CLINICAL REVIEW

David W. Eisele, MD, Section Editor

ELECTROPHYSIOLOGIC FACIAL NERVE MONITORING

DURING PAROTIDECTOMY
David W. Eisele, MD, Steven J. Wang, MD, Lisa A. Orloff, MD

Division of Head and Neck and Endocrine Surgery, Department of Otolaryngology–Head and Neck Surgery,
University of California, San Francisco, San Francisco, California. E-mail: deisele@ohns.ucsf.edu

Accepted 12 May 2009

Published online 11 August 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.21190

Abstract: Facial nerve monitoring is an adjunctive method

available to a surgeon during parotid surgery to assist with the
functional preservation of the facial nerve. This review
describes the goals, applications, technique, and benefits of
electrophysiologic facial nerve monitoring during parotid sur-
gery. A review and analysis of the relevant medical literature
related to electrophysiologic facial nerve monitoring during pa-
rotid surgery are included. V C 2009 Wiley Periodicals, Inc.
Head Neck 32: 399–405, 2010
Keywords: parotidectomy; facial nerve; nerve monitoring
Facial nerve injury is a feared complication of
parotidectomy. Facial nerve paralysis can cause
cosmetic and functional morbidity, ocular com-
plications, diminished quality of life, and medi-
cal malpractice litigation.1,2 Temporary facial
nerve dysfunction occurs in 20% to 40% of
patients undergoing parotidectomy, whereas
permanent facial nerve dysfunction is uncom-
mon and occurs in 0% to 4% of patients.3–10
There are numerous factors that may influ-
ence facial nerve injury during parotidectomy,
including tumor size, type, location, extent of
Correspondence to: D. W. Eisele
V
C 2009 Wiley Periodicals, Inc.
surgery, inflammation, and reoperation. Facial
nerve injury mechanisms during parotidectomy
include nerve division, stretch, compression, lig-
ature entrapment, thermal and electrical inju-
ries, and ischemia. The surgeon has control over
most of these mechanisms of facial nerve injury,
and proper, safe surgical technique is para-
mount for facial nerve preservation.
Nerve monitoring is an adjunctive method
that a surgeon can choose to use during surgery
to assist with the functional preservation of a
motor nerve or nerves. Facial nerve monitoring
is widely used in otologic, neurotologic, and
skull base surgery. Improvement in the func-
tional preservation of the facial nerve with
facial nerve monitoring in acoustic neuroma
surgery and its cost-effectiveness in otologic
surgery have been demonstrated.11–13
Another application of facial nerve monitor-
ing is during parotid surgery, due to the inti-
mate relationship of the facial nerve and the
parotid gland. The purpose of this report was to
describe the goals, applications, technique, and
benefits of electrophysiologic facial nerve
monitoring during parotidectomy. A review of
the relevant medical literature related to

Electrophysiologic Facial Nerve Monitoring HEAD & NECK—DOI 10.1002/hed March 2010 399
electrophysiologic facial nerve monitoring dur-
ing parotidectomy is included.
GOALS OF FACIAL NERVE MONITORING
The goals of facial nerve monitoring during pa-
rotidectomy are the same as those during oto-
logic and neurotologic surgery and include early
facial nerve identification, warning to the sur-
geon of unexpected facial nerve stimulation,
mapping of the course of the nerve, reduction of
mechanical trauma to the nerve, and evaluation
and prognosis of nerve function at the conclu-
sion of the procedure.14
Recent studies have demonstrated that the
majority of otolaryngologists/head and neck sur-
geons in the United States and in the United
Kingdom use nerve monitoring during parotid
surgery.15–17 U.S. surgeons are more likely to
use nerve monitoring during parotidectomy if
they have used nerve monitoring during their
surgical training and if they frequently perform
parotid surgery.15 In addition, U.S. surgeons
who use facial nerve monitoring in their prac-
tice are less likely to have a history of a parotid
surgery–related lawsuit.15
Facial Nerve Monitoring Methods. Several meth-
ods of facial nerve monitoring during parotidec-
tomy exist. One approach is to visually monitor
for facial movements during surgery. With this
method, an assistant alerts the surgeon to facial
movements that are evoked electrically with a
nerve stimulator or evoked mechanically during
surgical dissection.
