Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research.

OBJECTIVE: The "Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research" aims to review the latest evidence regarding the treatment of Bell's palsy and to provide appropriate recommendations. METHOD: Regarding the treatment of Bell's palsy, a guideline panel identified key clinical questions using an analytic PICO framework. The panel produced recommendations following the standards for trustworthy guidelines and the GRADE approach. The panel considered the balance of benefits, harm, and preferences when making recommendations. RESULTS: The panel identified nine key clinical questions: systemic (high/standard dose) corticosteroids, intratympanic corticosteroids, systemic antivirals, decompression surgery, acupuncture, physical therapy, botulinum toxin, and reanimation surgery. CONCLUSION: These guidelines strongly recommend systemic standard-dose corticosteroids for the clinical management of Bell's palsy. Other treatments are weakly recommended due to insufficient evidence. The absolute risk reduction of each treatment differed according to the disease severity. Therefore, physicians and patients should decide on treatment based on the disease severity.

Evaluation of quality of life for patients with resolved facial nerve palsy.

OBJECTIVES: The quality of life (QOL) for patients with resolved facial nerve palsy has not been evaluated adequately. The objective of this study is to investigate QOL for patients with resolved facial nerve palsy. METHODS: Forty-seven patients with resolved facial nerve palsy were included and the patients' QOL was evaluated using the Facial Clinimetric Evaluation Scale (FaCE Scale). RESULTS: Twenty-two of the 47 patients (46.8%) with resolved facial nerve palsy showed impaired QOL, especially in terms of facial comfort and eye comfort. In 10 cases followed-up after the condition was judged to be resolved, the median scores for the FaCE scale at the time the condition was judged to be resolved and at the last visit were 65.5 and 72, respectively. The mean durations from the onset of the palsy to diagnosis of cure and to the last visit were 2.4 ± 1.6 and 4.3 ± 2.2 months, respectively. There was a significant improvement in QOL after the condition was judged to be resolved. CONCLUSION: There were discrepancies between QOL and facial movement as evaluated by physicians in patients in whom facial nerve palsy was resolved as in patients with non-cured facial nerve palsy. Patients' QOL continued to improve even after physicians judged the condition to be resolved and this result indicated that there were cases where improvement in QOL was delayed in comparison to improvement in facial movement.

Post-vaccination Adverse Reactions After Receiving the Pfizer-BioNTech Coronavirus Disease 2019 Vaccines Among Healthcare Workers in Sapporo, Japan.

Background/objective Although a third dose of the coronavirus disease 2019 vaccine was initiated, the reports of the post-vaccination adverse reactions after dose three from Japan were limited. We aimed to report on post-vaccination adverse reactions to the third dose of the vaccine among healthcare workers and compare the results with those after the first two doses of vaccine at a tertiary medical center in Japan. Materials and methods After each vaccine (Pfizer-BioNTech) administration, healthcare workers answered a Web-based questionnaire for two consecutive days regarding local and systemic adverse reactions and anaphylaxis reactions. Information about those who took antipyretics and analgesics was also collected. Data were collected using Microsoft Forms (Microsoft, Redmond, WA, USA), a web-based questionnaire software. We compared the proportions of post-vaccination adverse reactions among the three doses of vaccine using the chi-squared test. Results A total of 1,990 employees received the first dose in March 2021, 1,988 employees received the second dose in April 2021, and 1,748 employees received the third dose between December 2021 and January 2022. The median age was 32 years and 21% were men. Local and systemic adverse reactions were greater after dose three than those with the primary series, except for nausea and vomiting. Injected site pain, fatigue, and headache were the three most commonly reported adverse reactions throughout the three sessions. A total of four employees developed anaphylaxis reactions. Additionally, 944 and 1,016 employees reported taking antipyretics and analgesics after doses two and three. Conclusions The coronavirus 2019 booster vaccine was safe and well-tolerated. Clinicians should encourage the public to receive the coronavirus 2019 vaccine series.

Psychological evaluation for patients with non-cured facial nerve palsy.

OBJECTIVE: The aim of the present study was to evaluate the psychological condition of patients with non-cured facial nerve palsy and to investigate whether their psychological condition is correlated with the degree of facial nerve palsy, synkinesis or quality of life. METHODS: Thirty patients with non-cured facial nerve palsy were enrolled in this study. Psychological conditions were evaluated by questionnaires including State-Trait Anxiety Inventory and Self-rating Depression Scale. RESULTS: Of the thirty patients with non-cured facial nerve palsy, 17 (56.7%) and 15 patients (50.0%) felt anxiety and depression, respectively. Although there were no significant correlations between their psychological condition and the degree of facial nerve palsy or that of sequelae, significant correlations were observed between psychological condition and the degree of QOL, especially in terms of social function. CONCLUSIONS AND SIGNIFICANCE: Disabilities associated with facial nerve palsy may be overlooked when evaluation is performed by physician-graded instruments alone. To resolve this problem, patients with non-cured facial nerve palsy should be evaluated by not only physician-graded tools but also patient-based assessment tools.

