Those costs, Dr. Roland noted, quickly add up because of the complex interventions needed to mitigate some of the devastating effects of facial nerve injury. Those sequelae include alterations of facial appearance, exposure of the eye to vision-threatening desiccation and infection, and impairment of the oral sphincter, resulting in drooling and alterations in vocal quality, he said. “And that doesn’t even take into consideration the exorbitant cost of fighting—and in several cases, losing—malpractice cases alleging fault in cases of facial nerve injury,” he said.
Explore This IssueMay 2014
Dr. Roland also offered some caveats regarding FNM. “Monitoring is not a panacea, and it does not substitute for an in-depth understanding of anatomy,” he said. In fact, “if you rely on that monitor to tell you where the facial nerve is likely located, without having a really good understanding of where it might be situated—for example, based on a structural abnormality such as dehiscence—you are heading for a world of trouble.”
“For me, going into an otologic surgery without monitoring for the facial nerve is almost like operating blind,” said Dr. Roland. “It’s a tool I certainly don’t want to be without in most cases.”
He also stressed that understanding the basics of how the various monitors work, including their proper calibration and use, is critical to success. Dr. Kartush echoed that point. “As I noted, poor monitoring is worse than no monitoring,” he said. “That’s why practice guidelines that outline proper setup and interpretation are critical.”
Survey Shows High Degree of FNM Expertise
Fortunately, the results of Dr. Kartush’s survey indicate that most otologists already follow the key steps necessary to help ensure accurate facial nerve monitoring, including assessing current flow and impedance and performing a tap test. But not all of the practitioners do so, he noted, and it is the failure to take such key steps in every operation that can allow even experienced surgeons to be lured into complacency.
“If the monitor is improperly set up and the surgeon never stimulates but only relies on the monitor to sound during mechanical trauma, they and their patient may have a heartbreaking surprise in the recovery room when an unexpected facial palsy is identified,” he said. “The facial nerve may be injured, but the alarm may not be triggered if the monitoring setup is improper.”
To help avoid such outcomes, Dr. Kartush has developed an FNM protocol that he taught to many surgeons and technologists over the decades (click here to read Dr. Kartush’s protocol). Such materials underscore the fact that “the age of practice guidelines and surgical checklists is here,” he said. “After more than a quarter century of facial nerve monitoring, it is high time to assure our specialty incorporates monitoring practice guidelines in our training programs, core curricula, and departmental programs. As in the adoption of oxygen monitoring guidelines by anesthesia, the result will benefit patient and surgeons alike.”