Ultrasound-Guided Injections for Treatment of Facial Paralysis Sequelae: A Randomized Study on Body Donors.

BACKGROUND: Botulinum toxin injection is the accepted standard treatment for synkinesis and gustatory hyperlacrimation in patients with facial paralysis. However, poor injection accuracy can result in inconsistent treatment outcomes, variable treatment durations, and complications. Ultrasound guidance should increase injection accuracy in the facial region; however, this has not been proven. METHODS: Twenty-six hemifaces of nonembalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated using several measures. RESULTS: Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance ( P < 0.001). This was most pronounced in the lacrimal gland (62% versus 8%), depressor anguli oris (100% versus 46%), and mentalis (100% versus 54%) ( P < 0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance versus 29% without ( P < 0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance versus 83% without ( P < 0.01). Twenty-three percent of the landmark-guided depressor anguli oris injections stained the facial artery ( P = 0.22). CONCLUSIONS: Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in the surrounding tissue compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in patients with facial paralysis.

Orbital floor fractures-a comparison between CT images and findings at surgery.

PURPOSE: The present study aims to investigate how well CT images correlate to surgical findings in orbital floor fractures and to the presence of diplopia. METHODS: In this cross-sectional study, 27 consecutive patients already selected for surgery due to an orbital floor fracture underwent a routine CT scan (axial, coronal, sagittal). An ophthalmologist established any presence of diplopia. Extent of fracture/injury seen on CT was compared to that discovered during surgery. RESULTS: In the surgeons´ opinions CT-images were in concordance with surgical findings in 71% of the cases. Agreement for pure blow out fractures was high (92%). Tetrapod fractures as a cause of an orbital floor fracture was only identified as such by surgeons in three of 11 cases, all subjected to orbital exploration, not only a closed reduction. Diplopia showed a significant correlation to rounding of the inferior rectus muscle at coronal CT. "Rounding" significantly correlated with the presence of a floor defect, to herniation of soft tissues and to the volume of displaced tissue. CONCLUSIONS: The results imply that the joint professional interaction between neuroradiology and surgery is important and would benefit from the use of an easy and well-defined classification system of orbital floor fractures. In Sweden a national record to collect data on all zygomaticomaxillary complex fractures assessed is to be started aiming at making general statements possible by time.

Virtual magnetic resonance elastography has the feasibility to evaluate preoperative pituitary adenoma consistency.

PURPOSE: To evaluate the use of preoperative virtual Magnetic Resonance Elastography (vMRE) for patients undergoing transsphenoidal resection of pituitary adenomas (PA). METHODS: Ten patients (60.2 ± 19.6 years; 8 males) were prospectively examined with the vMRE-method prior to transsphenoidal surgery. vMRE-images, reflecting tissue stiffness were reconstructed. From these images, histograms as well as the mean stiffness values over the tumor body were extracted. Finally, vMRE-data was compared with the PA consistency at surgery blinded to vMRE. RESULTS: In all patients, successful vMRE-examination was performed enabling evaluation of even small PAs. For tumors with homogenous tissue, the mean stiffness value increased with surgical consistency grading. For heterogenous tumors, however, the mean stiffness value did not consistently reflect the grading at surgery. On the other hand, the vMRE-images and histograms were found to be able to characterize the tumor heterogeneity and display focal regions of high stiffness that were found to affect the surgery outcome in these PAs. The vMRE-images and histograms showed great promise in characterizing the consistency at surgery for these PAs. CONCLUSION: Evaluation of PA consistency in preparation for surgery seems to be feasible using the vMRE-method. Our findings also address the need for high resolution diagnostic methods that can non-invasively display focal regions of increased stiffness, as such regions may increase the difficulty of transsphenoidal PA-resection.

A 7-Channel High-[Formula: see text] SQUID-Based On-Scalp MEG System.