A single-center comparative analysis of outpatients with and without COVID-19 in Sapporo, Japan.

This study aimed to investigate the demographic, clinical, and epidemiological statistics of Japanese patients attending a designated outpatient clinic for COVID-19 in Sapporo, Japan, and contrast the clinical and epidemiological features between those with and without mild COVID-19. A total of 27 (8.6%) of 315 patients were diagnosed with COVID-19. They had higher proportions of myalgia, direct contact with a confirmed COVID-19 patient, and attendance of social gatherings in close confines. We believe that our study makes a significant contribution to the literature because it provides a clinical picture of mild COVID-19 in the Japanese population, which has not been studied extensively. It can also assist in optimizing the local preventive measures to reduce the transmission of COVID-19.

Hospital-wide antigen screening for coronavirus disease in a tertiary reference center in Sapporo, Japan: A single-center observational study.

ABSTRACT: Hospital-wide screenings for coronavirus disease (COVID-19) are important to identify healthcare workers at risk of exposure. However, the currently available diagnostic tests are expensive or only identify past infection. Therefore, this single-center observational study aimed to assess the positivity rate of hospital-wide antigen screening tests for COVID-19 and evaluate clinical factors associated with antigen positivity during a COVID-19 institutional outbreak in Sapporo, Japan.We analyzed the data of 1615 employees who underwent salivary or nasal swab antigen tests on November 18, 2020, to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Laboratory confirmation using reverse transcriptase polymerase chain reaction was performed for those with positive viral serology. The demographic characteristics, job titles, and risk of contact with COVID-19 patients were compared between employees with and without COVID-19.A total of 19 employees (1.2%) tested positive for the SARS-CoV-2 antigen. The positivity rate was high among rehabilitation therapists (2.1%) and employees in the low-risk contact group (6.1%). Although there was no association between the job titles and the seropositivity rate, those in the low-risk contact group had an increased risk of testing positive for the viral antigen (odds ratio, 8.67; 95% confidence interval, 3.30-22.8).The antigen positivity rate was low during the hospital outbreak, suggesting that risk assessment of exposure to COVID-19 patients may provide more useful information than using job titles to identify infected health care providers.

Characteristics of and Prognosis for Facial Palsy in Patients With Otitis Media With ANCA-Associated Vasculitis (OMAAV).

OBJECTIVES: The aim of the present study was to investigate the characteristics and prognosis of facial palsy in patients with otitis media with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV). STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Thirty-seven patients with OMAAV. MAIN OUTCOME MEASURES: The patients were divided into the facial palsy group and non-palsy group. The severity of and prognosis for facial palsy were evaluated using the House-Brackmann facial grading system (HB). Characteristics were compared between the facial palsy group and non-palsy group. RESULTS: Facial palsy was observed in eight patients. The last HB grade for all patients was either grade I or II after treatment with a combination of corticosteroids and immunosuppressant therapy. There were no cases in which palsy relapsed. Facial palsy in OMAAV was significantly more common in female patients, and patients with facial palsy demonstrated significantly higher rates of hypertrophic pachymeningitis than did those without facial palsy. CONCLUSIONS: Facial palsy in patients with OMAAV was detected in 21.6% and a good prognosis was obtained by use of the appropriate treatment. Facial palsy is one of the most important symptoms by which to diagnose OMAAV. When encountering the patients with intractable otitis media complicated with facial palsy, appropriate examination including ANCA titer should be performed.

Evaluation of Semicircular Canal Function by Video Head Impulse Test in Patients With Facial Nerve Schwannoma.

OBJECTIVES: The aim of the present study was to evaluate semicircular canal function by video Head Impulse Test (vHIT) in patients with facial nerve schwannoma (FNS). STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Seven patients with FNS underwent vHIT examination. MAIN OUTCOME MEASURES: The gain in vestibulo-ocular reflex and the presence of catch-up saccade were examined for the semicircular canals including the vertical canals. RESULTS: Dysfunction of the semicircular canals was detected by vHIT in three of seven cases. Nystagmus beating toward the non-affected side was observed in all three cases with semicircular canal dysfunction. Dysfunction was observed in a case with no direct compression of the vestibular nerve or semicircular canals by FNS. CONCLUSIONS: Semicircular canal function in patients with FNS could be evaluated by vHIT. vHIT has two advantages for the evaluation of vestibular function in patients with FNS. First, vHIT could be used for the patients in whom a tumor exists in the external auditory canal or middle ear, unlike caloric testing. Second, as vHIT could evaluate all three canals, impaired vestibular nerves could be speculated from vHIT results when a tumor exists in internal auditory canal. vHIT should be performed in patients with FNS, especially before surgery, to evaluate vestibular function.

