Clinical application of physical therapy in facial paralysis treatment: A review.

This review aims to summarize recent studies regarding the specific modalities of physical therapy as a form of treatment for patients with facial paralysis, analyze the different components of physical therapy, and provide healthcare providers with guidance for their best practice in treating patients with facial paralysis. This paper will discuss the mechanism, indications, and impact factors for facial retraining, evaluate the standards for facial retraining, the creation of a treatment plan, and analyze the combined use of facial retraining with botulinum toxin injections and the application of facial retraining in post facial reanimation patients. Other modes of physical therapy, including electrical stimulation, dry needling, and acupuncture, will be addressed. Lastly, the application of new digital technology will be discussed.

Efficacy of Mirror Biofeedback Rehabilitation on Synkinesis in Acute Stage Facial Palsy in Children.

OBJECTIVES: To evaluate the efficacy of mirror biofeedback rehabilitation for synkinesis in severe acute facial paralysis in children. METHODS: Eight pediatric patients with facial paralysis with an initial electroneurography (ENoG) value less than 10% who underwent mirror biofeedback rehabilitation (the child-rehabilitation group) were enrolled. Seven infants (under age 2 yr) who were unable to undergo rehabilitation (the infant-and-toddler control group) and adult patients (n = 13, range, 33-56 yr) who underwent rehabilitation (the adult-rehabilitation group) comprised the control groups. All the patients enrolled were baseline House-Brackmann (H-B) grade VI at onset. The patients began daily facial biofeedback rehabilitation using a mirror at the first sign of muscle contraction on the affected side and were instructed to keep their eyes symmetrically open using a mirror during mouth movements. The training was continued for 12 months after the onset of facial paralysis. The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry in eye opening width during mouth movements. The synkinesis index was calculated as a percentage of the interpalpebral space width ([normal side - affected side]/normal side). Statistical analyses used non-parametric tests (the Kruskal-Wallis test and Steel-Dwass posthoc test). RESULTS: The synkinesis index was significantly lower in the child-rehabilitation group than in the infant-and-toddler control group or the adult-rehabilitation group (p < 0.001). CONCLUSION: Children who underwent mirror biofeedback rehabilitation had less synkinesis than the infant-and-toddler control group, suggesting that mirror biofeedback rehabilitation is more effective in preventing the exacerbation of synkinesis in children.

Laryngeal Synkinesis: A Viable Condition for Laryngeal Pacing.

Laryngeal synkinesis as a form of defective healing is the rule rather than the exception in persistent vocal fold paralysis. It typically occurs 4-6 months after the onset of the recurrent laryngeal nerve paralysis. The incidence is up to 85%. Not all laryngeal muscles need to be equally affected. Reliable evidence can only be provided by a laryngeal electromyography. Physiological co-activation of the laryngeal muscles during antagonistic maneuvers must be considered. Although synkinesis undeniably worsens the prognosis for a motion recovery, it protects the muscle fibers from degeneration. A differentiation is required between favorable synkinesis (type I according to Crumley), which does not always require further therapy in the case of unilateral paralysis, and unfavorable forms of synkinesis (type II-IV) according to Crumley, which are associated with a functionally relevant malposition of the vocal fold(s) or with vocal fold jerks. Particularly when bilateral vocal fold motion does not return, type I synkinesis can be a good prerequisite for new dynamic therapy approaches, such as laryngeal pacing. The rarely occurring type II-IV synkinesis should, whenever possible, be transformed into a more favorable type I synkinesis by selective or non-selective reinnervation at an early stage of the disease. The latter applies to expected muscle atrophy with insufficient regrowth of nerve fibers.

Electroneurography cannot predict when facial synkinesis develops in patients with facial palsy.

