Temporary and permanent facial palsy (FP) might be induced by a broad spectrum of disorders, including stroke, tumor, trauma, iatrogenic (e.g., resection of vestibular schwannomas or tumors of the parotid gland) or idiopathic paralysis (i.e., Bell’s Palsy) (1, 2). It is a debilitating and highly visible condition that can lead to physical complaints (e.g., corneal irritation, problems with drinking) and psychological problems due to appearance-affecting facial asymmetry and resulting stigmatization (3–7). In skull base surgery, the current EANO guidelines for vestibular schwannomas therefore more often recommend irradiation or—in case of large tumors—partial resection followed by irradiation to prevent FP (8, 9). However, previous studies also demonstrated that residual tumor can affect patient’s quality of life (QoL) or increase the risk of recurrence (10–12). Recurrence surgery, in turn, increases the risk of FP in comparison to primary resection. Furthermore, potential recovery of the facial nerve should not be underestimated. Improvement of facial function may occur up to approximately 1.5 years after the onset of FP, and depends on, e.g., the cause and severity of the palsy as well as effectiveness of medical support (13–18). Consequently, in addition to preventing the occurrence of FP, there should be an increased effort to encourage specialized treatment options for facial rehabilitation.

FP patients are likely to have contact with numerous medical specialties and disciplines. Neurologists are often the initial patient contact in new, non-iatrogenic FP. Conservative therapy is often guided by speech therapists and physiotherapists. Neurosurgeons and otolaryngologists are involved in the treatment of iatrogenic FP after, e.g., the resection of parotid tumors or vestibular schwannomas. In case conservative treatment is not satisfactory, ophthalmologists, maxillofacial and plastic surgeons are involved, e.g., in the treatment of lagophthalmos. However, therapists and physicians are often not specialized in FP, as it is only a minor topic of their specialty. Moreover, a standardized therapy does not exist: There are numerous physiotherapeutic approaches (e.g., Bobath, Proprioceptive Neuromuscular Facilitation) (19), that often originate from extremity rehabilitation and are adapted to the face. For surgical procedures, ENT surgeons mainly use direct (facio-facial and hypoglossal-facial) extracranial reconstruction techniques, whereas neurosurgeons are more familiar with intracranial facio-facial and/or hypoglossal-facial nerve reconstruction (20). In contrast, maxillofacial and plastic surgeons mostly use masseteric-facial and cross-face reconstructions in FP (21). This unidisciplinary segregation can imply that patients (i) receive a therapy that is not the most suitable for them, but the one that their physician is familiar with, or (ii) that they have to pass through a series of medical appointments and travel long distances to get there. A previous study analyzing the health service situation for FP patients in Great Britain demonstrated that in total 10% of the patients had to travel >115 miles to receive specific FP therapy (22). In Germany, there are also only a few interdisciplinary healthcare services that are specifically established for patients with FP.

In this context, the present survey study evaluated uni-and interdisciplinary outpatient services for patients with facial palsy. A set of self-rating questionnaires—which in the past have shown high reliability in predicting generic QoL (i.e., SF-36), depression (i.e., PHQ-9), facial function-associated QoL (i.e., FaCE and FDI), and treatment satisfaction (i.e., ZUF-8) (23–27), were used to investigate factors impacting QoL and treatment satisfaction in patients with FP. The objective of these analyses is to improve future patient management of patients with FP and, thus, contribute to an improvement in facial recovery and quality of life for patients.

The occurrence of facial palsy is an impactful life event compromising patients’ mental and physical quality of life (4–6, 34). Treatment objectives should provide patients with the most holistic care possible, exhausting the full regenerative potential of the facial nerve. However, while many medical disciplines get in touch with FP patients, the disorder “facial palsy” usually represents only a minor topic in which only a few therapists specialize. This leads to an inadequate supply and possibly unspecific therapy (22). The present study examined treatment satisfaction and QoL in patients with FP in uni-and interdisciplinary treatment settings.

