Referral patterns in Australian patients with facial palsy after surgery for benign intracranial tumours

Introduction

In addition to tumour resection, preservation of facial nerve function represents a crucial outcome in the management of benign intracranial tumours (1). Cerebellopontine angle tumours, namely acoustic neuroma (AN) and meningioma, are among the most common benign neoplasms which subject the facial nerve to risk of iatrogenic injury during surgical resection (2). Improvements in microsurgical techniques and the use of electromyography have enabled intraoperative anatomical preservation of the facial nerve in up to 98% of cases (3). Despite this, a significant proportion of patients experience persistent facial nerve dysfunction post-operatively, characterised by debilitating facial muscle weakness, often with incomplete recovery (4). The pathogenesis of facial paresis following surgical resection despite anatomical preservation of the facial nerve is poorly understood. The theorised aetiology includes neuropraxia and axonotmesis secondary to direct trauma, nerve stretching, devascularisation and thermal injury (5). While the majority of these patients regain partial or complete facial nerve function by 6 months following tumour resection, up to 10% demonstrate moderate to complete facial nerve paralysis at 1-year post-operatively (3,6). In addition to loss of function, patients may also experience bothersome facial dysfunction including synkinesis, hyperkinesis, hypercontracture, epiphora, dysarthria, nasal valve collapse, lip and cheek biting (7). The psychosocial sequalae of facial nerve palsy (FNP) are devastating, with patients subject to increased levels of anxiety, depression and poor quality of life (8).

Management of patients with FNP following intracranial tumour resection is dependent on the anatomical condition of the facial nerve post-operatively. In the case of recognised nerve discontinuity, neural reconstruction by primary neurorrhaphy, nerve grafting or nerve transfer is the preferred management, followed by intensive facial motor rehabilitation (3). However, in the majority of cases where facial nerve preservation is achieved, and there is a facial nerve weakness noted post operatively, the management pathway is less clear.

In 2015, Boahene (7) described options and timing of intervention for FNP following AN resection. The suggested management pathway is divided according to the reversibility of paralysis, which is dependent on the duration of nerve denervation. It is postulated that after 12 months of denervation, neuronal and muscular cellular change render nerves physiologically unviable, which significantly reduces the response to surgical reinnervation (7). Accordingly, observation of recovery over 6 months after surgery is often employed by clinicians. In respect to facial nerve function, lack of recovery at 6 months after surgery is a poor prognostic indicator, and this group of patients benefit from early facial reinnervation (7). Lauda et al. (9) assessed the effectiveness of neural anastomosis in patients with FNP after lateral skull base or middle ear surgery. The authors reported patients with a longer duration of FNP before facial nerve reanimation faced poorer facial nerve function following surgery. Accordingly, delayed intervention can lead to potentially avoidable and permanent facial motor paralysis or weakness.

Despite this crucial time sensitivity, patients with facial nerve paralysis following intracranial tumour resection may face absent or delayed management of their condition. Samii et al. (10) suggested that the specialised expertise needed for microsurgical neural reconstitution contributes to delays in management. In contrast, robust management principles regarding other complications of intracranial tumour resection including hearing loss and loss of eye closure are well practiced. We noted anecdotally that many patients presented to the Prince of Wales Hospital (POWH) facial nerve clinic several years after surgery, often discovering the service via internet searches or social media forums. To our knowledge, there are no other studies which investigate referral patterns, in this subgroup of patients with FNP, to a health professional with expertise in managing facial nerve disorders. This study therefore aimed to determine how facial weakness is managed following benign intracranial tumour resection, with a focus on the patient’s experience and how this can be optimised in the clinical setting. We were also interested to determine the proportion of patients with FNP following surgical resection of a benign intracranial tumours who were referred to a health professional with expertise in managing FNP, the timeline in which this occurred, and their management outcomes.