The objective of this study is to clarify when facial palsy patients with lower value of Electroneurography (ENoG) should begin the rehabilitation to prevent the development of facial synkinesis. For this purpose, we examined the relationship between the value of ENoG measured 10-14 days after facial palsy onset and the onset day of the development of oral-ocular synkinesis. Sixteen patients with facial palsy including 11 with Bell's palsy and 5 with Ramsay Hunt syndrome (7 men and 9 women ; 15-73 years old ; mean age, 41.6 years) were enrolled in this study. There was no correlation between ENoG value and the onset day of the development of oral-ocular synkinesis (ρ = .09, p = .73). Oral-ocular synkinesis began to develop in 4.0 ±â€…0.7 months (mean ±â€…SD ; range : 3.1-5.0 months) after facial palsy onset regardless of ENoG value. In conclusion, ENoG value cannot predict when facial synkinesis develops in patients with facial palsy. We recommend that facial palsy patients with a high risk for the development of synkinesis begin the biofeedback rehabilitation with mirror to prevent the development of facial synkinesis 3 months after facial palsy onset. J. Med. Invest. 67 : 87-89, February, 2020.

Tolerability of facial electrostimulation in healthy adults and patients with facial synkinesis.

PURPOSE: To evaluate optimal stimulation parameters with regard to discomfort and tolerability for transcutaneous electrostimulation of facial muscles in healthy participants and patients with postparetic facial synkinesis. METHODS: Two prospective studies were performed. First, single pulse monophasic stimulation with rectangular pulses was compared to triangular pulses in 48 healthy controls. Second, 30 healthy controls were compared to 30 patients with postparetic facial synkinesis with rectangular pulse form. Motor twitch threshold, tolerability threshold, and discomfort were assessed using a numeric rating scale at both thresholds. RESULTS: Discomfort at motor threshold was significantly lower for rectangular than for triangular pulses. Average motor and tolerability thresholds were higher for patients than for healthy participants. Discomfort at motor threshold was significantly lower for healthy controls compared to patients. Major side effects were not seen. CONCLUSIONS: Surface electrostimulation for selective functional and tolerable facial muscle contractions in patients with postparetic facial synkinesis is feasible.

Altered facial muscle innervation pattern in patients with postparetic facial synkinesis.

OBJECTIVES/HYPOTHESIS: Using surface electrostimulation, we aimed to use facial nerve mapping (FNM) in healthy subjects and patients with postparetic facial synkinesis (PPFS) to define functional facial target regions that can be stimulated selectively. STUDY DESIGN: Single-center prospective cohort study. METHODS: FNM was performed bilaterally in 20 healthy subjects and 20 patients with PPFS. Single-pulse surface FNM started at the main trunk of the facial nerve and followed the peripheral branches in a distal direction. Stimulation started with 0.1 mA and increased in 0.1 mA increments. The procedure was simultaneously video recorded and evaluated offline. RESULTS: A total of 1,873 spots were stimulated, and 1,875 facial movements were evaluated. The stimulation threshold was higher on the PPFS side (average = 9.8 ± 1.0 mA) compared to the contralateral side (4.1 ± 0.8 mA) for all stimulation sites or compared to healthy subjects (4.1 ± 0.5 mA; all P < .01). In healthy subjects, selective electrostimulation ± one unintended coactivation was possible at all sites in >80% of cases, with the exception of pulling up the corner of the mouth (65%-75%). On the PPFS side, stimulation was possible for puckering lips movements in 60%/75% (selective stimulation ± one coactivation, respectively), blinking in 55%/80%, pulling up the corner of the mouth in 50%/85%, brow raising in 5%/85, and raising the chin in 0%/35% of patients, respectively. CONCLUSIONS: FNM mapping for surgical planning and selective electrostimulation of functional facial regions is possible even in patients with PPFS. FNM may be a tool for patient-specific evaluation and placement of electrodes to stimulate the correct nerve branches in future bionic devices (e.g., for a bionic eye blink). LEVEL OF EVIDENCE: 2b Laryngoscope, 130:E320-E326, 2020.

Toward the Bionic Face: A Novel Neuroprosthetic Device Paradigm for Facial Reanimation Consisting of Neural Blockade and Functional Electrical Stimulation.