Electrophysiological monitoring is another,
more sophisticated method of facial nerve moni-
toring. With this approach, facial muscle electro-
myographic (EMG) activity is monitored by an
electrophysiologist or by the surgical team dur-
ing surgery. Several electrophysiologic nerve
monitoring systems are commercially available,
including the NIM-Response 2.0 Nerve Integrity
Monitor (NIM-2; Medtronic Xomed, Jackson-
ville, FL), the Neurosign 400 (Magstim Co., Ltd,
Whitland, South West Wales, UK), and the Vi-
king II–EMG System (Nicolet Biomedical, Madi-
son, WI). These multichannel systems
continuously track facial muscle activity during
surgery and have a built-in pulse generator for
electrically evoked EMG responses. The NIM-
Response 2.0 is popular in the United States,
particularly for surgeons who perform their own
400 Electrophysiologic Facial Nerve Monitoring
nerve monitoring, because this device requires
minimal user input during surgery. The Neuro-
sign 400 is a 4-channel device manufactured in
Europe, where it is the most popular nerve mon-
itoring system used. The Viking II is another
multichannel system that features a switchable
amplifier and is often used in operative settings
where nerve monitoring is being performed by a
neurophysiologist.
Electrophysiologic monitoring is generally
the preferred method of facial nerve monitoring
because it is more sensitive and specific than
visual monitoring of facial movements. The
degree of facial muscle activity detected is also
quantifiable. An adjustable pulsed stimulator
allows for electrically evoked EMGs. With facial
nerve stimulation, either related to surgical
manipulation or from electrical stimulation of
the nerve, an immediate EMG response is visi-
ble, with a characteristic waveform and ampli-
tude. In addition, the response is immediately
audible and its volume correlates directly with
its EMG amplitude.
Technique. For electrophysiologic monitoring of
the facial nerve, neuromuscular blockade should
be avoided.18 Needle electrodes are placed in
optimal locations to record activity from the fa-
cial muscles, typically in the 4 areas innervated
by the facial nerve: frontal, zygomatic, buccal,
and marginal mandibular.19 Ground and stimu-
lator anode electrodes are also placed. A stimu-
lation probe is included on the sterile operative
field. All electrode wires are connected to an
interface circuit box. Stimulus intensity, dura-
tion, rate, and event threshold are set. Typical
parameters used at our institution are: stimulus
intensity, 0.5 mA; duration, 100 microseconds;
rate 4 bursts/s; and event threshold, 100
microvolts.
Event Interpretation and Caveats. Intraopera-
tively, the surgeon or the neurophysiologist per-
forming the monitoring must differentiate true
EMG events from artifacts such as those that
occur from contact between surgical instruments
in the operative field. EMG waveform character-
istics, EMG amplitude, and the surgical context
of the event aid in this differentiation. A false-
positive event should be excluded because this
may give the surgeon a false sense of insecurity.
It must be emphasized that the absence of
an electrically evoked response does not exclude
the possibility that the stimulated tissue is the
HEAD & NECK—DOI 10.1002/hed March 2010
facial nerve. In this situation, proper system
operating function must be confirmed. A false-
negative event may give the surgeon a false
sense of security. The surgeon must exercise
proper judgment in event interpretation, and
anatomic information should always trump
physiologic information.
Electrosurgical units and other electrical
equipment can create an electrical artifact that
interferes with facial muscle response recording.
Thus, the use of electrosurgical dissection can
create a gap in continuous facial nerve monitor-
ing, and this limitation should be considered.
Benefits. The potential benefits of electrophy-
siologic facial nerve monitoring during paroti-
dectomy are numerous. When facial nerve
monitoring is planned for a given case, the sur-
geon can explain its use and benefits to the
patient. This information reinforces the fact
that the surgeon will use all means available to
preserve and protect the facial nerve—this can
be greatly reassuring to a patient.