Make-Up Therapy for Patients With Facial Nerve Palsy.

OBJECTIVES: To investigate the effectiveness of make-up therapy for patients with facial nerve palsy. METHODS: Seven female patients with facial nerve palsy who received specialist make-up therapy were enrolled. The objective of the make-up therapy was to obtain a symmetrical facial appearance. RESULTS: Overall score for the Facial Clinimetric Evaluation (FaCE) scale was significantly improved after make-up therapy. There was a tendency for symptoms of depression to be improved among patients after make-up therapy. CONCLUSION: Make-up therapy to improve the symmetry of facial appearance could afford a noninvasive and low-cost treatment for patients with facial nerve palsy, especially in terms of patient quality of life and psychological condition.

Effect of early tracheostomy in mechanically ventilated patients.

OBJECTIVE: To investigate the effect of the timing of tracheostomy in patients who required prolonged mechanical ventilation using two methods: analysis of early versus late tracheostomy and landmark analysis. STUDY DESIGN: Retrospective cohort study. METHODS: Patients who were emergently intubated and admitted into the intensive care unit or high dependency unit between January 2011 and August 2016, with or without tracheostomy, were included. In the early and late tracheostomy analysis, all patients were divided into early (≤10 days, n = 88) and late (>10 days, n = 132) groups. In the landmark analysis, 198 patients requiring ventilation for more than 10 days were divided into early tracheostomy (≤10 days, n = 57) and nonearly tracheostomy (>10 days, n = 141) groups. We compared 60-day ventilation withdrawal rate and 60-day mortality. RESULTS: Early tracheostomy was a significant factor for early ventilation withdrawal, as shown by log-rank test results (early and late tracheostomy: P = .001, landmark: P = .021). Multivariable analysis showed that the early group was also associated with a higher chance of ventilation withdrawal in each analysis (early and late tracheostomy: adjusted hazard ratio [aHR] = 1.69, 95% confidence interval [CI] = 1.20-2.39, P = .003; landmark: aHR = 1.61, 95% CI = 1.06-2.38, P = .027). Early tracheostomy, however, was not associated with improved 60-day mortality (early and late tracheostomy: aHR = 0.88, 95% CI = 0.46-1.69, P = .71; landmark: aHR = 1.46; 95% CI = 0.58-3.66; P = .42). CONCLUSION: For patients requiring ventilation, performing tracheostomy within 10 days of admission was independently associated with shortened duration of mechanical ventilation; 60-day mortality was not associated with the timing of tracheostomy. LEVEL OF EVIDENCE: 2b.

Factors affecting the effect of physical rehabilitation therapy for synkinesis as a sequela to facial nerve palsy.

OBJECTIVE: To investigate factors affecting the effect of physical rehabilitation therapy for synkinesis as a sequela to facial nerve palsy. METHODS: A total of 37 patients with peripheral facial nerve palsy in Teine-Keijinkai Hospital were enrolled in this study. All patients showed synkinesis at 6 months after the onset of facial nerve palsy and were instructed in physical rehabilitation by expert staff from their first visit. The degree of synkinesis was evaluated at 6, 9 and 12 months after the onset of facial nerve palsy based on Sunnybrook facial grading system score and asymmetry in eye opening width. The patients were divided into two groups by age, gender, cause of palsy, electroneurography (ENoG) value, onset of synkinesis, initial treatment and timing of the start of physical rehabilitation. RESULTS: Female patients and younger patients did not show any deterioration in synkinesis. Patients in the lower ENoG group and the later onset of synkinesis group showed significant deterioration in synkinesis after the 6th month from onset of facial palsy. CONCLUSION: Physical rehabilitation was shown to prevent significant deterioration in synkinesis in female and younger patients with facial nerve palsy. Careful follow-up with regard to synkinesis is required in cases in which the facial nerve damage is thought to be severe.

Two Cases of Heerfordt's Syndrome: A Rare Manifestation of Sarcoidosis.

