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September 24, 2020

Physical Therapy for Iatrogenic Facial Paralysis: A Systematic Review

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 2graduate of Wayne State University School of Medicine, Detroit, Michigan
  • 3currently a medical student at Washington University School of Medicine in St Louis, St Louis, Missouri
  • 4Bernard Becker Medical Library, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 5Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
JAMA Otolaryngol Head Neck Surg. Published online September 24, 2020. doi:10.1001/jamaoto.2020.3049
Key Points

Question  In adults with iatrogenic facial paralysis (FP), is noninvasive physical therapy (PT) compared with no PT or other intervention associated with improved facial nerve outcomes?

Findings  Among 15 studies and 313 patients with iatrogenic FP in this systematic review, PT overall was associated with improved FP outcomes in patients with iatrogenic FP. Heterogeneity in outcome reporting precluded direct comparisons of the different types of PT interventions.

Meaning  Physical therapy may provide improvement for iatrogenic FP rather than watchful waiting; however, standardized facial function outcome reporting is critically important to inform clinicians, patients, and researchers on how to best manage this challenging clinical scenario.


Importance  Facial paralysis (FP) after surgery has substantial functional, emotional, and financial consequences. Most iatrogenic FP is managed by watchful waiting, with the expectation of facial function recovery. A potential treatment is physical therapy (PT).

Objective  To investigate whether noninvasive PT compared with no PT or other intervention improves facial nerve outcomes in adults with iatrogenic FP.

Evidence Review  Patients with noniatrogenic FP, facial reanimation surgery, and invasive adjunctive treatments (acupuncture or botulinum toxin injection) were excluded. A systematic review was conducted for records discussing iatrogenic FP and PT; a search for these records was performed using Ovid MEDLINE (1946-2019), Embase (1947-2019), Scopus (1823-2019), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform (2004-2019), and ClinicalTrials.gov (1997-2019). The references of all the included articles were also assessed for eligible studies. All human participant, English-language study designs with at least 2 cases were included. Quality assessment was performed using the Methodological Index for Non-randomized Studies (MINORS) and the revised Cochrane Risk of Bias 2 (RoB 2) tool for randomized controlled trials. All search strategies were completed on May 16, 2019, and again on October 1, 2019.

Findings  Fifteen studies (7 of which were retrospective cohort studies) and 313 patients with iatrogenic FP were included in the systematic review. Most iatrogenic FP (166 patients [53%]) was associated with parotidectomy; traditional PT (ie, facial massage) was the most common intervention (196 patients [63%]). The use of various facial grading systems and inconsistent reporting of outcomes prevented direct comparison of PT types.

Conclusions and Relevance  Because of heterogeneity in reported outcomes of facial nerve recovery, definitive conclusions were unable to be made regarding the association between PT and outcomes of iatrogenic FP. Physical therapy probably has benefit and is associated with no harm in patients with iatrogenic FP.

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