The stimulation probe is useful in assisting
the surgeon to identify the main trunk of the fa-
cial nerve when nerve localization is difficult, to
identify a peripheral nerve branch during retro-
grade facial nerve dissection, and to distinguish
facial nerve from sensory nerve or non-nerve tis-
sue during parotid dissection. After surgical dis-
section of the facial nerve, electrical stimulation
of the nerve with the probe is recommended to
allow assessment of the functional integrity of
the nerve and to aid in prediction of postopera-
tive facial nerve function.
Electrical stimulation can assist the surgeon
in facial nerve identification in cases in which
nerve localization is difficult, despite the use of
standard anatomic landmarks for nerve visual-
ization. Such instances may include anatomic
distortion attributed to tumor or scarring from
prior surgery. Electrical confirmation of the
identity of the facial nerve can reassure the sur-
geon and improve surgical confidence.
Electrical stimulation may also assist in the
identification of peripheral facial nerve branches
as is performed during retrograde facial nerve
dissection.20,21 In addition, the topographical
identity of facial nerve branches can be deter-
mined. This may be beneficial in cases of altered
nerve location due to tumor or for expediting
dissection in partial parotidectomy.
Electrical stimulation allows the surgeon to
differentiate nerve from non-nerve tissue, a
Electrophysiologic Facial Nerve Monitoring
determination that may be difficult visually. In
addition, electrical stimulation can differentiate
the facial nerve from a sensory nerve. Mechani-
cally evoked responses during surgical dissec-
tion can alert the surgeon to the proximity of
the facial nerve. In addition, mechanically
evoked responses can provide immediate feed-
back to the surgeon regarding the extent of
nerve manipulation. Accordingly, this informa-
tion may prompt the surgeon to adjust surgical
manipulation of the nerve or tissues near the
nerve.
The factors that may reduce facial nerve
injury with facial nerve monitoring during pa-
rotidectomy are multiple. These include: (1) an
improved ability to identify the facial nerve with
less trauma; (2) improved ability to differentiate
the facial nerve from other tissue; additionally,
(3) the surgeon is alerted to potentially injurious
manipulation of the facial nerve and uses this
information to modify the surgical technique to
minimize nerve trauma; and (4) the surgeon is
alerted to facial nerve proximity when the nerve
is not anticipated.
Spontaneous EMG activity of the facial
muscles will typically increase as the depth of
anesthesia diminishes. This information may be
useful for adjustment of the depth of anesthesia.
After partial or complete facial nerve dissec-
tion, electrically evoked responses allow the sur-
geon to assess the functional integrity of the
nerve which aids in the prediction of postopera-
tive facial function. Normal response thresholds
typically predict normal facial function. Ele-
vated response thresholds may predict facial pa-
resis of variable degree postoperatively. This
information can be beneficial in patient counsel-
ing postoperatively. Absent response thresholds
indicate either temporary or permanent loss of
nerve integrity. The absence of responses should
prompt the surgeon to carefully examine the
nerve for a correctable or repairable lesion.
Applications. Applications of facial nerve moni-
toring during parotidectomy include instances
in which facial nerve identification, dissection,
and preservation are potentially difficult. Such
situations include reoperation, prior radiation
therapy, malignant neoplasm, large or deep lobe
neoplasm with anatomic distortion, chronic par-
otitis, and minimally invasive surgical proce-
dures, such as intraparotid sentinel lymph node
biopsy. Similar to its role during parotidectomy,
facial nerve monitoring during sentinel lymph
HEAD & NECK—DOI 10.1002/hed March 2010 401
node biopsy is useful to confirm the identity of
peripheral facial nerve branches and to provide
warning to the surgeon, through mechanically
evoked responses, when dissection is occurring
in close proximity to a facial nerve branch.