OBJECTIVE: To present the technical design and demonstrate the feasibility of a multi-channel on-scalp magnetoencephalography (MEG) system based on high critical temperature (high-[Formula: see text]) superconducting quantum interference devices (SQUIDs). METHODS: We built a liquid nitrogen-cooled cryostat that houses seven YBCO SQUID magnetometers arranged in a dense, head-aligned array with minimal distance to the room-temperature environment for all sensors. We characterize the performance of this 7-channel system in terms of on-scalp MEG utilization and present recordings of spontaneous and evoked brain activity. RESULTS: The center-to-center spacing between adjacent SQUIDs is 12.0 and 13.4 mm and all SQUIDs are in the range of 1-3 mm of the head surface. The cryostat reaches a base temperature of  âˆ¼ 70 K and stays cold for 16 h with a single 0.9 L filling. The white noise levels of the magnetometers is 50-130 fT/Hz1/2 at 10 Hz and they show low sensor-to-sensor feedback flux crosstalk ( 0.6%). We demonstrate evoked fields from auditory stimuli and single-shot sensitivity to alpha modulation from the visual cortex. CONCLUSION: All seven channels in the system sensitively sample neuromagnetic fields with mm-scale scalp standoff distances. The hold time of the cryostat furthermore is sufficient for a day of recordings. As such, our multi-channel high-[Formula: see text] SQUID-based system meets the demands of on-scalp MEG. SIGNIFICANCE: The system presented here marks the first high-[Formula: see text] SQUID-based on-scalp MEG system with more than two channels. It enables us to further explore the benefits of on-scalp MEG in future recordings.

Incident Chronic Rhinosinusitis Is Associated With Impaired Sleep Quality: Results of the RHINE Study.

STUDY OBJECTIVES: Chronic rhinosinusitis (CRS) is a common inflammatory disease of the nasal cavity and paranasal sinuses. Associations between CRS and poor sleep quality have been reported. This 10-year follow-up study investigates possible associations between incident CRS and sleep quality. METHODS: A questionnaire was sent to 16,500 individuals in Sweden, Norway, Denmark, Iceland and Estonia in 2000. It included questions on airway diseases, age, sex, body mass index, smoking habits, comorbidities, education and sleep quality. In 2010, a second questionnaire was sent to the same individuals, with a response rate of 53%. A subgroup of 5,145 individuals without nasal symptoms in 2000 was studied. Multiple logistic regression was performed to examine associations between CRS (defined according to the European position paper on rhinosinusitis and nasal polyps epidemiological criteria) at follow-up and sleep quality, with adjustment for potential confounders. Individuals with the respective sleep problem at baseline were excluded. RESULTS: Over 10 years, 141 (2.7%) of the individuals without nasal symptoms in 2000 had developed CRS. CRS was associated with difficulties inducing sleep (adjusted odds ratio 2.81 [95% CI 1.67-4.70]), difficulties maintaining sleep (2.07 [1.35-3.18]), early morning awakening (3.03 [1.91-4.81]), insomnia (2.21 [1.46-3.35]), excessive daytime sleepiness (2.85 [1.79-4.55]), and snoring (3.31 [2.07-5.31]). Three insomnia symptoms at baseline increased the risk of CRS at follow-up by 5.00 (1.93-12.99). CONCLUSIONS: Incident CRS is associated with impaired sleep quality and excessive daytime sleepiness. Insomnia symptoms may be a risk factor for the development of CRS.

[New possibilitys in surgery for brain tumors with intraoperative MRI]. / Intraoperativ MRT ger nya möjligheter för neurokirurgi.

In surgery for brain tumors, the main challenge is to resect the tumor completely without causing injury to surrounding structures. Intraoperative MRI can provide updated information on remaining tumor and the relationship to critical brain structures. We report our initial experiences from an intraoperative 3 T MRI suite from a surgical, radiological and anesthesiological perspective. The technique has been useful in treating pediatric brain tumor patients, pituitary tumors, low-grade gliomas and epilepsy surgery patients. Image quality has been comparable to conventional diagnostic MRI and there have been no adverse events from the technique. Team-based training and simulation are key factors to manage this complex technical environment and make intraoperative MRI into a routine procedure.