Methods

Inclusion criteria were: surgical resection of a benign intracranial tumour (e.g., AN, meningioma, or cranial nerve schwannoma), post-operative facial palsy (FP), and registration with the Acoustic Neuroma Association Australia (ANAA) with consent for contact. The ANAA is a support group for patients who have been diagnosed with AN and other benign intracranial tumours. We also included patients referred to the POWH facial nerve clinic, Sydney, who met the same criteria and provided consent for research use of their information. Patients were included If they met the above criteria and presented to the clinic between November 2024 to February 2025. The POWH facial nerve clinic is comprised of an otolaryngologist, head & neck surgeon, facial nerve physiotherapist, head & neck clinical nurse, and otolaryngology trainees. The multidisciplinary service provides diagnostic assessment, surgical planning, neurotoxin treatment and rehabilitation education for patients with facial nerve dysfunction from a variety of aetiologies. Patients were excluded if they declined consent or could not be contacted for follow-up. The study is reported according to the CROSS reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-13/rc).

Participants were recruited through two pathways: targeted emails to ANAA members and direct invitations to eligible patients presenting to the POWH facial nerve clinic. A convenience sampling approach was employed. While this method reflects the characteristics of both clinic-attending and ANAA-registered patients, it limits the generalisability of the findings. A single investigator conducted phone interviews using a structured questionnaire (see Appendix 1). This was an original structured interview which captured demographic data, diagnosis details, and referral history. Responses were collected between November 2024 and February 2025 and securely stored on a local institutional network. Medical record validation was performed by the senior author where available.

The primary aim was to conduct a narrative analysis of patient experiences, supported by descriptive statistics using GraphPad Prism 8 (11). Responses with missing or uncertain data were excluded from the corresponding analyses. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethics approval was obtained from the Prince of Wales Hospital Human Research Ethics Committee, Randwick, Sydney (No. 2024/ETH01871). Patient confidentiality was maintained by anonymizing data, and individual consent was waived for this retrospective analysis.

Results

A total of 31 patients responded to this phone survey (Table 1). Patient responses were validated against medical records by the senior author where possible (n=17). There was a 100% response rate amongst consecutive patients recruited via the POWH facial nerve clinic (n=10). The response rate among patients recruited from the ANAA (n=21) is unknown, given some of its members may not suffer from FNP. The total number of ANAA members with AN and FNP is not known. The majority (n=28) had AN, while there was one facial nerve schwannoma, one trigeminal schwannoma and one meningioma. Within the cohort average age at time of surgery was 45 years [standard error of the mean (SEM) ±2.2, range, 24–68 years]. The average time between surgery and interview was 10 years (SEM ±1.6, range, 0–37 years). No patients had FNP prior to surgery. Seven patients had their surgery performed by an Ear, Nose and Throat (ENT) surgeon, 6 by a neurosurgeon and 18 had combined neurosurgical and ENT surgery. All patients in the cohort had FNP after surgery. The majority (90%) developed facial weakness immediately after surgery, although 2 patients reported onset 1–7 days, and one patient 1–2 weeks after surgery. Twenty-three patients reported complete facial paralysis post-operatively, while 8 had subtotal facial paresis. Regarding the anatomical condition of the facial nerve post-operatively, 26 patients (84%) were told their nerve was intact post-operatively, while there were 3 cases of recognised nerve discontinuity, and 2 patients were unsure. Twenty-four (77%) patients had persistent FNP at the time of interview.

Ninety percent of respondents (n=28) reported they had seen a health professional to manage their facial weakness after surgery. In regard to the method of referral, 39% (n=12) independently arranged their own referral. After choosing their desired practitioner through internet searches, social media forums or word of mouth, these patients approached their general practitioner (GP)/primary care provider to request a referral. Of these patients, 50% (n=6) chose a surgeon with sub-speciality expertise in facial nerve weakness, while the remaining 50% (n=6) consulted a facial physiotherapist. Three patients who consulted a facial physiotherapist were subsequently referred to a surgeon with facial nerve expertise by their physiotherapist. 61% (n=16) had referrals from their treating surgeon. Of these, 10 patients were referred to an otolaryngologist, head & neck surgeon and 2 to a plastic and reconstructive surgeon. The remaining 4 patients were referred to a facial physiotherapist or speech therapists. The average time to referral to a health practitioner to manage facial weakness was 32 months after surgery (SEM ±9.9, range, 0–204 months).

