Electrodiagnostic methods to verify Guillain-Barré syndrome subtypes in Istanbul: A prospective multicenter study.

BACKGROUND AND AIMS: This study aimed to identify the clinical characteristics and electrodiagnostic subtypes of Guillain-Barré syndrome (GBS) in Istanbul. METHODS: Patients with GBS were prospectively recruited between April 2019 and March 2022 and two electrodiagnostic examinations were performed on each patient. The criteria of Ho et al., Hadden et al., Rajabally et al., and Uncini et al. were compared for the differentiation of demyelinating and axonal subtypes, and their relations with anti-ganglioside antibodies were analyzed. RESULTS: One hundred seventy-seven patients were included, 69 before the coronavirus disease 2019 pandemic (April 2019-February 2020) and 108 during the pandemic (March 2020-March 2022), without substantial changes in monthly frequencies. As compared with the criteria of Uncini et al., demyelinating GBS subtype diagnosis was more frequent according to the Ho et al. and Hadden et al. criteria (95/162, 58.6% vs. 110/174, 63.2% and 121/174, 69.5%, respectively), and less frequent according to Rajabally et al.'s criteria (76/174, 43.7%). Fourteen patients' diagnoses made using Rajabally et al.'s criteria were shifted to the other subtype with the second electrodiagnostic examination. Of the 106 analyzed patients, 22 had immunoglobulin G anti-ganglioside antibodies (14 with the axonal subtype). They had less frequent sensory symptoms (54.5% vs. 83.1%, p = 0.009), a more frequent history of previous gastroenteritis (54.5% vs. 22.9%, p = 0.007), and a more severe disease as compared with those without antibodies. INTERPRETATION: Serial electrodiagnostic examinations are more helpful for accurate subtype diagnosis of GBS because of the dynamic pathophysiology of the disease. We observed no significant increase in GBS frequency during the pandemic in this metropolis.

Myoclonus and tremor in chronic inflammatory demyelinating polyneuropathy: a multichannel electromyography analysis.

BACKGROUND: Information regarding involuntary movements in chronic inflammatory polyneuropathy (CIDP) is gradually increasing. Our goal is to identify the types of involuntary movements in CIDP. METHODS: All patients who were followed with the diagnosis of CIDP were invited for clinical and electrophysiological evaluations. Demographic and clinical findings (age, gender, duration of illness, diagnosis, treatments) were noted. Clinical examination and multichannel surface electromyography were done. We also performed routine upper and lower extremity peripheral nerve conduction studies, F-waves, long latency reflexes, blink reflex, mixed nerve silent period and cutaneous silent period in all patients. RESULTS: Twenty-two patients accepted the invitation. Eleven patients with CIDP had involuntary movements. Ten (45.5%) patients with CIDP had tremor and seven (31.8%) had short-duration and high-amplitude myoclonus. Regarding demographic, clinical and electrophysiological features, there was no significant difference between patients with and without tremor. The latencies of R1, R2 and R2c components of BR were longer among CIDP patients without tremor compared to CIDP patients with tremor. Presence of myoclonus (p = 0.007) and delayed F-waves (p = 0.008) were associated with the presence of tremor. CONCLUSION: Tremor and myoclonus were frequent in CIDP. The fact that myoclonus was detected in the majority of patients only by multichannel surface EMG who were clinically evaluated as pure tremor suggests that a more detailed electrophysiological evaluation is required. There was no difference in the medications used or other clinical features between patients with and without tremor.

Cutaneous silent period in patients with spinal muscular atrophy type 2 and type 3.

OBJECTIVE: The aim of this study was to examine cutaneous silent periods (CSPs) in spinal muscular atrophy (SMA) type 2 and type 3 patients. METHODS: Fourteen patients with SMA and 14 healthy subjects were included. CSPs were recorded from thenar muscles after painful stimulation of the index finger during slight thumb abduction. CSP parameters (including onset latency, duration, index of suppression, long-loop reflex, and post-inhibitory rebound activity) were measured. All parameters were compared between SMA patients and healthy subjects using the Mann-Whitney U test. We then correlated CSP parameters to Hammersmith Functional Motor Scale Expanded (HFMSE) scores in SMA patients by Spearman-rho testing. RESULTS: No CSP parameter except E3% (i.e., the post-inhibitory rebound activity relative to pre-stimulus baseline) differed significantly between SMA patients and healthy subjects. E3% was significantly smaller in patients than healthy individuals. HFMSE scores of SMA patients correlated negatively with CSP duration and positively with E3%. DISCUSSION: Smaller E3%, correlating with longer CSP duration, in SMA patients with more severe clinical findings and therefore more marked motoneuron loss suggests that the E3 component following the CSP is directly affected by motoneuron loss.