Cranial Nerve Coactivation and Implication for Nerve Transfers to the Facial Nerve.

In reanimation surgery, effortless smile can be achieved by a nonfacial donor nerve. The underlying mechanisms for this smile development, and which is the best nonfacial neurotizer, need further clarification. The aim of the present study was therefore to further explore the natural coactivation between facial mimic muscles and muscles innervated by the most common donor nerves used in smile reanimation. The study was conducted in 10 healthy adults. Correlation between voluntary facial muscle movements and simultaneous electromyographic activity in muscles innervated by the masseter, hypoglossal, and spinal accessory nerves was assessed. The association between voluntary movements in the latter muscles and simultaneous electromyographic activity in facial muscles was also studied. Smile coactivated the masseter and tongue muscles equally. During the seven mimic movements, the masseter muscle had fewer electromyographically measured coactivations compared with the tongue (two of seven versus five of seven). The trapezius muscle demonstrated no coactivation during mimic movements. Movements of the masseter, tongue, and trapezius muscles induced electromyographically recorded coactivation in the facial muscles. Bite resulted in the strongest coactivation of the zygomaticus major muscle. The authors demonstrated coactivation between voluntary smile and the masseter and tongue muscles. During voluntary bite, strong coactivation of the zygomaticus major muscle was noted. The narrower coactivation pattern in the masseter muscle may be advantageous for central relearning and the development of a spontaneous smile. The strong coactivation between the masseter muscle and the zygomaticus major indicates that the masseter nerve may be preferred in smile reanimation.

fMRI after Phalloplasty with Nerve Anastomosis in a Trans-Man Patient.

We report on a case of a trans-man patient, who underwent penile reconstruction with the use of a radial forearm flap, urethroplasty, vaginectomy and scrotoplasty, insertion of testicle implants, and penile erection implants, similar to previously described methods. One of the requirements for an ideal phalloplasty is the preservation of erogenous sensitivity, which is often demanded by the patients for fulfilling their sexual well-being. For the first time known to us, we use a functional magnetic resonance imaging following radial forearm flap phalloplasty with nerve anastomosis to assess the cortical activation after clitoral stimulation. The patient was poked with a plastic pen on the neophallus and the groin. Regular block design with T1 and BOLD-T2* images were used. The results contradict the classic Penfield and Rasmussen homunculus, that is, the activations in the primary somatosensory cortex (S1) were bilateral with a left-sided dominance in the lateral parts of the medial postcentral gyrus (same region as the groin), and no activations were observed in the mesial parts of the postcentral gyrus. We also reported bilateral activations with a left-sided dominance in the secondary somatosensory cortex (S2) and near Broca's area at the sylvian fissure just posterior to ramus ascendens. Our findings are similar to previous studies reporting on imaging related to genital sensitivity.

Chronic Rhinosinusitis Impairs Sleep Quality: Results of the GA2LEN Study.