Some surgeons routinely use facial nerve
monitoring for all parotid surgery. Benefits of
routine use of facial nerve monitoring include
its intraoperative availability if an unantici-
pated need for its use arises. Routine use
ensures surgeon familiarity with the nerve mon-
itoring system and facility with methods of trou-
bleshooting the system. After an initial learning
curve, the surgeon can properly interpret vari-
ous signals and differentiate artifact from true
events. Routine use of nerve monitoring may
also result in a reduction in operative time.
Surgeons may not use facial nerve monitoring
during parotid surgery for a variety of reasons.
These include the expense of the monitoring
equipment and the cost of monitoring personnel,
if used. Some surgeons lack training or experi-
ence with nerve monitoring. The additional time
to set up the monitoring equipment, although
minimal, may also be a factor that influences the
decision to avoid its use.
Expert surgeons may find no benefit to the
use of monitoring in either the performance of
parotid surgery or in reducing their extremely
low rates of permanent facial paralysis. The lat-
ter point guides some surgeons, who may
believe that present evidence shows no benefit
to the use of facial nerve monitoring in the
reduction of rates of facial paralysis in paroti-
dectomy. The literature that addresses both this
issue and other aspects of facial nerve monitor-
ing is reviewed below.
Complications of Facial Nerve Monitoring. Elec-
trophysiologic facial nerve monitoring is safe.
Because electrically evoked facial nerve
responses during electrophysiologic facial nerve
monitoring are obtained using a pulsed nerve
stimulator, facial nerve injury arising from over-
stimulation that theoretically may occur from
prolonged stimulation with a battery-powered
direct current nerve stimulator is unlikely.22
Complications of facial nerve monitoring are
uncommon. A potential complication is surgeon
reliance on a false-negative response with subse-
quent nerve division. Surgical judgment and
anatomic information should always supersede
adjunctive information provided with nerve
monitoring.
402 Electrophysiologic Facial Nerve Monitoring
Nerve electrodes can result in infection,
bleeding, or injury to adjacent structures. These
complications are rare with sterile technique
and proper needle electrode placement. Needle
electrodes are a potential source of injury to the
surgical team during both placement and
removal.
Haenggeli et al23 reported 3 cases of facial
burns related to a technical deficit in a nerve
monitoring device. Their report emphasizes the
importance of using approved and properly func-
tioning nerve monitoring equipment for this
application.
Prior Reports of Electrophysiologic Facial Nerve
Monitoring for Parotidectomy. There have been
multiple reports in the medical literature
regarding intraoperative facial nerve monitoring
during parotidectomy. Early reports were
largely descriptive of the application of facial
nerve monitoring in parotid surgery and of the
methodology.24–27 Subsequent reports have been
retrospective or prospective case series with
case controls or historical controls. In this sec-
tion, these studies will be summarized.
Cillero Ruiz et al28 reported their experience
with facial nerve monitoring in 35 patients using
the NIM-2 system. In this retrospective case se-
ries, 2 patients (5.7%) experienced some degree
of persistent facial paresis. The authors found no
correlation between intraoperative responses
and early postoperative functional results.
Olsen and Daube29 described their results
with continuous intraoperative facial nerve mon-
itoring as an aid to reoperation for recurrent
pleomorphic adenoma of the parotid. EMG staff
performed the monitoring and event interpreta-
tion. Seven patients were reported in this retro-
spective case series. Five of the 7 patients (71%)
had normal postoperative facial function, and 2
of the 7 patients had altered facial function
related to deliberate sacrifice of facial nerve
branches intraoperatively. There was no instance
of inadvertent traumatic facial nerve loss.
Wolf et al30 used facial nerve monitoring in
35 consecutive patients with benign parotid neo-
plasms and in 4 patients with recurrent benign
tumors. Twenty-four similar patients served as
controls in this retrospective case series. The
authors noted not only a reduction in operative
time but also a better facial functional outcome
in the monitored group. No patient who had
reoperation for recurrent tumor had permanent
facial paralysis.