Ulnar Neuropathy at Elbow in Patients With Type 2 Diabetes Mellitus.

PURPOSE: In diabetes mellitus (DM), upper extremity entrapment neuropathies are suggested to be a component of polyneuropathy (PNP). Our aim is to examine the presence of ulnar neuropathy at the elbow (UNE) and its relation to other findings including PNP in symptomatic and asymptomatic type-2 DM patients who were admitted for routine examinations. METHODS: The study included all cases referred for electromyography because of type-2 DM between November 2017 and May 2018. Demographic and clinical characteristics were recorded. Routine electromyography examinations in all cases included the following: bilateral motor conduction of the median, ulnar, peroneal, and tibial nerves and sensory conduction of the median, ulnar, and sural nerves. For ulnar nerve examination, stimuli were given at the wrist, below the elbow, and above the elbow. Electrophysiological findings were evaluated according to the American Association of Neuromuscular and Electrodiagnostic Medicine criteria. RESULTS: Eighty-two patients with type-2 DM and 144 upper extremities were included in the study. Of the 82 patients who participated in the study, 3 had findings suggesting ulnar neuropathy, and electrophysiology confirmed UNE in only one. Electrophysiological studies showed UNE in 36 patients. Other diagnoses identified by electrophysiology were carpal tunnel syndrome and PNP. Ulnar neuropathy at the elbow was more commonly associated with PNP compared with carpal tunnel syndrome. Gender and PNP were independent risk factors for the development of UNE. CONCLUSIONS: Although the majority of diabetic patients were asymptomatic for the UNE, approximately one third of all patients with DM were found to have UNE. Ulnar neuropathy at the elbow is closely related with PNP.

Occipitalis muscle: using for repetitive facial nerve stimulation in myasthenia gravis.

Repetitive nerve stimulation (RNS) is a highly sensitive electrophysiological test used for diagnosing myasthenia gravis (MG). Here, we evaluated electrodiagnostic value of RNS using facial nerve and occipitalis muscle. Patients with generalized MG were included. Clinical findings were assessed. RNS test was performed on occipitalis, nasalis, trapezius, abductor policis brevis (APB) and abductor digiti minimi (ADM) muscles. Twenty-five (78%) patients had relevant decrement during RNS test of at least one muscle. Nasalis muscle had the highest diagnostic potential (68.8%), followed by trapezius (53.3%), occipitalis (50%), APB (30%) and ADM (16.7%) muscles. There was not a significant relationship between clinical symptoms and facial RNS recorded on occipitalis muscle. In conclusion, we suggest that facial RNS recording over occipitalis muscle can be added in electrodiagnosis of MG because of cranial nerve innervation and proximal location. Facial RNS recording over occipitalis muscle provides a good choice under the conditions such as atrophy, cosmetic surgery, or botulinum toxin application in which nasalis muscle is unavailable for use.

Guillain-Barré Syndrome and Its Variants: Clinical Course and Prognostic Factors.

INTRODUCTION: We aimed to analyze the frequency, clinical characteristics, medical treatment options and final functional status of Guillain-Barré syndrome (GBS) and its variants in a population from a tertiary hospital setting. METHODS: All medical records of patients with acute inflammatory polyneuropathy between the years of 1998-2013 were retrospectively screened. Demographic, clinical and laboratory information, treatment options and the rate of recovery of the patients were gathered. RESULTS: A total of 183 patients met the study criteria. Subtypes were typical demyelinating form (n=102, 79.1%), acute motor sensory axonal variant (n=11, 8.5%), acute motor axonal variant (n=10, 7.8%), Miller-Fisher syndrome (n=5, 3.9%), and pure sensory subtype (n=1, 0.8%). Remaining patients had the diagnosis of acute-onset chronic inflammatory demyelinating polynuropathy. The data of treatment option were available for 70 patients. Most of the patients received intravenous immunoglobulin (IVIg) treatment or the combination of IVIg and methylprednisolone. One patient died, there was no improvement in eight patients and rest showed improvement with varying degrees. CONCLUSIONS: We did not observe major change of recovery between different treatment options, however, most of the patients using methylprednisolone required IVIg because of inadequate response.