Heerfordt's syndrome is a rare manifestation of sarcoidosis characterized by the presence of facial nerve palsy, parotid gland enlargement, anterior uveitis, and low grade fever. Two cases of Heerfordt's syndrome and a literature review are presented. Case 1. A 53-year-old man presented with swelling of his right eyelid, right facial nerve palsy, and swelling of his right parotid gland. A biopsy specimen from the swollen eyelid indicated sarcoidosis and he was diagnosed with incomplete Heerfordt's syndrome based on the absence of uveitis. His symptoms were improved by corticosteroid therapy. Case 2. A 55-year-old woman presented with left facial nerve palsy, bilateral hearing loss, and swelling of her bilateral parotid glands. She had been previously diagnosed with uveitis and bilateral hilar lymphadenopathy. Although no histological confirmation was performed, she was diagnosed with complete Heerfordt's syndrome on the basis of her clinical symptoms. Swelling of the bilateral parotid glands and left facial nerve palsy were improved immediately by corticosteroid therapy. Sarcoidosis is a relatively uncommon disease for the otolaryngologist. However, the otolaryngologist may encounter Heerfordt's syndrome as this syndrome presents with facial nerve palsy and swelling of the parotid gland. Therefore, we otolaryngologists should diagnose and treat Heerfordt's syndrome appropriately in cooperation with pneumologists and ophthalmologists.

Efficacy of Dietitian-instructed Low Iodine Diet for Radioiodine Remnant Tissue Ablation for Thyroid Cancer.

We evaluated the significance of dietary instruction (DI) for patients who are going on a low iodine diet (LID) as a preparation for remnant tissue ablation for thyroid cancer. DI was done by a dietarian using a dedicated handbook we have developed. To assess the effect of LID on depleting body iodine, urinary iodine concentration (UIC) in patients with post-surgical papillary thyroid cancer was measured twice, before and after LID. UIC on the day of radioiodine administration was compared with radioiodine uptake (RU) in the remnant tissue. Additionally, the association between clinical and lifestyle-related features of patients and the outcome of LID were investigated. A questionnaire survey was conducted to determine whether the DI helped patients go on LID. The mean value of UIC after the one-week LID was decreased to about 15% of the baseline value. There was a significant inverse correlation between UIC and RU (r= -0.694). Age and UIC before the start of LID were linked to successful outcome of LID. In the questionnaire survey, 84% of the participants answered that the handbook helped them go on a LID. Likewise, 80% answered that they could manage their LID without using the boil-in-the-bag low iodine food. LID successfully decreased UIC in patients undergoing remnant tissue ablation. DI by a dietitian may make a practice of LID easier.

Comparison of facial synkinesis at 6 and 12 months after the onset of peripheral facial nerve palsy.

OBJECTIVE: To investigate the time course of synkinesis as a sequela of facial nerve palsy so that we are able to determine an appropriate time for deciding the outcome of recovery in patients with facial nerve palsy. METHODS: Nineteen consecutive patients with peripheral facial nerve palsy who developed synkinesis were enrolled. We compared the degree of synkinesis at 6 and 12 months after the onset of palsy. Our investigation consisted of (1) scoring using the Sunnybrook facial grading system and (2) computing the asymmetry (%) in eye opening width. We also judged whether all 19 cases were cured or not based on the treatment outcome criteria of the Japan Society of Facial Nerve Research at 6 and 12 months. RESULTS: The synkinesis score based on Sunnybrook facial grading system and the degree of asymmetry in eye opening width during mouth movement deteriorated significantly between the 6th and 12th month after the onset of palsy. One of the cases regarded as "cured" at the 6th month was later judged to be "non-cured" due to deterioration in the synkinesis score at the 12th month. CONCLUSION: From our results, synkinesis deteriorated after the 6th month from the onset of palsy. Therefore, we should follow up the degree of synkinesis until at least the 12th month, and the outcome of recovery in patients with facial synkinesis should be evaluated at least 12 months after the onset.

[Introduction of Percutaneous Dilational Tracheotomy in Otolaryngology Residency Training].

In 2009, we introduced percutaneous dilational tracheotomy (PDT) in otolaryngology residency training. PDT was performed in 21 cases and five residents had an opportunity to learn PDT. No major complications occurred. Decannulation was achieved in 17 of the 18 cases, excluding 3 mortalities. All residents felt that their knowledge of PDT had advanced. Introduction of PDT has great significance in otolaryngology residency training.

Idiopathic oculostapedial synkinesis without history of facial nerve palsy.