Eight patients stated they were not aware that FNP was a potential complication of their surgery prior to their operation. None of the patients we surveyed received pre-operative information about what to expect if facial nerve weakness occurred as a result of surgery. Only 2 patients were aware that specialists with surgical expertise in managing facial nerve dysfunction can offer interventions for iatrogenic facial weakness.

Twenty-nine patients underwent management of their FNP. Of patients who received surgical treatment for their FNP (n=11), 3 (27%) underwent nerve transfer surgery, 2 (18%) underwent static procedures (facial sling) and 6 (55%) underwent eyelid weight insertion and/or blepharoplasty. The 3 patients who underwent facial reanimation by nerve transfer had recognised nerve discontinuity intra-operatively. While 6 patients reported undergoing combined surgical and conservative treatment, most patients (n=18) had solely non-operative management of their facial weakness. This included either individual or combined facial botulinum toxin injection, physiotherapy, acupuncture and electrical stimulation.

Patients also provided qualitative feedback regarding their facial nerve weakness following benign intracranial tumour resection. Thematic analysis of patient responses revealed that although facial weakness was described as a risk of surgery at the time of consent, the potential severity of this was not explained. Some patients also reported that while their eye closure and hearing loss were addressed by their surgeon, the management of their facial weakness felt neglected. Accordingly, many patients expressed feeling unsupported in the process to find professional healthcare to manage their facial weakness.

Discussion

In this study, we present a narrative analysis, supported by statistics, of referral methods, timing and management outcomes of patients with iatrogenic FNP following surgical resection of benign intracranial tumours. Although half of patients were referred to a health practitioner with expertise in managing facial weakness by their treating surgeon, a significant proportion (39%) of patients independently arranged this referral via their GP. To our knowledge, this is the only study which reports referral patterns of patients with iatrogenic facial nerve injury following benign intracranial tumour resection. Online surveys have reported nearly 50% of patients use online searches to select a health practitioner, compared to only 29% who follow a referral from their provider (12). In regards to FNP specifically, Hayler and colleagues (13) reported the majority of referrals (54.5%) to their facial nerve clinic was by GPs, followed by ENT surgeons (26.9%), plastic surgeons (12.4%), neurologists (4.2%) and neurosurgeons (0.7%). Iatrogenic causes of FP were the most common in their study cohort (38%), though GPs were the commonest method of referral to their service.

Our investigation highlights a protracted referral timeline, with patients being referred, on average, nearly three years following their surgical procedures. Multiple studies have demonstrated favourable outcomes of facial nerve recovery following early referral (<12 months) to a facial nerve centre for consideration of facial reanimation following iatrogenic facial nerve injury (2,7,14). Fibrotic and atrophic change occurs approximately 12 months after injury (14,15), which emphasises the importance of prompt referral to intervene prior to irreversible nerve paralysis. In 2012, Terzis & Konofaos (16) reported that mimetic muscular denervation time of more than 6 months was associated with poorer outcomes following cross-facial nerve grafts. To our knowledge, our investigation is the first to report the timing of referral for management of facial nerve weakness in patients with iatrogenic facial nerve injury following benign intracranial tumour resection. In 2020, Györi and colleagues (2) reported 7.8 years as the average time of FP prior to first reconstructive procedure in patients with iatrogenic FNP. In keeping with this prolonged duration, the authors reported static procedures to improve facial symmetry as the majority of performed procedures owing to nerve fibrosis/atrophy which reduces effectiveness of re-innervation. They reported favourable outcomes in respect to post-operative smile in patients who had a shorter duration of FP.

The results of our investigation and similar studies in the literature have highlighted the predominance of GPs as a first point of contact for patients with iatrogenic FNP, which often occurs over 12 months after injury. We hypothesise that patients present late in the course of their facial nerve injury due to expectations of nerve recovery. As such, this highlights the key role of primary care physicians in detecting patients who may be amenable to facial nerve reanimation. Prompt referral to a medical practitioner with expertise in facial nerve injury should be encouraged in this setting. Additionally, pre-operative patient education of expectations regarding recovery of iatrogenic facial nerve damage may reduce the prolonged referral time observed in this investigation, leading to more favourable patient outcomes in respect to facial function and recovery.