BACKGROUND: Facial palsy is a devastating condition potentially amenable to rehabilitation by functional electrical stimulation. Herein, a novel paradigm for unilateral facial reanimation using an implantable neuroprosthetic device is proposed and its feasibility demonstrated in a live rodent model. The paradigm comprises use of healthy-side electromyographic activity as control inputs to a system whose outputs are neural stimuli to effect symmetric facial displacements. The vexing issue of suppressing undesirable activity resulting from aberrant neural regeneration (synkinesis) or nerve transfer procedures is addressed using proximal neural blockade. METHODS: Epimysial and nerve cuff electrode arrays were implanted in the faces of Wistar rats. Stimuli were delivered to evoke blinks and whisks of various durations and amplitudes. The dynamic relation between electromyographic signals and facial displacements was modeled, and model predictions were compared against measured displacements. Optimal parameters to achieve facial nerve blockade by means of high-frequency alternating current were determined, and the safety of continuous delivery was assessed. RESULTS: Electrode implantation was well tolerated. Blinks and whisks of tunable amplitudes and durations were evoked by controlled variation of neural stimuli parameters. Facial displacements predicted from electromyographic input modelling matched those observed with a variance-accounted-for exceeding 96 percent. Effective and reversible facial nerve blockade in awake behaving animals was achieved, without detrimental effect noted from long-term continual use. CONCLUSIONS: Proof-of-principle of rehabilitation of hemifacial palsy by means of a neuroprosthetic device has been demonstrated. The use of proximal neural blockade coupled with distal functional electrical stimulation may have relevance to rehabilitation of other peripheral motor nerve deficits.

The Contribution of Surface Electromyographic Assessment for Defining the Stage of Peripheral Facial Paralysis: Flaccid or Sequelae Stage

Abstract Introduction Surface electromyographic activity may not be symmetric, even in subjects with no facial paralysis history. Objective To evaluate the contribution of the index of electromyographic (IEMG) activity in the identification of the two extremes of the facial paralysis course. Methods Thirty-four subjects with unilateral peripheral facial paralysis were selected. A control group was composed of volunteers without a history of facial paralysis. The electromyographic assessment of the facial muscle was performed by placing surface electrodes during movements of the forehead, eyes and lips using MIOTEC equipment, such as the MIOTOOL (Miotec, Porto Alegre, Brazil) software. The electromyographic activity was also recorded in other channels during the primary activity to identify the presence of synkinesis. The statistical analysis was performed using the Statistical Package for Social Sciences for Macintosh (SPSS Inc, Chicago, IL, USA). The IEMG activity was obtained from the division of the electromyographic activity root mean square (RMS) values on both sides. Results There was a statistically significant difference among the groups in all the analyzed indexes. The ocular-oral synkinesis in all patients must be correctly identified (with 100% sensitivity and specificity) using an IEMG activity of 1.62 as a cutoff point. The oral-ocular synkinesis must be correctly identified (93.3% sensitivity and 95.9% specificity) using the IEMG activity of 1.79 as a cutoff point. Conclusion The IEMG activity is below the normal scores in patients in the flaccid stage, whereas patients in the sequelae stage can either show normal values or values above or below the normal scores. The IEMG activity was shown to have high sensitivity and specificity in the identification of synkinesis.

Recovery of facial expressions using functional electrical stimulation after full-face transplantation.