Effects of Melatonin and Dexamethasone on Facial Nerve Neurorrhaphy.

OBJECTIVES: To investigate the effects of topical and systemic administrations of melatonin and dexamethasone on facial nerve regeneration. MATERIALS AND METHODS: In total, 50 male albino Wistar rats underwent facial nerve axotomy and neurorrhaphy. The animals were divided into 5 groups: control, topical melatonin, systemic melatonin, topical dexamethasone, and systemic dexamethasone. Nerve conduction studies were performed preoperatively and at 3, 6, 9, and 12 weeks after drug administrations. Amplitude and latency of the compound muscle action potentials were recorded. Coapted facial nerves were investigated under light and electron microscopy. Nerve diameter, axon diameter, and myelin thickness were recorded quantitatively. RESULTS: Amplitudes decreased and latencies increased in both the melatonin and dexamethasone groups. At the final examination, the electrophysiological evidence of facial nerve degeneration was not significantly different between the groups. Histopathological examinations revealed the largest nerve diameter in the melatonin groups, followed by the dexamethasone and control groups (p<0.05). Axon diameter of the control group was smaller than those of the melatonin (topical and systemic) and topical dexamethasone groups (p<0.05). The melatonin groups had almost normal myelin ultrastructure. CONCLUSION: Electrophysiological evaluation did not reveal any potential benefit of dexamethasone and melatonin in contrast to histopathological examination, which revealed beneficial effects of melatonin in particular. These agents may increase the regeneration of facial nerves, but electrophysiological evidence of regeneration may appear later.

Reorganization of sensorimotor gating after peripheral facial palsy starts at brainstem.

Background and objective We aimed to analyze the alterations in sensorimotor gating at brainstem after peripheral facial palsy (PFP). To examine sensorimotor gating, we used prepulse modulation (PPM) of blink reflex (BR). We also recorded BR recovery to identify excitability changes in the facial nucleus. Patients and method We included 33 patients and 39 recordings. Control group was composed of 16 healthy subjects. Simultaneous bilateral baseline BR, BR recovery at ISI of 300-ms and BR-PPM at ISI of 100-ms recordings were performed after stimulation of trigeminal nerve on right sides of healthy subjects and on both sides of patients. Severity of PFP and time lapse from the onset was noted. Results Mean R1 amplitude was increased, whereas mean R2 and R2c magnitude were reduced in all groups after prepulse stimulation. However, multivariate ANOVA showed significance at group level (patients and healthy subjects), at prepulse level (no prepulse and 100-ms prepulse) and group and prepulse level. Suppression of R2 or R2c was lower on both sides of patients compared to healthy subjects and the deficit first started on the symptomatic side. Conclusion Suppression of R2 and R2c after prepulse stimulation is reduced in PFP suggesting decreased filtering of facial sensory input at brainstem level. Trigeminal sensitization at brainstem develops early after PFP.

Pattern of startle reflex to somatosensory stimuli changes after spinal cord injury.

INTRODUCTION: Spinal cord injury (SCI) may cause functional changes at various levels in central and peripheral nervous systems. One of these changes is increased excitability above the lesion such as enhanced auditory startle responses (ASR). Startle response may also be obtained after somatosensory stimulus (startle reflex to somatosensory stimuli, SSS). In this study, we investigated changes of both ASR and SSS in SCI. METHOD: We examined ASR and SSS in 14 patients with SCI and 18 age-matched healthy volunteers. SSS responses were recorded from orbicularis oculi (O.oc), sternocleidomastoid (SCM) and biceps brachii (BB) muscles by electrical stimulation of median nerve at the wrist. ASR was evoked by binaural auditory stimuli and recorded from O.oc, masseter, SCM and BB muscles. Probability, latency, amplitude and duration of responses were compared between two groups for each muscle. RESULTS: Presence of response over O.oc after somatosensory stimuli was decreased in patients compared to controls (P = 0.004). There were no differences in SSS responses of other muscles. ASR latency was shorter in masseter, SCM and BB in patients with SCI, but only BB had significantly reduced latency (P = 0.033). The duration of O.oc response was longer and the amplitude of SCM was larger in patients with SCI (P = 0.037 and P = 0.015, respectively). CONCLUSION: ASR is enhanced after SCI whereas SSS of eye muscles is hypoactive and pattern of SSS after median stimulation changes in SCI.