While the primary focus of surgical tumour resection understandably lies in achieving oncological control, the findings of our study suggest a potential tendency to deprioritise the management of iatrogenic facial nerve injuries. This could reflect a combination of factors, including the perception that addressing the underlying pathology outweighs functional or aesthetic concerns, limited awareness or training regarding accessible management options, or the lack of integration of multidisciplinary approaches in postoperative care. The consequences of such oversight, however, can significantly impact patients’ quality of life, underscoring the need for a more holistic approach to patient outcomes. No patients in our study cohort were provided information about what to expect with respect to the prognosis and management options if FNP were to occur as a result of their surgery. As a result, patients reported using internet searches, social media and “word of mouth” to seek help in managing their condition, often after the aforementioned time sensitive window where surgical re-innervation is more effective. Facial nerve injury and its sequalae including weakness, tightness, synkinesis and epiphora already remain physically and psychologically challenging to patients, with negative implications on social interaction and quality of life (17,18). Soh et al. (19) reported that involvement of the surgeon with early diagnosis and management following iatrogenic nerve injury in orthopaedic surgery helps also reduce the emotional impact, in addition to achieving favourable recovery outcomes. Accordingly, encouraging early recognition and management of FNP by the treating surgeon may help improve patient satisfaction outcomes and quality of life, in addition to widening potential treatment options within the 12-month window before damaged nerves are subject to diminished responsiveness to surgical intervention (7).

One of the limitations of our investigation was the propensity for sample bias. We selected a group of patients who had either presented to our facial nerve clinic or were part of an online support group (ANAA) for patients with iatrogenic FNP. Therefore, these patients may have been more inclined to seek help, which may overestimate the proportion of independent referrals. Furthermore, despite stratifying the completeness of facial nerve weakness into total (complete unilateral FP) and subtotal paralysis (some preserved facial motor function), we were unable to record the severity of symptoms using a validated measure given the inability to subjectively grade facial nerve weakness during a phone interview, and the retrospective nature of our study. However, the aim of this study was to capture the patient’s experience in regards to managing this iatrogenic complication, as opposed to analysing the effect of intervention on facial nerve outcomes. Also, given the average time to phone interview after surgery was 10 years, some patients may have provided inaccurate or incomplete answers owing to memory bias. However, over a third of patients had their surgery within 5 years from interview, and patient responses were validated against medical records by the senior author where possible (n=17). Future studies may aim to provide more complete in-person assessment of facial nerve function using validated tools and surgical follow-up data to more accurately gauge referral and management outcomes.

Conclusions

Iatrogenic FNP following benign intracranial tumour resection is a devastating but manageable surgical complication. Timing of referral between 6–12 months is the single most important factor dictating mimetic motor recovery following nerve injury. Despite this, these patients may face delayed, or even absent referrals many years after surgery. Patients describe feeling unsupported in managing their condition and rely on independent research to seek professional medical assistance. Accordingly, we intend the results of this study to advocate for multi-faceted improvements in referral pathways for these patients. Accessible online information, to both patients and primary care physicians, in combination with more thorough and evidence based pre-operative counselling, may engender dramatic improvements in FP outcomes with more prompt presentation to a surgeon with sub-speciality expertise in facial nerve weakness.

Acknowledgments

The authors thank the President of the Acoustic Neuroma Association Australia, Linden Kelleher, for her support in this project.