Study objectives: To analyze the prevalence of sleep problems in subjects with Chronic rhinosinusitis (CRS) and to determine whether the disease severity of CRS affects sleep quality. Methods: Questionnaires were sent to a random sample of 45 000 adults in four Swedish cities. Questions on CRS, asthma, allergic rhinitis, co-morbidities, tobacco use, educational level, and physical activity were included. CRS was defined according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) epidemiological criteria. The disease severity of CRS was defined by the number of reported CRS symptoms. Sleep quality was assessed using the Basic Nordic Sleep Questionnaire. Results: Of the 26 647 subjects, 2249 (8.4%) had CRS. Reported sleep problems were 50%-90% more common among subjects with CRS compared with those without or the total population. The prevalence of reported sleep problems increased in conjunction with the severity of CRS. After adjusting for gender, BMI, age, tobacco use, asthma, somatic diseases, physical activity level, and educational level, participants with four symptoms of CRS (compared with subjects without CRS symptoms) displayed a higher risk of snoring (adj. OR [95% CI]: 3.13 [2.22-4.41]), difficulties inducing sleep (3.98 [2.94-5.40]), difficulties maintaining sleep (3.44 [2.55-4.64]), early morning awakening (4.71 [3.47-6.38]) and excessive daytime sleepiness (4.56 [3.36-6.18]). The addition of persistent allergic rhinitis to CRS further increased the risk of sleep problems. Conclusions: Sleep problems are highly prevalent among subjects with CRS. The disease severity of CRS negatively affects sleep quality.

Impact of nasal obstruction on sleep quality: a community-based study of women.

The aim of the study was to analyse the impact of self-reported nasal obstruction on sleep quality in women. A community-based sample of 400 women underwent a full night of polysomnography. Airway diseases, allergies and sleep-related symptoms were assessed by questionnaires. Women with subjective nasal obstruction were subdivided into three groups: persistent nasal obstruction (PNO, n = 46), hay fever (n = 88) and nasal obstruction at night (NON, n = 30). Sleep problems and related daytime symptoms were most prevalent among women with NON. After adjusting for age, BMI, smoking and asthma, NON was an independent predictor of 'Difficulties inducing sleep due to nasal obstruction' [adjusted odds ratio (95 % CI): 89.5 (27.0-296.7)], 'Snoring' [4.2 (1.7-10.2)], 'Sweating at night' [2.6 (1.1-6.1)], 'Difficulties maintaining sleep' [2.7 (1.2-6.2)], and 'Waking up hastily gasping for breath' [32.2 (8.7-119.1)]. 'Dry mouth on awakening' [7.7 (3.2-18.4)], 'Waking up unrefreshed' [2.7 (1.2-6.0)], 'Excessive daytime sleepiness' [2.6 (1.1-6.0)], and 'Daytime nasal obstruction' [12.2 (4.8-31.2)] were also associated with NON. Persistent nasal obstruction and hay fever were both associated with some reported sleep problems due to an overlap with NON. When women with NON were excluded, only 'Daytime nasal obstruction' was still significantly associated with PNO, while hay fever was associated with 'Daytime nasal obstruction' and 'Waking up hastily gasping for breath'. There were no significant differences in objectively measured sleep variables between any of the three subgroups and the study cohort. Self-reported nasal obstruction at night in women has a significant effect on several subjective day- and nighttime symptoms, but it does not appear to affect objectively measured sleep quality.

Interleukin-6 concentrations in the urine and dipstick analyses were related to bacteriuria but not symptoms in the elderly: a cross sectional study of 421 nursing home residents.

BACKGROUND: Up to half the residents of nursing homes for the elderly have asymptomatic bacteriuria (ABU), which should not be treated with antibiotics. A complementary test to discriminate between symptomatic urinary tract infections (UTI) and ABU is needed, as diagnostic uncertainty is likely to generate significant antibiotic overtreatment. Previous studies indicate that Interleukin-6 (IL-6) in the urine might be suitable as such a test. The aim of this study was to investigate the association between laboratory findings of bacteriuria, IL-6 in the urine, dipstick urinalysis and newly onset symptoms among residents of nursing homes. METHODS: In this cross sectional study, voided urine specimens for culture, urine dipstick and IL-6 analyses were collected from all residents capable of providing a voided urine sample, regardless of the presence of symptoms. Urine specimens and symptom forms were provided from 421 residents of 22 nursing homes. The following new or increased nonspecific symptoms occurring during the previous month were registered; fatigue, restlessness, confusion, aggressiveness, loss of appetite, frequent falls and not being herself/himself, as well as symptoms from the urinary tract; dysuria, urinary urgency and frequency. RESULTS: Recent onset of nonspecific symptoms was common among elderly residents of nursing homes (85/421). Urine cultures were positive in 32% (135/421), Escherichia coli was by far the most common bacterial finding. Residents without nonspecific symptoms had positive urine cultures as often as those with nonspecific symptoms with a duration of up to one month. Residents with positive urine cultures had higher concentrations of IL-6 in the urine (p < 0.001). However, among residents with positive urine cultures there were no differences in IL-6 concentrations or dipstick findings between those with or without nonspecific symptoms. CONCLUSIONS: Nonspecific symptoms among elderly residents of nursing homes are unlikely to be caused by bacteria in the urine. This study could not establish any clinical value of using dipstick urinalysis or IL-6 in the urine to verify if bacteriuria was linked to nonspecific symptoms.