Repetitive Facial Nerve Stimulation Using Occipitalis Muscle.

PURPOSE: We aimed to evaluate the reliability and reproducibility of repetitive nerve stimulation recorded on occipitalis muscle by comparing recordings on nasalis muscle in healthy subjects. METHODS: A total of 23 healthy subjects (mean age: 44.7 ± 13.8 years) underwent detailed neurological examination and repetitive nerve stimulation using nasalis and occipitalis muscles. Amplitude and area percentage changes of compound muscle action potentials (CMAPs) after repetitive nerve stimulation with different frequency were compared between right and left sides and between recordings on nasalis and occipitalis muscles. RESULTS: Comparisons of percentage amplitude changes of nasalis and occipitalis CMAPs showed no differences (+0.1% ± 3.8% vs. +1.4% ± 3.9%, P = 0.129). Average area percentage change of nasalis CMAPs was 0.3% ± 19.0%, whereas the value of occipitalis CMAP was +2.8% ± 15.2% (P = 0.851). Comparisons of nasalis and occipitalis CMAPs values showed no differences. CONCLUSIONS: The repetitive nerve stimulation recorded on occipitalis muscle is simple, easy to apply, noninvasive, consistent, and reproducible.

Evaluation of the Tibial Nerve with Shear-Wave Elastography: A Potential Sonographic Method for the Diagnosis of Diabetic Peripheral Neuropathy.

Purpose To evaluate the value of shear-wave elastography (SWE) in the detection of diabetic peripheral neuropathy (DPN) of the tibial nerve. Materials and Methods This study was approved by the institutional review board, and written informed consent was obtained from all study participants. The study included 20 diabetic patients with DPN (10 men, 10 women), 20 diabetic patients without DPN (eight men, 12 women), and 20 healthy control subjects (nine men, 11 women). The tibial nerve was examined at 4 cm proximal to the medial malleolus with gray-scale ultrasonography and SWE. The nerve cross-sectional area (in square centimeters) and the mean nerve stiffness (in kilopascals) within the range of the image were recorded. Inter- and intrareader variability, differences among groups, and correlation of clinical and electrophysiologic evaluation were assessed with intraclass correlation coefficients, the Mann Whitney U test, and the Wilcoxon signed rank test. Results Between diabetic patients with and diabetic patients without DPN, mean age (60 years [range, 38-79 years] vs 61 years [range, 46-75 years], respectively), mean duration of diabetes (10 years [range, 1-25 years] vs 10 years [range, 2-26 years]), and mean body mass index (31.4 kg/m2 [range, 24.7-48.1 kg/m2] vs 29.8 kg/m2 [range, 22.9-44.0 kg/m2]) were not significantly different. Diabetic patients without DPN had significantly higher stiffness values on the right side compared with control subjects (P < .001). Patients with DPN had much higher stiffness values on both sides compared with both diabetic patients without DPN (P < .001) and healthy control subjects (P < .001). A cutoff value of 51.0 kPa at 4 cm proximal to the medial malleolus revealed a sensitivity of 90% (95% confidence interval [CI]: 75.4%, 96.7%) and a specificity of 85.0% (95% CI: 74.9%, 91.7%). Conclusion Tibial nerve stiffness measurements appear to be highly specific in the diagnosis of established DPN. The increased stiffness in subjects without DPN might indicate that the nerve is affected by diabetes. © RSNA, 2016 Online supplemental material is available for this article.

Deficient prepulse inhibition of blink reflex in migraine and its relation to allodynia.