HEAD & NECK—DOI 10.1002/hed March 2010
 Terrell et al31 reported the largest retrospec-
tive case control series of facial nerve monitor-
ing during parotidectomy to date. Monitoring
was performed by audiologists. Of the 56
patients who had nerve monitoring, 44% had
temporary facial paralysis, whereas 62% of the
61 nonmonitored patients had temporary facial
paralysis. This difference was statistically sig-
nificant (p ¼ .03). There was no statistical dif-
ference, however, in the incidence of permanent
facial paralysis between the 2 groups. In addi-
tion, there was no difference in operative times
between the 2 groups.
Witt32 reported a retrospective case control
series of 53 audiologist-monitored patients who
underwent lateral parotidectomy for mobile, su-
perficial lobe parotid masses. Of the 20 moni-
tored patients, 4 patients (20%) had temporary
facial paresis, whereas 9 patients (15%) of the
33 unmonitored patients had temporary facial
weakness. There was no statistical difference
between these 2 rates. No patient had a perma-
nent facial nerve injury in this series.
Dulguerov and colleagues33 analyzed 70 pa-
rotidectomy patients in a prospective case series
with historical controls. This group of surgeons
performed their own nerve monitoring. Tempo-
rary facial paralysis occurred in 27% of patients,
and 4% had permanent facial paralysis. The
authors concluded that these results compared
favorably with historical controls.
Brennan et al34 also reported a prospective
case series of 44 patients with historical con-
trols. Cases were surgeon-monitored. Temporary
facial paresis occurred in 16% of patients. There
were no instances of permanent facial paralysis.
One patient was noted to have a stimulation
threshold of >0.5 mA. This was the sole
instance in which complete facial paresis
occurred. This elevated threshold therefore pre-
dicted total facial paresis postoperatively.
Lopez et al35 used facial nerve monitoring in
25 patients during parotidectomy. Twenty-seven
patients served as case controls in this retro-
spective study. These authors found that the
monitored patients had a statistically significant
lower incidence of temporary facial paresis (36%
vs 70%, p ¼.013) and permanent facial paralysis
(4% vs 30%, p ¼ .025).
Doikov et al36 reported a retrospective analy-
sis of 15 patients who underwent parotidectomy
with facial nerve monitoring using the Neuro-
sign 100 monitor. In all cases, monitoring was
successful in locating, identifying, and evaluat-
Electrophysiologic Facial Nerve Monitoring
ing the integrity of the facial nerve. No postop-
erative nerve injury was detected clinically.
Makeieff and colleagues37 reported a retro-
spective case control study of 32 patients with
recurrent pleomorphic adenoma. Fourteen
patients had surgeon facial nerve monitoring
and 18 patients were unmonitored. The authors
found a statistically significant lower distribu-
tion of the House–Brackmann grade of facial pa-
resis with the monitored group compared with
the unmonitored group (p ¼ .011). One case of
complete facial palsy (5.6%) occurred in the
unmonitored patients, but none was noted in
the monitored group. In addition, there was a
close correlation between the duration of facial
nerve recovery and severity of the initial facial
paresis; that is, the monitored patients had a
shorter duration of postoperative facial paresis.
Also, the mean surgery time was shorter in the
monitored group (204 minutes) than in the
unmonitored group (321 minutes) (p ¼ .001).
Meier et al38 reported a retrospective case se-
ries of 37 patients undergoing facial nerve moni-
toring for various types of parotidectomy. With
their method, a dedicated neurophysiologist
recorded neurotonic discharges intraoperatively,
and these data were blindly analyzed postopera-
tively by a neurologist and neurophysiologist
and correlated with postoperative facial func-
tion. The presence or absence of electrical dis-
charges did not correlate with facial nerve
function. Only 16% of patients had an abnormal
EMG intraoperatively, yet 65% of patients had
facial weakness postoperatively.
Wang et al39 reported 22 patients with be-
nign parotid neoplasms in a retrospective case
series. Each patient had facial nerve monitoring
during parotidectomy, and none experienced fa-
cial nerve paresis.