Footnote

Reporting Checklist: The authors have completed the CROSS reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-13/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-13/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-13/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-13/coif). C.M. serves as an unpaid editorial board member of Australian Journal of Otolaryngology from November 2022 to December 2027. C.M. also participated as a guest lecturer for AbbVie (Mascot, NSW) on the use of ‘Botulinum Toxin for Blepharospasm and Hemifacial Spasm’ in 2024, with no ongoing commitment or financial relationship. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethics approval was obtained from the Prince of Wales Hospital Human Research Ethics Committee, Randwick, Sydney (No. 2024/ETH01871). Patient confidentiality was maintained by anonymizing data, and individual consent was waived for this retrospective analysis.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Yao L, Wang B, Lu F, et al. Facial nerve in skullbase tumors: imaging and clinical relevance. Eur J Med Res 2023;28:121. [Crossref] [PubMed]
2. Györi E, Mayrhofer M, Schwaiger BM, et al. Functional results after facial reanimation in iatrogenic facial palsy. Microsurgery 2020;40:145-53. [Crossref] [PubMed]
3. Sampath P, Holliday MJ, Brem H, et al. Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery: etiology and prevention. J Neurosurg 1997;87:60-6. [Crossref] [PubMed]
4. Cuenca-Martínez F, Zapardiel-Sánchez E, Carrasco-González E, et al. Assessing anxiety, depression and quality of life in patients with peripheral facial palsy: a systematic review. PeerJ 2020;8:e10449. [Crossref] [PubMed]
5. Franz L, Marioni G, Mazzoni A, et al. Contemporary Perspectives in Pathophysiology of Facial Nerve Damage in Oto-Neurological and Skull Base Surgical Procedures: A Narrative Review. J Clin Med 2023;12:6788. [Crossref] [PubMed]
6. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7. [Crossref] [PubMed]
7. Boahene K. Facial reanimation after acoustic neuroma resection: options and timing of intervention. Facial Plast Surg 2015;31:103-9. [Crossref] [PubMed]
8. Fu L, Bundy C, Sadiq SA. Psychological distress in people with disfigurement from facial palsy. Eye (Lond) 2011;25:1322-6. [Crossref] [PubMed]
9. Lauda L, Sykopetrites V, Caruso A, et al. Masseteric-facial anastomosis and hypoglossal-facial anastomosis after lateral skull base and middle ear surgery. Eur Arch Otorhinolaryngol 2024;281:6653-9. [Crossref] [PubMed]
10. Samii M, Matthies C. Management of 1000 vestibular schwannomas (acoustic neuromas): the facial nerve--preservation and restitution of function. Neurosurgery 1997;40:684-94; discussion 694-5. [Crossref] [PubMed]
11. GraphPad Prism 8, 8.4.2 ed. Boston, Massachusetts, USA; 2020.
12. Harmony Healthcare IT. Finding a New Doctor: 22% Never Find a Primary Doctor After Moving; 2024. Available online: https://www.harmonyhit.com/healthcare-moving-habits/
13. Hayler R, Clark J, Croxson G, et al. Sydney Facial Nerve Clinic: experience of a multidisciplinary team. ANZ J Surg 2020;90:856-60. [Crossref] [PubMed]
14. Hohman MH, Bhama PK, Hadlock TA. Epidemiology of iatrogenic facial nerve injury: a decade of experience. Laryngoscope 2014;124:260-5. [Crossref] [PubMed]
15. Frijters E, Hofer SO, Mureau MA. Long-term subjective and objective outcome after primary repair of traumatic facial nerve injuries. Ann Plast Surg 2008;61:181-7. [Crossref] [PubMed]
16. Terzis JK, Konofaos P. Experience with 60 adult patients with facial paralysis secondary to tumor extirpation. Plast Reconstr Surg 2012;130:51e-66e. [Crossref] [PubMed]
17. Coulson SE, O'dwyer NJ, Adams RD, et al. Expression of emotion and quality of life after facial nerve paralysis. Otol Neurotol 2004;25:1014-9. [Crossref] [PubMed]
18. Nellis JC, Ishii M, Byrne PJ, et al. Association Among Facial Paralysis, Depression, and Quality of Life in Facial Plastic Surgery Patients. JAMA Facial Plast Surg 2017;19:190-6. [Crossref] [PubMed]
19. Soh JY, Hill J, Power DM. Iatrogenic nerve injuries in orthopaedics. J Musculoskelet Surg Res 2019;3:9-14.