The effect of prednisolone on sequelae in Bell's palsy.

OBJECTIVE: To study whether prednisolone reduces sequelae in Bell's palsy. DESIGN: Prospective, randomized, double-blind, placebo-controlled, multicenter trial with 12 months of follow-up. SETTING: Seventeen referral centers. PATIENTS: In all, 829 patients aged 18 to 75 years. INTERVENTIONS: Randomization within 72 hours in a factorial fashion to placebo plus placebo (n = 206); prednisolone, 60 mg/d for 5 days, with the dosage then tapered for 5 days, plus placebo (n = 210); valacyclovir hydrochloride, 1000 mg 3 times daily for 7 days, plus placebo (n = 207); or prednisolone plus valacyclovir (n = 206). MAIN OUTCOME MEASURES: Facial function at 12 months assessed with the Sunnybrook and House-Brackmann grading systems. RESULTS: In 184 of the 829 patients, the Sunnybrook score was less than 90 at 12 months; 71 had been treated with prednisolone and 113 had not (P < .001). In 98 patients, the Sunnybrook score was less than 70; 33 had received prednisolone and 65 had not (P < .001). The difference between patients who received prednisolone and who did not in House-Brackmann gradings higher than I and higher than II was also significant (P < .001 and P = .01, respectively). No significant difference was found between patients who received prednisolone and those who did not in Sunnybrook scores less than 50 (P = .10) or House-Brackmann grades higher than III (P = .80). Synkinesis was assessed with the Sunnybrook score in 743 patients. Ninety-six patients had a synkinesis score more than 2, of whom 33 had received prednisolone and 63 had not (P = .001). Sixty patients had a synkinesis score more than 4, of whom 22 had received prednisolone and 38 had not (P = .005). CONCLUSION: Prednisolone significantly reduces mild and moderate sequelae in Bell's palsy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00510263.

Sunnybrook and House-Brackmann systems in 5397 facial gradings.

OBJECTIVES: To study the correlation between Sunnybrook and House-Brackmann facial grading systems at different time points during the course of peripheral facial palsy. STUDY DESIGN: Prospective multicenter trial. SETTING: Seventeen otorhinolaryngological centers. SUBJECTS AND METHODS: Data are part of the Scandinavian Bell's palsy study. The facial function of 1920 patients with peripheral facial palsy was assessed 5397 times with both Sunnybrook and House-Brackmann (H-B) facial grading systems. Grading was done at initial visit, at days 11 to 17 of palsy onset, and at 1 month, 2 months, 3 months, 6 months, and 12 months. Statistical evaluation was by Spearman correlation coefficient and box plot analysis. RESULTS: Spearman correlation coefficient varied from -0.81 to -0.96, with the weakest correlation found at initial visit. Box plot analysis for all assessments revealed that Sunnybrook scores were widely spread over different H-B grades. With 50% of the results closest to the median, Sunnybrook composite scores varied in H-B grades as follows: H-B I, 100; H-B II, 71 to 90; H-B III, 43 to 62; H-B IV, 26 to 43; H-B V, 13 to 25; and H-B VI, 5 to 14. CONCLUSION: Gradings correlated better in follow-up assessments than at initial visit. As shown by the wide overlap of the grading results, subjective grading systems are only approximate. However, a conversion table for Sunnybrook and H-B gradings was obtained and is included in the article. It can be used for further development of facial grading systems.