OBJECTIVE: Prepulse inhibition (PPI) of the blink reflex (BR) is a reduction in BR excitability due to a conditioning stimulus, reflecting sensory gating by brainstem structures. We aimed to analyze PPI changes during a painful episode in chronic or episodic migraine and its relation to allodynia, since abnormal brainstem filtering has been hypothesized in migraine pathophysiology. METHODS: We included 20 patients with migraine during headache episode, and age- and gender-matched 22 healthy subjects. We recorded BR after unconditioned and conditioned supraorbital stimuli. For conditioned stimuli, we applied preceding subthreshold stimulus to the median nerve at wrist. The presence of PPI was compared between the two groups, as well as the specific BR parameters (latency, amplitude or area of R1 and R2 components) in unconditioned (test) and conditioned (PPI) paradigms. RESULTS: In the patient group, seven (35%) patients did not have R2-PPI whereas all healthy subjects had R2-PPI (P=0.003). Healthy subjects displayed significantly increased R1 amplitude and reduced R2 amplitude and area after conditioned stimuli. In migraine patients, we observed significant reduction only in R2 amplitude. Logistic regression demonstrated that allodynia was independently related with the presence of PPI (beta: -0.535, P=0.021). CONCLUSIONS: Our study provides evidence for sensory gating impairment at brainstem level in migraine headache, related to the presence of allodynia.

Electrophysiologic Evaluation of the Facial Nerve and Blink Reflex Pathways in Asymptomatic Cochlear Implant Users.

OBJECTIVE: To evaluate the functional integrity of the facial nerve and blink reflex (BR) pathways in asymptomatic patients who underwent cochlear implantation (CI). STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Twenty-four deafened patients with unilateral CI who had no complications were enrolled. Bilateral compound muscle action potentials (CMAPs) of the facial nerve were recorded over the nasalis and occipitalis muscles, whereas BR responses were recorded over the orbicularis oculi after supraorbital nerve stimulation. All recordings were performed when the external part of the implant was in place (CIp) and after its removal (CIr), except occipitalis recordings, which were performed only after removal. The amplitude and latency of CMAP were measured to evaluate the axonal integrity of the zygomatic and posterior branches of the facial nerve. Latency, amplitude, and duration of the BR were measured to investigate the integrity of trigeminofacial connections. RESULTS: The amplitude and latency of CMAP over the nasalis muscle were bilaterally normal, and the difference between CIp and CIr was not statistically significant. No CMAP of the occipitalis muscle was recorded in 4 (16.7%) patients, and low-amplitude responses were recorded on the implant side of 20 (83.3%). Amplitudes of the contralateral R2 response were higher in the CIp condition versus the CIr condition (P = .031). There were no differences among other BR components. CONCLUSION: During functioning of the CI system, excitability of the facial circuit may increase either through the facial motor nucleus or through removal of the inhibitory effect of the descending pathway.

Human olfactory stem cells for injured facial nerve reconstruction in a rat model.

BACKGROUND: The purpose of this study was to show the efficacy of olfactory stem cells for injured facial nerve reconstruction in a rat model. METHODS: Olfactory stem cells were isolated from the olfactory mucosa of human participants. A 2-mm excision was performed on the right facial nerve of all rats. Reconstruction was performed with a conduit in group 1 (n = 9); a conduit and phosphate-buffered saline in group 2 (n = 9); and a conduit and labeled olfactory stem cell in group 3 (n = 9). Rats were followed for whisker movements and electroneuronography (ENoG) analyses. RESULTS: The whisker-movement scores for group 3 were significantly different from other groups (p < .001). ENoG showed that the amplitude values for group 3 were significantly different from group 1 and group 2 (p = .030; p < .001). Group 3 showed marked olfactory stem cell under a fluorescence microscope. CONCLUSION: This study suggests that olfactory stem cells may be used as a potent cellular therapy for accelerating the regeneration of peripheral nerve injuries. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2011-E2020, 2016.

A novel muscle for electroneurography in peripheral facial palsy: occipitalis.

Electroneurography (ENoG) is one of the most objective tests in grading the damage and prediction of prognosis in peripheral facial palsy (PFP). We aimed to determine temporal changes of ENoG recorded over occipitalis muscle in acute idiopathic PFP. Consecutive 21 patients with unilateral acute idiopathic PFP and age- and sex-matched 15 healthy volunteers were included in the study. Nasal and occipital ENoG values were recorded once in the control group and the same procedure was repeated daily between the second and eight days of the disorder in the PFP group. Occipital ENoG value began to increase on the third day while nasal ENoG value was still within the normal range (27.04 vs 7.69 %, p = 0.0001). In the fourth, fifth and sixth days, occipital ENoG value was significantly high compared to nasal ENoG value (p = 0.0001 for each day) whereas nasal and occipital ENoG values were very similar in the seventh and eighth days (p = 0.181 and p = 0.584, respectively). Our study presents further support for technical possibility of occipital ENoG which may reflect the degree of fiber degeneration earlier than the nasalis muscle in PFP.