Prior Study Analysis. The available literature on
facial nerve monitoring during parotidectomy is
limited. The 12 studies summarized in the pre-
ceding section are generally of small sample
size. The number of patients reported in these
studies ranged from 7 to 117, with a mean of 46.
In addition, these reports are generally retro-
spective case series with or without controls.
Furthermore, these studies lack randomization.
Only 2 of the 12 studies were prospective33,34;
therefore, the level of evidence for these studies
is low.
Additional limitations of the literature on
this subject include case heterogeneity (tumor
HEAD & NECK—DOI 10.1002/hed March 2010 403
types, extent of surgery, patient-related factors,
reoperation, etc) and lack of monitoring stand-
ardization (equipment type, number of muscle
groups monitored, and monitor credentials). In
addition, the studies varied in terms of the fa-
cial nerve grading method that was performed.
Conclusions from the Literature. Two case–con-
trol studies, Terrell et al31 and Lopez et al,35 dem-
onstrated a statistically significant reduction in
temporary facial paralysis with facial nerve mon-
itoring. In addition, 1 study demonstrated a
lower distribution of House–Brackmann grade of
facial paresis and a shorter duration of paresis
with monitoring.37 Only 1 study showed a statis-
tically significant reduction in permanent facial
paralysis; however, the rates of temporary and
permanent facial paralysis were inexplicably
high (70% and 30%, respectively) in the unmoni-
tored group compared with other rates reported
in the literature.35
Permanent facial paralysis is an uncommon
event related to parotidectomy. The low inci-
dence of this complication is similar to the low
rate of permanent recurrent laryngeal nerve pa-
ralysis in thyroid surgery. To demonstrate the
benefit of facial nerve monitoring in reducing
the frequency of this complication, a prospective,
randomized study of sufficient size and statisti-
cal power would be necessary. As an example, to
demonstrate reduction in permanent facial
nerve paralysis from 2% to 1% (a ¼ 0.05, power
¼ 0.8, 1-tailed t test), 1000 patients would be
needed.40
Two studies showed no correlation of intrao-
perative nerve responses with postoperative fa-
cial nerve function.28,38 In 1 report, an elevated
nerve response (>0.5 mA) was predictive of
postoperative facial paresis.34
Two studies demonstrated reduced operative
time for patients who had nerve monitoring,30,37
whereas 1 study showed no difference in opera-
tive times with or without monitoring.31
The Future. Facial nerve monitoring equipment
of the future will likely be more refined. A
recent report describes optical nerve stimulation
using pulsed infrared optical radiation.41 This
new method may contribute to improved spatial
selectivity of stimulation.
Prospective, randomized controlled studies
are needed to resolve the question as to whether
facial nerve monitoring reduces the incidence of
permanent facial paralysis during parotidec-
404 Electrophysiologic Facial Nerve Monitoring
tomy. Due to the size of such a study that would
be necessary to have sufficient statistical power
to address this issue, a multi-institutional coop-
erative study is likely to be needed. In the in-
terim, facial nerve monitoring will continue to
be used by parotid surgeons who feel that they
and their patients benefit from the anatomic,
diagnostic, and prognostic information that
facial nerve monitoring provides.
REFERENCES
1. Ryzenman JM, Pensak ML, Tew JM Jr. Facial paralysis
and surgical rehabilitation: a quality of life analysis in a
cohort of 1,595 patients after acoustic neuroma surgery.
Otol Neurotol 2005;26:516–521.
2. Lydiatt DD. Medical malpractice and facial nerve paraly-
sis. Arch Otolaryngol Head Neck Surg 2003;129:50–53.
3. Nouraei SA, Ismail Y, Ferguson MS, et al. Analysis of
complications following surgical treatment of benign pa-
rotid disease. ANZ J Surg 2008;73:134–138.
4. Upton DC, McNamar JP, Connor NP, et al. Parotidec-
tomy: ten-year review of 237 cases at a single institu-
tion. Otolaryngol Head Neck Surg 2007;136:788–792.