Successful epilepsy surgery in a patient with neurosarcoidosis.

This case concerns a patient with generalized neurosarcoidosis and pharmacoresistant focal epilepsy. Although immunosuppressive therapy resulted in remission of the neurosarcoidosis, seizures continued and were shown to originate from the right temporal lobe (TL). The patient underwent a right anterior temporal lobe resection (TLR) and obtained >90% reduction of seizure frequency.

Short-term clinical results of Nobel Direct implants: a retrospective multicentre analysis.

PURPOSE: The present retrospective clinical study was undertaken to evaluate the survival rate and marginal bone conditions around Nobel Direct one-piece implants. The purpose was also to compare the results with when these implants are used for immediate/early loading with implants allowed to heal before loading. MATERIAL AND METHODS: Forty-three consecutive patients previously treated with 117 Nobel Direct implants at four different centres were evaluated. The implants had been used in both jaws for treatment after loss of single and multiple teeth. Immediate/early loading (within 2 weeks) with a provisional crown/bridge was applied to 95 implants, while 22 implants healed unloaded for 6 weeks to 6 months before loading. Calculations of marginal bone loss were performed in radiographs taken at placement and after an average of 10.2 months (range 1-18 months) of loading. RESULTS: Six (5.1%) of the 117 implants were removed during the follow up. All failed implants belonged to the immediate/early loading group giving a failure rate of 6.3% for this group and 0% for two-stage implants. The failure rate was higher for flapless (7.9%) than for flap surgery (0%). The marginal bone loss was -2.4 mm (SD 1.5) for all implants, while 37.6% showed more than 3 mm of loss during the follow up. Bone loss increased with time of follow up. Implants subjected to immediate/early loading showed more bone loss than two-stage implants: -2.6 mm (SD 1.5) vs. -1.6 mm (SD 1.1). Moreover, 41.3% of immediately loaded and 22.7% of two-stage implants presented with more than 3 mm of bone loss. CONCLUSIONS: This short-term retrospective analysis showed a poor clinical outcome of Nobel Direct implants. Extensive marginal bone loss (>3 mm) was found around more than 1/3 of the implants evaluated. Less resorption and no failures were experienced when implants were allowed to heal from 6 weeks to 6 months before occlusal loading. Within the limitations of the present study design, data indicate that immediate loading, the use of this implant for multi-unit constructions and flapless surgery are risk factors for failure of Nobel Direct implants.

Intersubject variability in the anterior extent of the optic radiation assessed by tractography.

INTRODUCTION: Temporal lobe resection for epilepsy involves a risk of damaging the anterior part of the optic radiation, Meyer's loop, causing a contralateral upper quadrant visual field defect. This study aims to assess the intersubject variability in the course of Meyer's loop in vivo by diffusion tensor imaging and tractography. METHODS: Seven healthy volunteers and two patients with previous temporal lobe resection were recruited. Diffusion tensor imaging and tractography were used to visualize the optic radiation. The distances from the anterior edge of Meyer's loop to landmarks in the temporal lobe were calculated. RESULTS: In the healthy subjects, the mean distance between the most anterior part of Meyer's loop and the temporal pole was 44 mm (range 34-51 mm). Meyer's loop did not reach the tip of the temporal horn in any subject. A disruption in Meyer's loop could be demonstrated in the patient with quadrantanopia after temporal lobe resection. CONCLUSIONS: Meyer's loop has a considerable variability in its anterior extent. Tractography may be a useful method to visualize Meyer's loop, and assess the risk of a visual field defect, prior to temporal lobe resection.