BACKGROUND: We assessed the recovery of 2 face transplantation patients with measures of complexity during neuromuscular rehabilitation. Cognitive rehabilitation methods and functional electrical stimulation were used to improve facial emotional expressions of full-face transplantation patients for 5 months. Rehabilitation and analyses were conducted at approximately 3 years after full facial transplantation in the patient group. We report complexity analysis of surface electromyography signals of these two patients in comparison to the results of 10 healthy individuals. METHODS: Facial surface electromyography data were collected during 6 basic emotional expressions and 4 primary facial movements from 2 full-face transplantation patients and 10 healthy individuals to determine a strategy of functional electrical stimulation and understand the mechanisms of rehabilitation. A new personalized rehabilitation technique was developed using the wavelet packet method. Rehabilitation sessions were applied twice a month for 5 months. Subsequently, motor and functional progress was assessed by comparing the fuzzy entropy of surface electromyography data against the results obtained from patients before rehabilitation and the mean results obtained from 10 healthy subjects. RESULTS: At the end of personalized rehabilitation, the patient group showed improvements in their facial symmetry and their ability to perform basic facial expressions and primary facial movements. Similarity in the pattern of fuzzy entropy for facial expressions between the patient group and healthy individuals increased. Synkinesis was detected during primary facial movements in the patient group, and one patient showed synkinesis during the happiness expression. Synkinesis in the lower face region of one of the patients was eliminated for the lid tightening movement. CONCLUSIONS: The recovery of emotional expressions after personalized rehabilitation was satisfactory to the patients. The assessment with complexity analysis of sEMG data can be used for developing new neurorehabilitation techniques and detecting synkinesis after full-face transplantation.

Efficacy of Tape Feedback Therapy on Synkinesis Following Severe Peripheral Facial Nerve Palsy.

BACKGROUND: Mirror feedback rehabilitation is effective in preventing the development of oro-ocular synkinesis following severe facial palsy. However, we do not have effective maneuvers to prevent the deterioration of oculo-oral synkinesis. We developed a new method of biofeedback rehabilitation using tape for the prevention of oculo-oral synkinesis. OBJECTIVE: The aim of the present study was to investigate the efficacy of taping feedback rehabilitation. METHODS: Twelve consecutive patients with peripheral facial nerve palsy who developed synkinesis were divided into 2 groups. Six patients were treated with the new training method, and the remaining 6 patients were treated with conventional therapy as controls. In the experiment group, tape was placed around the mouth, and the patient was instructed to close the eyes so that no movements of the mouth would be perceived from sensations of the taped skin. After 4 weeks of training, facial movements were recorded and movie images were graded for mouth synkinesis using the revised Sunnybrook facial grading system by examiners blinded to patient grouping. RESULTS: Mouth corner contraction during eye closure was significantly weaker in the experimental group than in the control group. CONCLUSIONS: Our new feedback method could help prevent the deterioration of oculo-oral synkinesis.

Current Treatment Options for Bilateral Vocal Fold Paralysis: A State-of-the-Art Review

Vocal fold paralysis (VFP) refers to neurological causes of reduced or absent movement of one or both vocal folds. Bilateral VFP (BVFP) is characterized by inspiratory dyspnea due to narrowing of the airway at the glottic level with both vocal folds assuming a paramedian position. The primary objective of intervention for BVFP is to relieve patients’ dyspnea. Common clinical options for management include tracheostomy, arytenoidectomy and cordotomy. Other options that have been used with varying success include reinnervation techniques and botulinum toxin (Botox) injections into the vocal fold adductors. More recently, research has focused on neuromodulation, laryngeal pacing, gene therapy, and stem cell therapy. These newer approaches have the potential advantage of avoiding damage to the voicing mechanism of the larynx with an added goal of restoring some physiologic movement of the affected vocal folds. However, clinical data are scarce for these new treatment options (i.e., reinnervation and pacing), so more investigative work is needed. These areas of research are expected to provide dramatic improvements in the treatment of BVFP.

Long-term facial improvement after repeated BoNT-A injections and mirror biofeedback exercises for chronic facial synkinesis: a case-series study.