5. Gaillard C, Perie S, Susini B, St. Guily JL. Facial nerve
dysfunction after parotidectomy: the role of local factors.
Laryngoscope 2005;115:287–291.
6. Guntinas-Lichius O, Klussmann JP, Wittekindt C, Sten-
nert E. Parotidectomy for benign disease at a university
teaching hospital: outcome of 963 operations. Laryngo-
scope 2006;116:534–540.
7. Witt RL. Facial nerve function after partial superficial
parotidectomy: an 11-year review (1987–1997). Otolaryn-
gol Head Neck Surg 1999;121:210–213.
8. Bron LP, O’Brien CJ. Facial nerve function after paroti-
dectomy. Arch Otolaryngol Head Neck Surg 1997;123:
1091–1096.
9. Leverstein H, van der Wal JE, Tiwari RM, et al. Surgical
management of 246 previously untreated pleomorphic
adenomas of the parotid gland. Br J Surg 1997;84:399–
403.
10. Laccourreye H, Laccourreye O, Cauchois R, et al. Total
conservative parotidectomy for primary benign pleomor-
phic adenoma of the parotid gland: a 25-year experience
with 229 patients. Laryngoscope 1994;104:1487–1494.
11. Lalwani AK, Butt FY, Jackler RK, et al. Facial nerve
outcome after acoustic neuroma surgery: a study from
the era of cranial nerve monitoring. Otolaryngol Head
Neck Surg 1994;111:561–570.
12. Morikawa M, Tamaki N, Nagashima T, Motooka Y.
Long-term results of facial nerve function after acoustic
neuroma surgery—clinical benefit of intraoperative facial
nerve monitoring. Kobe J Med Sci 2000;46:113–124.
13. Wilson L, Lin E, Lalwani A. Cost-effectiveness of intrao-
perative facial nerve monitoring in middle ear and mas-
toid surgery. Laryngoscope 2003;113:1736–1745.
14. Silverstein H, Rosenberg S. Intraoperative facial nerve
monitoring. Otolaryngol Clin North Am 1991;24:709–
725.
15. Lowry TR, Gal TJ, Brennan JA. Patterns of use of facial
nerve monitoring during parotid gland surgery. Otolar-
yngol Head Neck Surg 2005;133:313–318.
16. Hopkins C, Khemani S, Terry RM, Golding-Wood D.
How we do it; nerve monitoring in ENT surgery: current
UK practice. Clin Otolaryngol 2005;30:195–198.
17. O’Regan B, Bharadwaj G, Elders A. Techniques for dis-
section of the facial nerve in benign parotid surgery: a
cross specialty survey of oral and maxillofacial and ear
HEAD & NECK—DOI 10.1002/hed March 2010
 nose throat surgeons in the UK. Br J Oral Maxillofac
Surg 2008;46:564–566.
18. Theide O, Klusener T, Sielenkamper A, et al. Interfer-
ence between muscle relaxation and facial nerve moni-
toring during parotidectomy. Acta Otolaryngol 2006;126:
422–428.
19. Guo L, Jasiukaitis P, Pitts, Cheung SW. Optimal place-
ment of recording electrodes for quantifying facial nerve
compound action potential. Otol Neurotol 2008;29:710–
713.
20. Bhattacharyya N, Richardson ME, Gugino LA. An objec-
tive assessment of the advantages of retrograde paroti-
dectomy. Otolaryngol Head Neck Surg 2004;131:392–396.
21. O’Regan B, Bharadwaj G, Bhopal S, Cook V. Facial
nerve morbidity after retrograde nerve dissection in pa-
rotid surgery for benign disease: a 10-year prospective
observational study of 136 cases. Br J Oral Maxillofac
Surg 2007;45:101–107.
22. Love JT Jr, Marchbanks JR. Injury to the facial nerve
associated with the use of a disposable nerve stimulator.
Otolaryngology 1978;86:61–64.