While overall satisfaction with FP treatment reached the ZUF-8 cut-off level of 24 points (29), no significant difference of satisfaction was found between UNI and INTER. This is contrary to the expectation that an interdisciplinary approach results in higher level of satisfaction (35). However, several factors may contribute to this discrepancy and suggest that interdisciplinary care could nevertheless preferable for the patient (20, 35, 36): (i) We found a significant difference between UNI and INTER regarding the cause of FP, duration and degree of recovery. While the UNI group exhibited a proportion of causes similar to that described in the literature (2), iatrogenic FP causes were overrepresented in the INTER group. This can be attributed to the direct affiliation of the interdisciplinary facial outpatient service with the Department of Neurosurgery in Tuebingen, which is a center for vestibular schwannomas. However, previous studies have shown that idiopathic FP generally recover better than palsies of iatrogenic origin and that improvement and chances for reinnervation may differ (14, 15), which could affect QoL and patient satisfaction. Vicente-Ruiz and Hontanilla (37) found that a longer duration of FP prior to reconstructive treatment was associated with decreased treatment satisfaction. Accordingly, it should further be evaluated whether different types of care are required for different causes of FP or whether interdisciplinary care should be offered in a standardized manner, e.g., after a certain period of time when the paresis has not improved (38, 39); (ii) While the overall response rate of the study was in good average compared to other questionnaire studies, there was a significantly better response rate in the INTER compared to the UNI group. This may be an indirect sign of patient satisfaction. However, a higher response rate due to the patient’s relationship with the researcher (KM), who also attends the interdisciplinary consultation, cannot be completely excluded (40); (iii) The distance to home was larger in the INTER group, suggesting that patients were willing to travel a greater distance for this treatment; (iv) Patients in the INTER group who were not completely satisfied with the treatment did not indicate a preference for an UNI setting, but wished the involvement of other disciplines (especially psychological and ophthalmological care). On the contrary, dissatisfied patients in the UNI group emphasized that they would have liked to have known about the option of specialized interdisciplinary consultation earlier.

Interdisciplinary treatment in this context offers the chance to treat a patient more holistically, as unidisciplinary treatment result in a narrower perspective on patient care. This has already been demonstrated in numerous oncological studies (41). With regard to the postoperative treatment of vestibular schwannomas, e.g., the control of the tumor as well as the treatment of FP can be performed simultaneously. Neurosurgeons are principally familiar with nerve surgery through the specialty of peripheral nerve surgery. However, the expertise in the area of the face is low. While HFGN are still performed, MFGN and CFNG are less common (20). Furthermore, there is often a lack of expertise in static procedures. Seeberger et al. (42) demonstrated in a nationwide study how often various types of procedures were preferred by different disciplines in FP. Interventions in the area of the mouth or eye were rarely performed by neurosurgeons. Through a joint consultation, the inhibition threshold in patients for plastic or maxillofacial surgery treatment can be lowered. While many patients may feel ashamed or embarrassed about seeking help from a plastic surgeon or there is a general societal stigma associated with cosmetic surgery, treatment by a “nerve surgeon” is more recognized; also by the health insurance companies, which are more often reluctant to cover costs of plastic surgery treatment although plastic surgery can be a valuable tool for improving the QoL of patients with FP, helping to restore their confidence and self-esteem (43, 44). In this context, our results show that significantly more patients in the INTER group received surgical treatment or injection with botulinum toxin compared with the UNI group. Almost all of these patients were satisfied with the surgical intervention. Similarly, Bradbury et al. found high levels of patient satisfaction after reconstructive surgery in FP (45).

Our results indicated that PHQ-9 scores were elevated in FP compared with the average normal population (46). In this context, previous studies showed that not only physical but also mental QoL was impaired. An U.S. study showed that patients with FP had depression in 47.7%, while only 5.1% of the control group had depression. Further investigations confirm considerable psychological distress in patients with facial palsy (47, 48). Though, there is disagreement whether the degree of FP determines the extent of QoL or depression (4, 5, 7, 48). While some studies have failed to demonstrate a correlation between these factors, other studies have shown a significant correlation, consistent with our findings. Regardless of this, psychological/psychiatric co-care of FP patients seems to be useful and was explicitly requested by patients. The effect of psychological counseling of FP patients to improve QoL and mental health has rarely been systematically investigated. However, a pilot study by Siemann et al. with a small number of cases suggests a positive effect of psychological counseling (49). Moreover, a significant reduction in anxiety and depression has been demonstrated as a result of psychological co-care in other medical conditions with a high psychosocial burden, such as oncological diseases (50, 51). Corresponding studies should also be performed for patients with FP in the future.

Treatment satisfaction of patients with FP depends on multifactorial aspects, whereby the present study could not demonstrate a difference in satisfaction between uni-and interdisciplinary consulting. However, in addition to treatment of physical impairments, psychological support should be provided. Surgical interventions should not be underestimated as potential treatment options in the absence of recovery, as they can improve quality of life and treatment satisfaction. Finally, the aspect of uni-and interdisciplinarity should be verified in future studies by addressing described limitations and using more homogeneous study groups.

The raw data supporting the conclusions of this article will be made available by the authors on reasonable request without undue reservation.

The studies involving humans were approved by ethical board of the University Hospital Tuebingen. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

KM: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft. LO: Data curation, Investigation, Methodology, Writing – review & editing. SW: Data curation, Writing – review & editing. EW: Data curation, Writing – review & editing. MG: Data curation, Writing – review & editing. HL: Methodology, Writing – review & editing. AD: Conceptualization, Resources, Writing – review & editing. MT: Conceptualization, Resources, Writing – review & editing. GN: Conceptualization, Resources, Writing – review & editing. RS: Conceptualization, Data curation, Investigation, Writing – original draft.