BACKGROUND: Only few studies have considered the effects of the combined treatment with onabotulinumtoxinA (BoNT-A) injections and biofeedback (BFB) rehabilitation in the recovery of postparetic facial synkinesis (PPFS). AIM: To explore the presence of a persistent improvement in facial function out of the pharmacological effect of BoNT-A in subjects with established PPFS, after repeated sessions of BoNT-A injections combined with an educational facial training program using mirror biofeedback (BFB) exercises. Secondary objective was to investigate the trend of the presumed persistent improvement. STUDY DESIGN: Case-series study. SETTING: Outpatient Clinic of Physical Medicine and Rehabilitation Unit. POPULATION: Twenty-seven patients (22 females; mean age 45±16 years) affected by an established peripheral facial palsy, treated with a minimum of three BoNT-A injections in association with mirror BFB rehabilitation. The interval between consecutive BoNT-A injections was at least five months. METHODS: At baseline and before every BoNT-A injection+mirror BFB session (when the effect of the previous BoNT-A injection had vanished), patients were assessed with the Italian version of Sunnybrook Facial Grading System (SB). The statistical analysis considered SB composite and partial scores before each treatment session compared to the baseline scores. RESULTS: A significant improvement of the SB composite and partial scores was observed until the fourth session. Considering the "Symmetry of Voluntary Movement" partial score, the main improvement was observed in the muscles of the lower part of the face. CONCLUSIONS: In a chronic stage of postparetic facial synkinesis, patients may benefit from a combined therapy with repeated BoNT-A injections and an educational facial training program with mirror BFB exercises, gaining an improvement of the facial function up to the fourth session. This improvement reflects the acquired ability to use facial muscle correctly. It doesn't involve the injected muscles but those trained with mirror biofeedback exercises and it persists also when BoNT-A action has vanished. CLINICAL REHABILITATION IMPACT: The combined therapy with repeated BoNT-A injections and an educational facial training program using mirror BFB exercises may be useful in the motor recovery of the muscles of the lower part of the face not injected but trained.

Prevention of synkinesis by biofeedback therapy: a randomized clinical trial.

OBJECTIVE: The aim of present study was to find a better procedure to prevent synkinesis in facial nerve palsy. DESIGN: A randomized clinical trial. SETTING: Clinical rehabilitation faculty and general rehabilitation centers. SUBJECTS: Twenty- nine patients with facial nerve palsy were selected via electrodiagnosis tests. INTERVENTION: The experimental group (n = 16) was treated with biofeedback electromyography, whereas the control group (n = 13) received common physiotherapy. All patients received 1-year treatment. MAIN OUTCOME MEASURES: Evaluation of facial grading scale before and after treatment and severity of synkinesia. RESULTS: At the end of treatment, there was a rise in facial grading system in both groups compared with baseline (p < 0.05, paired t test). There were significant differences in the facial grading system between 2 groups at the end of the study, but the experimental group showed better result than the other one. The number of patients with synkinesis and the severity of their synkinesis in the experimental group were lesser than those of the control group. CONCLUSION: Biofeedback therapy is more efficient than common physiotherapy. By using this approach, controlling and reducing synkinesis is more feasible.

Therapeutic strategies in post-facial paralysis synkinesis in pediatric patients.

UNLABELLED: Synkinetic movements comprise abnormal involuntary contractions of one or more facial muscle groups which follow the desired contraction of another facial muscle group. They are frequently encountered in patients with long standing facial paralysis and seriously affect their psychological status due to the impairment of their facial appearance, function and emotional expressivity. PATIENTS AND METHODS: Eleven pediatric patients (2 male and 9 female) presenting with post-facial paralysis synkinesis were included in the study. Mean age was 10.3±4 years and mean denervation time 72.5 months. RESULTS: Patients underwent the following types of treatment: --Cross facial nerve grafting (CFNG) and secondary microcoaptations with botulinum toxin injection which had an improvement of 100% (3 in the 3 grade synkinesis scale) (n=2). --Cross facial nerve grafting (CFNG) and secondary microcoaptations without botulinum toxin injection which had an improvement of 66%(2 in the 3 grade synkinesis scale) (n=5). --CFNG and direct muscle neurotization with (n=2) or without (n=1) botulinum toxin injection where the improvement was 33%. --Contralateral nasalis muscle myectomy was performed in one patient along with CFNG and secondary microcoaptations which resulted in 66% synkinesis improvement. Biofeedback was invariably undertaken by all patients. Postoperative improvement in eye closure and smile was also noted in the respective cases treated for synkinesis ranging from 25 to 50%, with all patients achieving optimum functional return. CONCLUSION: CFNG with secondary microcoaptations and botulinum toxin injections was found to be a very efficient surgical modality addressing post-facial palsy synkinesis with high improvement in facial function and symmetry. Facial neuromuscular re-education contributes considerably in the treatment.