23. Haenggeli A, Richter M, Lehmann W, Dulguerov P. A
complication of intraoperative facial nerve monitoring:
facial skin burns. Am J Otol 1999;20:679–682.
24. Metson R, Thornton A, Nadol JB Jr, Fee WE Jr. A new
design for intraoperative facial nerve monitoring. Otolar-
yngol Head Neck Surg 1988;98:258–261.
25. Rea JL. Use of hemostat/stimulator probe and dedicated
nerve locator/monitor for parotid surgery. Ear Nose
Throat J 1990;69:566,570–573.
26. Anon JB, Lipman SP, Guelcher RT, Sibly DA, Thumfart
W. Monitoring the facial nerve during parotidectomy.
Arch Otolaryngol Head Neck Surg 1991;117:1420.
27. Anon JP, Lipman SP, Thumfart W, Sibly DA. Parotidec-
tomy with the Nerve Integrity Monitor II. Eur Arch Oto-
laryngol 1994;S385–S386.
28. Cillero Ruiz G, Espinosa Sanchez JM, Ruis de Erenchun
Lasa I, et al. Intraoperative facial nerve monitoring:
results. Acta Otorrinolaringol Esp 1994;45:425–431.
29. Olsen KD, Daube JR. Intraoperative monitoring of the
facial nerve: an aid in the management of parotid gland
recurrent pleomorphic adenoma. Laryngoscope 1994;104:
229–232.
Electrophysiologic Facial Nerve Monitoring
30. Wolf SR, Schneider W, Suchy B, Eichhorn B. Intraopera-
tive facial nerve monitoring in parotid surgery. HNO
1995;43:294–298.
31. Terrell JE, Kileny PR, Yian C, et al. Clinical outcome of
continuous facial nerve monitoring during primary pa-
rotidectomy. Arch Otolaryngol Head Neck Surg 1997;
157:1081–1087.
32. Witt RL. Facial nerve monitoring in parotid surgery: the
standard of care? Otolaryngol Head Neck Surg 1998;119:
468–470.
33. Dulguerov P, Marchal F, Lehmann W. Postparotidectomy
facial nerve paralysis: possible etiologic factors and
results with routine facial monitoring. Laryngoscope
1999;109:754–762.
34. Brennan J, Moore EJ, Shuler KJ. Prospective analysis of
the efficacy of continuous intraoperative nerve monitor-
ing during thyroidectomy, parathyroidectomy, and parot-
idectomy. Otolaryngol Head Neck Surg 2001;124:537–
543.
35. Lopez M, Quer M, Leon X, et al. Usefulness of facial
nerve monitoring during parotidectomy. Acta Otorrino-
laringol Esp 2001;52:418–421.
36. Doikov IY, Konsulov SS, Dimov RS. Stimulation electro-
myography as a method of intraoperative localization
and identification of the facial nerve during parotidec-
tomy: review of 15 consecutive parotid surgeries. Folia
Med (Plovdiv) 2001;43:23–26.
37. Makeieff M, Venail F, Cartier C, et al. Continuous facial
nerve monitoring during pleomorphic adenoma recur-
rence surgery. Laryngoscope 2005;115:1310–1314.
38. Meier JD, Wenig BL, Manders EC, Nenonene EK. Con-
tinuous intraoperative facial nerve monitoring in pre-
dicting postoperative injury during parotidectomy.
Laryngoscope 2006;116:1569–1572.
39. Wang Z, Wu H, Huang Q, et al. Facial nerve monitoring
in parotid gland surgery. Lin Chuang Er Bi Yan Hou Ke
Za Zhi 2006;20:436–437.
40. Eisele DW. Intraoperative electrophysiologic monitoring
of the recurrent laryngeal nerve. Laryngoscope 1996;
106:443–449.
41. Teudt IU, Nevel AE, Isso AD, et al. Optical stimulation
of the facial nerve: a new monitoring technique? Laryn-
goscope 2007;117:1641–1647.
HEAD & NECK—DOI 10.1002/hed March 2010 405