Circadian Change in Blink Reflex Recovery in Restless Legs Syndrome.

INTRODUCTION: Restless legs syndrome (RLS) is associated with dysfunction of the dopaminergic systems in the pathways that specifically link the sensory input and motor output. Keeping in mind that clinical symptomatology in RLS and cerebrospinal fluid dopamine concentrations in healthy individuals show changes throughout the day, we hypothesized that excitability of the related pathways increases during the night in RLS, and in the present study, we aimed to analyze our hypothesis by the assessment of blink reflex (BR) recovery. METHODS: Eleven patients with primary RLS and eight age- and gender-matched healthy subjects were included in the study. All participants underwent detailed interviews and neurological examinations. BR responses were recorded after single and paired supraorbital stimulation during the early afternoon and late at night. For double stimulation, interstimulus intervals (ISI) of 100, 300, and 500 ms were used. Daytime and nighttime investigations were separately compared between the patient and control groups (between-group analyses). In-group analyses were conducted between daytime and nighttime investigations of the patient and control groups. RESULTS: BR responses to single stimuli were normal in all participants at all sessions. R2 recovery was the highest in the patient group during nighttime investigations. In-group analysis showed a reduction of R2 recovery during the night in healthy subjects. R2 recoveries at ISIs of 300 and 500 ms at nighttime were higher in RLS patients but did not reach statistical significance. CONCLUSION: The BR circuit is less excitable during the night in healthy individuals, whereas the reduction of excitability is lost in RLS. Despite the limited number of included subjects, we suggest that the normal circadian modulation of the BR circuit is lost in RLS.

Enhanced blink reflex recovery in juvenile myoclonic epilepsy.

Juvenile myoclonic epilepsy (JME), which has been attributed to the dysfunction of cortico-thalamic pathway, has been considered to be one of the system epilepsies. However, electrophysiological and functional neuroimaging techniques have revealed the functional involvement of various parts of the central nervous system, also. Here, we aimed to analyze the role of brainstem circuits in JME by using the blink reflex recovery cycle (BRrc). Electrophysiological recordings of 18 JME patients together with age and gender matched 18 healthy subjects were made during single and paired supraorbital stimulation. Constant current paired stimuli were delivered at interstimulus intervals (ISI) of 200 and 400ms. Amplitudes of R2 responses were measured on the non-dominant side, and percentages of the recovery cycles were calculated. All participants had normal and similar R1 and R2 components of blink reflex (BR). At ISI of 400ms, R2 recoveries were significantly higher in the JME group compared to healthy subjects (p=0.040). There was no correlation between R2-BRrc and ages of JME patients, disease duration and daily dosage of valproic acid. We suggest that in JME, the integrity of BR circuit is preserved while the excitability of the brainstem BR circuitry is enhanced.

Effects of Open Technique Rhinoplasty on Mimicry: Electroneurographic Evaluation.

OBJECTIVE: This study was designed to investigate the effects of open technique rhinoplasty on facial nerve terminal branches more concerned with mimicry via electroneurography (ENoG). METHODS: Twenty patients ages between 24 and 36 years were included in the study. Five nasal mimicry muscles were used to evaluate axonal loss of the facial nerve: bilateral transverse nasal, levator labii superioris alaeque nasi (LLSAN), and procerus muscles of all patients were evaluated preoperatively and postoperative third month by ENoG. The patients that have abnormalities regarding the amplitude and latency at third month were reevaluated at sixth month postoperatively. RESULTS: Mean latencies of the facial nerve were calculated to be increased for all muscles at third postoperative month, but this increase was significant only for left LLSAN (P = 0.002). Amplitudes of the facial nerve decreased in all of the groups, but this decrease was not significant (P > 0.05). Two patients with exceptionally long latency facial nerve response of transverse nasal muscle and 11 muscle recordings with abnormal low amplitudes of the facial nerve at the third month was reevaluated at sixth postoperative month and the values were improved. CONCLUSIONS: This study demonstrated that facial nerve integrity is minimally affected after rhinoplasty, yet all affected muscles were recovered on the long term.