Mirror biofeedback rehabilitation after administration of single-dose botulinum toxin for treatment of facial synkinesis.

OBJECTIVE: The efficacy of facial biofeedback rehabilitation with a mirror after administration of a single dose of botulinum A toxin on facial synkinesis was examined in patients with chronic facial palsy. STUDY DESIGN: Prospective clinical study. SETTING: University hospital. SUBJECTS AND METHODS: The present study includes 8 patients with Bell palsy and 5 with herpes zoster oticus showing facial synkinesis. A single dose of botulinum A toxin was used as the initial process of facial rehabilitation. Patients then continued a daily facial biofeedback rehabilitation with a mirror at home. They were instructed to keep their eyes symmetrically open using a mirror during mouth movements. The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry of eye opening width during mouth movements (% eye opening). RESULTS: After administration of a single dose of botulinum A toxin, temporary relief of facial synkinesis was observed in all patients. Patients were then instructed to continue the facial biofeedback rehabilitation with a mirror for 10 months. The mean values of the percent of eye opening during 3 designated mouth movements that included lip pursing /u:/, teeth baring /i:/, and cheek puffing /pu:/ increased significantly after 10 months when the effects of botulinum A toxin had completely disappeared. CONCLUSION: These findings demonstrate that facial biofeedback rehabilitation with a mirror after administration of a single dose of botulinum A toxin is a long-lasting treatment of established facial synkinesis in patients with chronic facial palsy.

Efficacy of functional training of the facial muscles for treatment of incomplete peripheral facial nerve injury.

OBJECTIVE: To investigate the efficacy of functional training of facial mimic muscles for patients with incomplete peripheral facial nerve injury. METHODS: Ninety-two patients with 241 injured branches of incomplete peripheral facial nerve injury were divided into a treatment group and a control group. The treatment group consisted of 58 cases that received functional training of facial mimic muscles. The rest of the cases served as controls. Assessment parameters included the House-Brackmann grading system, a quantitative facial nerve function estimating system and electroneurography. According to the three assessments, the facial nerve injury was divided into four grades: normal, minor, moderate and severe. The treatment group started training facial mimic muscle activity 2 weeks after facial nerve injury. After follow-ups of 1 to 4 years, the outcomes were statistically analysed. RESULTS: In the minor facial nerve injury group, there was no significant difference in the time needed for initial recovery (Ti, the time needed for significant recovery of the facial nerve function after injury) and final recovery (Tf, the time point after which no further improvement of facial nerve function was obtained) between the two groups (P > 0.05). No adverse effect was found in these cases. In the moderate facial nerve injury group, the Ti and Tf of the treatment group were shorter than those of the control group (P < 0.05). One case had synkinesis. In the patients with severe facial nerve injury, the recovery rate of facial nerve function in the treatment group was higher than that of the control group and the sequelae were less. CONCLUSION: Functional training of facial mimic muscles cannot shorten the time of recovery for the patients with minor facial nerve injury but it can speed up the recovery and reduce the undesirable sequelae such as synkinesis and hemifacial spasm for the patients with moderate and severe facial nerve injury.

Management of synkinesis.

Facial synkinesis is one of the most distressing consequences of facial paralysis. Synkinesis refers to the abnormal involuntary facial movement that occurs with voluntary movement of a different facial muscle group. The pathophysiologic basis of facial synkinesis is likely multifactorial although the predominant mechanism appears to be aberrant regeneration of facial nerve fibers to the facial muscle groups after facial nerve injury. Patients experience hypertonic contractures and synkinetic movements such as eye closure with volitional movement of the mouth or midfacial movement during volitional or reflexive eye closure. Synkinesis can cause functional limitation with activities such as eating, drinking, smiling, and may even lead to social isolation. Evaluation of synkinesis is primarily subjective with facial grading scales such as the Sunnybrook scale. Objective measures of synkinesis using computerized video analysis show promise although no objective techniques are currently widely used. The most common therapeutic modalities for the treatment of facial synkinesis include (1) botulinum toxin type A (BTX-A) injections for selective chemodenervation of affected muscle groups and (2) facial neuromuscular retraining. Biofeedback using mirrors or electromyography has been used both for the treatment and prevention of facial synkinesis. Other treatment options include surgical therapies, such as selective neurolysis or myectomy, although these have been rendered nearly obsolete with the advent of BTX-A.

