mastoidectomy, primary and revision mastoid surgeries, and facial recess approach. In addition, less invasive procedures such as a simple tympanoplasty or stapedectomy were much less likely to involve intraoperative FNM use. Our survey was also consistent with these earlier findings.8 It is always prudent to ascertain the cost-effectiveness of a procedure that places a cost burden on the health care delivery system. In this sense, intraoperative facial nerve monitoring has to be viewed from the standpoint of the following: (1) How effectively does it protect the patient from iatrogenic injury? (2) Is the cost burden that it places on the practitioner and/or the institution beyond any value that it might have for the patient? (3) Does it legally protect the practitioner in a manner that is measurably significant and does not prejudice the patient from harm? A few years ago, Wilson et al12 reviewed the cost-effectiveness of facial nerve monitoring and drew some interesting conclusions. They realized that CN VII injury was the second most common basis for litigation for the otologist and placed a punitive burden in the range of $250,000 to more than $1 million on the surgeon. More troubling were data that revealed that despite the use of high-quality surgical microscopes and related technical advances, the rate of such injuries was still nearly 4% with primary surgery and ballooned to almost 10% in revision surgery.1,2 Wilson and colleagues strongly favored the use of intraoperative facial nerve monitoring in all patients undergoing middle ear and mastoid surgery, adding about $222.73 to $528.00 to the total cost. This additional cost is offset by the overall reduction in costs associated with the management of facial paralysis.12 In addition, they showed that in terms of the qualityadjusted life year index (QALY), the use of facial nerve monitoring had the highest effect and lowest cost when measured in all patients undergoing middle ear and mastoid surgery.12 Our study demonstrated that 5% of respondents have had a formal complaint and/or lawsuit regarding facial nerve injury during chronic ear surgery. Among these, a FNM had
been used only one-fifth of the time. Furthermore, greater than half of the respondents felt that these complaints and/ or lawsuits changed their indications for use of a FNM during chronic ear surgery. A survey of FNM use in parotid gland surgery showed that surgeons who employed monitoring in their practice were 20.8% less likely to have instances of lawsuits because of facial nerve injury.7 From a legal standpoint, the law and medical professions appear to have a stark lack of consensus regarding the use of a FNM for otologic procedures. In a recent commentary, Ruhl et al,13 after surveying the malpractice landscape in otology, suggested that facial nerve injury (38%) is one of the most common alleged injuries and the routine use of a FNM should be adopted in ear and mastoid surgery. However, they also recognized the opinion from the legal literature that states that the use of this technique may ‘‘serve only to increase the time and cost of surgeries.’’14 The contrarian opinion also holds that such monitoring is cost-effective.12,15 Based on survey comments from our respondents, there seems to be a strong sentiment against the idea of standard use of a FNM for chronic ear surgery. The main arguments against the idea are that there is no substitute for fundamental knowledge of the temporal bone anatomy and reliance on an adjunctive tool is risky.10,11 Many respondents also dislike the legal implications of making the FNM ‘‘standard of care.’’ The comments on the opposing side agree that it is no replacement for knowledge of temporal bone anatomy and surgical skills, however, they argue that using a FNM can add another level of safety and its cost-benefit ratio is in favor of regular use.12,15 The routine use of a FNM during otologic surgery still remains controversial. The overall response rate (31%) was within the expected range from previous survey studies. It is interesting that we noted a higher return rate from the hard copy (36%) when compared to the electronic version (26%). There was also an unexplained and higher-than-expected return from those practicing in the academic setting. There were no significant differences when comparing the mailed versus electronic responses. Kaplowitz et al16 compared the web and mail survey response rates and revealed that the mail response rate (31%, n = 2594) was significantly higher than the email response rate (25%, n = 4440), likely due to age difference and web access rate. The response rates of our study are comparable to the above study but with fewer participants. Further research examining possible demographic differences in compliance with mail and web survey requests is desirable.
Conclusion There is a growing trend for routine intraoperative facial nerve monitoring in the setting of chronic ear surgery as compared to previous studies. This was especially noted with surgeons who completed their training within the past 10 years. A strong sentiment remains against the use of a FNM or the implications of FNM use being considered standard of care.
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Acknowledgments The authors thank Khaled Bahjri, MD, MPH, and Salem Dehom, MPH, for their assistance with the statistical analysis.
Author Contributions Jinwei Hu, analysis and interpretation of data, drafting the article, revision of article; Terry R. Fleck, design, acquisition of data, analysis and interpretation of data, revision of article; Jane Xu, analysis of data, drafting the article, revision of article; Jeffrey V. Hsu, analysis of data, drafting the article, revision of article; Helen X. Xu, substantial contributions to conception and design; analysis and interpretation of data; final approval of the version to be published.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
Supplemental Material Additional supporting information may be found at www.otojournal .org/supplemental
References 1. May M. The Facial Nerve. New York, NY: Thieme; 1986. 2. Wiet RJ. Iatrogenic facial paralysis. Otolaryng Clin N Am. 1982;15:773-780. 3. Silverstein H, Smouha EE, Jones R. Routine intraoperative facial nerve monitoring during otologic surgery. Am J Otol. 1988;9:269-275. 4. Benecke JE Jr, Calder HB, Chadwick G. Facial nerve monitoring during acoustic neuroma removal. Laryngoscope. 1987;97: 697-700.
5. Silverstein H, Rosenberg SI, Flanzer J, et al. Intraoperative facial nerve monitoring in acoustic neuroma surgery. Am J Otol. 1993;14:524-532. 6. Witt RL. Facial nerve monitoring in parotid surgery: the standard of care? Otolaryngol Head Neck Surg. 1998;119:468-470. 7. Lowry TR, Gal TJ, Brennan JA. Patterns of use of facial nerve monitoring during parotid gland surgery. Otolaryngol Head Neck Surg. 2005;133:313-318. 8. Greenberg JS, Manolidis S, Stewart MG, et al. Facial nerve monitoring in chronic ear surgery: US practice patterns. Otolaryngol Head Neck Surg. 2002;126:108-114. 9. Roland PS, Meyerhoff WL. Intraoperative electrophysiological monitoring of the facial nerve: is it standard of practice? Am J Otolaryngol. 1994;15:267-270. 10. Weber PC. Iatrogenic complications from chronic ear surgery. Otolaryng Clin N Am. 2005;38:711-722. 11. Silverstein H, Rosenberg S. Intraoperative facial nerve monitoring. Otolaryng Clin N Am. 1991;24:709-725. 12. Wilson L, Lin E, Lalwani A. Cost-effectiveness of intraoperative facial nerve monitoring in middle ear or mastoid surgery. Laryngoscope. 2003;113:1736-1745. 13. Ruhl DS, Hong SS, Littlefield PD. Lessons learned in otologic surgery: 30 years of malpractice cases in the United States. Otol Neurotol. 2013;34:1173-1179. 14. Goldsmith LS. Medical Malpractice: Guide to Medical Issues. New York, NY: Matthew Bender and Company; 1986. 15. Heman-Ackah SE, Gupta S, Lalwani AK. Is facial nerve integrity monitoring of value in chronic ear surgery? Laryngoscope. 2013;123:2-3. 16. Kaplowitz MD, Hadlock TD, Levine R. A comparison of web and mail survey response rates. Public Opinion Quarterly. 2004;68:94-101.
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