OBJECTIVE: To report a case of idiopathic oculostapedial synkinesis without facial nerve disorder. PATIENT: A 30-year-old woman with tinnitus synchronous with eye closure is presented. The patient had no history of facial nerve disorder. RESULT: An impedance audiometer, in the absence of an auditory stimulus, was used to record tympanic membrane compliance without sound stimulation, revealing decreased compliance in the concomitant with eye blinking. Her symptoms disappeared spontaneously, so no intervention was undertaken. CONCLUSION: Although oculostapedial synkinesis is often observed as one of the sequelae of facial nerve palsy, idiopathic oculostapedial synkinesis is very rare. The use of an impedance audiometer in the absence of an auditory stimulus is very useful for demonstrating objective changes in the compliance of the tympanic membrane. It is assumed that the cause of the synkinesis in our case was abnormal transmission of signals for orbicularis oculi muscle to the stapedial and orbicularis oris muscles rather than misdirected regenerating fibers. Resection of the stapedial muscle tendon should be considered if her symptoms recur.

[A videoendoscopic swallowing examination using a scoring system for prediction of successful oral intake after discharge from an acute care hospital].

It is often difficult to decide whether to restart an oral diet during acute hospitalization. We investigated retrospectively the predictive factors for successful oral intake after discharge from an acute care hospital or transfer to a recovery rehabilitation hospital. A total of 45 inpatients were enrolled, presenting with dysphagia due to various diseases during hospitalization in an acute care hospital. Between October 2011 and December 2012 the patients were examined with a videoendoscopic examination of swallowing (VE). We classified the feeding procedure after discharge from the hospital into three groups-the first group (group 1) had no oral intake limitation, the second group (group 2) had limited oral intake, and the third group (group 3) had no oral intake ability. We then assessed the factors of age, sex, VE score, and functional independence measure (FIM) score to compare the activities of daily living (ADL) between group 1 and group 2 + 3. FIM score consists of motor and cognitive scores. We observed a statistically significant difference in age, VE score, motor FIM score and cognitive FIM score in a univariate analysis (p = 0.03, p = 0.0036, p = 0.0019, p = 0.0125). The VE score also showed a statistically significant difference in a multivariate analysis (p = 0.0396), indicating that the VE score was an independent variable related to prediction of the feeding procedure. A VE score of 4 as the cut-off point between group 1 and group 2 + 3 provided a specificity of 0.944 and a positive predictive value of 0.923. On the other hand, a VE score of 9 as the cut-off point between group 3 and group 1 + 2 provided a specificity of 0.969 and a positive predictive value of 0.857. These results indicate that the VE score is a useful tool for the prediction of successful oral intake after discharge from an acute care hospital. In addition, age and ADL are also useful predictive factors for the feeding procedure.

A Case of Associated Laryngeal Paralysis Caused by Varicella Zoster Virus without Eruption.

We report a patient with significant weakness of the left soft palate, paralysis of the left vocal cord, and left facial nerve palsy. Although the patient showed no herpetic eruption in the pharyngolaryngeal mucosa and auricle skin, reactivation of varicella zoster virus (VZV) was confirmed by serological examination. She was diagnosed with zoster sine herpete. After treatment with antiviral drugs and corticosteroids, her neurological disorder improved completely. When we encounter a patient with associated laryngeal paralysis, we should consider the possibility of reactivation of VZV even when no typical herpetic eruption is observed.

Alpha-defensin overexpression in patients with Bell's palsy and Ramsay Hunt syndrome.

OBJECTIVES: To investigate the biological factors related to the onset of Bell's palsy, we sought to identify differentially expressed genes in peripheral blood mononuclear cells (PBMCs) and plasma of patients with Bell's palsy and Ramsay Hunt syndrome (RHS). METHODS: We carried out DNA microarray analyses using PBMCs taken from patients with Bell's palsy at their initial visit and 2 to 4 weeks later. To validate these analyses, we measured the relative messenger RNA levels of alpha-defensin in paired PBMCs by reverse transcription-polymerase chain reaction. The plasma concentrations of alpha-defensin in patients and healthy volunteers were quantified by enzyme-linked immunosorbent assay. RESULTS: The DNA microarray analysis identified alpha-defensin as a candidate gene related to the onset of Bell's palsy. Reverse transcription-polymerase chain reaction analysis showed that the relative alpha-defensin messenger RNA levels in PBMCs from the later visit were increased at least twofold in 9 of 13 patients (69%) with Bell's palsy and in 4 of 6 patients (67%) with RHS. The plasma alpha-defensin concentrations in the patients with RHS were significantly higher than those in healthy volunteers (p = 0.0013) and in the patients with Bell's palsy (p = 0.0306). Elevations of plasma alpha-defensin were observed in 5 of the 9 patients with Bell's palsy who demonstrated alpha-defensin overexpression in PBMCs. CONCLUSIONS: alpha-Defensin may be one of the biological factors related to the onset of Bell's palsy and RHS.