Usefulness of BFB/EMG in facial palsy rehabilitation.

OBJECTIVE: To analyze and to compare the recovery and the development of synkinesis in patients with idiopathic facial palsy (Bell's palsy) following treatment with two methods of rehabilitation, kinesitherapy (KT) and biofeedback/EMG (BFB/EMG). STUDY DESIGN: Retrospective cases--series review. METHODS: Seventy-four patients with Bell' palsy were clinically evaluated within 1 month from onset of palsy and at 12 months after palsy (House scale and synkinesis evaluation). Electromyography (EMG) and Electroneurography (ENG) were performed about 4 weeks after palsy to better evaluate functional abnormalities due to facial nerve lesion. The patients followed two different protocols for rehabilitation: the first 32 patients were treated with therapeutic exercises performed by therapists (KT group), the latter 42 patients were treated using BFB/EMG methods (BFB group) with inhibition of synkinetic movement as the primary goal. RESULTS: KT and BFB patients were evaluated for clinical and neurophysiological characteristics before rehabilitative treatment. BFB patients showed better clinical recovery and minor synkinesis than KT patients. CONCLUSIONS: BFB/EMG seems to be more useful than KT in Bell's palsy treatment. This could be due to the fact that BFB/EMG gives more accurate information than KT on muscle activation with better modulation in voluntary recruitment of motor unit.

Neuromotor functions in Inuit preschool children exposed to Pb, PCBs, and Hg.

The aim of this study was to examine the effects of prenatal and postnatal chronic exposure to mercury (Hg), polychlorinated biphenyls (PCBs) and lead (Pb) on the neuromotor development of preschool children. The study population consisted of 110 preschool Inuit children from Nunavik (Canada). Blood Hg, PCBs and Pb concentrations were measured at birth (cord blood) and at the time of testing. Gross motor functions were evaluated and a neurological examination was performed. Fine neuromotor performance was assessed using quantitative measures of postural hand tremor, reaction time, sway oscillations, as well as alternating and pointing movements. Potential covariates were documented including demographic and familial characteristics, other prenatal neurotoxicants (alcohol, tobacco) and nutrients (selenium (Se), Omega-3 polyunsaturated fatty acids (n-3 PUFA)). Hierarchical multivariate regression analyses were performed, controlling for significant covariates. Gross motor development was not linked to prenatal exposures. However, significant associations were observed between blood Pb concentration at testing time and changes in reaction time, sway oscillations, alternating arm movements and action tremor. For some of these outcomes, neuromotor effects of Pb exposure are observed at blood concentrations below 10 microg/dl. Negative effects of PCBs on neuromotor development were not clearly observed, neither were the potential beneficial effects of n-3 PUFA and selenium. Tremor amplitude was related to blood Hg concentrations at testing time, which corroborate an effect already reported among adults.

A Case of Oculostapedial Synkinesis Following Bell's Palsy / 대한이비인후과학회지

Oculostapedial synkinesis following Bell's palsy, Ramsay Hunt syndrome and traumatic facial nerve paralysis is a rarely reported phenomenon. Oculostapedial synkinesis accompanying with hemifacial spasm also has been reported. We experienced a 51-year-old woman with persistent loud rumbling noise from her left ear related with voluntary left eye closure compatible with oculostapedial synkinesis after Bell's palsy. We objectively proved this oculostapedial synkinesis with impedance audiometry. The patient was successfully treated by transmeatal tenotomy of the left stapedius muscle tendon under local anesthesia.