Association Between Thyroid-Stimulating Hormone Level and Bell's Palsy.

OBJECTIVE: To investigate whether dysregulated thyroid hormone function is associated with Bell's palsy. STUDY DESIGN: Cross-sectional. SETTING: Electronic medical record database of Clalit Health Services (CHS). CHS is an Israeli payer-provider, integrated health care system, serving >4.5 million members (54% of the Israeli population). PATIENTS: Older than 18 years with Bell's palsy, during 2002 to 2019. INTERVENTIONS: None. METHODS: A total of 1,374 patients with Bell's palsy who had thyroid-stimulating hormone (TSH) blood levels measured up to 60 days before the palsy were matched (1:2) for age and sex with 2,748 controls who had TSH blood levels and no history of Bell's palsy. RESULTS: Retrospective review of the CHS database, from 2002 to 2019 yielded 11,268 patients with Bell's palsy, of which, 1,374 met the inclusion criteria. Mean age was 57.9 years, and 61.4% were female. A higher percentage of patients in the Bell's palsy group had low TSH (≤0.55 mIU/L) compared with controls (5.7% vs. 3.6%, p < 0.001). Low TSH compared with TSH > 0.55 mIU/L, was independently associated with 1.45-fold increased odds for having Bell's palsy (95% CI 1.11-2.02, p < 0.001), when controlled for age, sex, body mass index, diabetes, hypertension, prior cerebrovascular accident, hemoglobin level, and purchasing thyroid hormone drugs. Among the patients with TSH ≤ 0.55 mIU/L, 95.5% had normal free thyroxin and 97.7% had normal free triiodothyronine levels (subclinical hyperthyroidism). For 47.1% of patients, TSH remained ≤0.55 mIU/L, 3 to 12 months after the Bell's palsy occurred and most patients had normal free thyroxin (95.4%) and normal free triiodothyronine (91.8%). CONCLUSIONS: Subclinical hyperthyroidism is independently associated with Bell's palsy after controlling for multiple confounding factors.

Incidence rate, risk factors, and management of Bell's palsy in the Qurayyat region of Saudi Arabia.

Background: Bell's palsy is an idiopathic facial nerve dysfunction causing temporary paralysis of muscles of facial expression. This study aimed to determine the incidence rate, common risk factors, and preferred treatment by the Saudi patients with Bell's palsy. Method: This cross-sectional study was carried out in the Qurayyat region of Saudi Arabia. The retrospective medical records were searched from 2015-2020 of patients diagnosed with Bell's palsy at Qurayyat General Hospital and King Fahad hospital. A 28-item questionnaire was developed by a team of experts and pre-tested among patients with Bell's palsy before being sent to the eligible participants. The data were analyzed using summary statistics, Chi-square test, Fisher exact test and Likelihood ratio test. Results: We identified 279 cases of Bell's palsy from the medical records of the hospitals from the years 2015 to 2020, accounting for 46.5 cases per year and an incidence rate of 25.7 per 100,000 per year. Out of 279 patients with Bell's palsy, only 171 returned the questionnaire accounting for a response rate of 61.2%. Out of 171 patients with Bell's palsy, females (n = 147, 86.0%) accounted for the majority of cases. The most affected age group among participants with Bell's palsy was 21-30 years (n = 76, 44.4%). There were 153 (89.5%) cases who reported Bell's palsy for the first time. The majority of the participants experienced right-sided facial paralysis (n = 96, 56.1%). Likelihood ratio test revealed significant relationship between exposure to cold air and common cold with age groups (χ 2(6, N = 171) = 14.92, p = 0.021), χ 2(6, N = 171) = 16.35, pp = 0.012 respectively. The post hoc analyses revealed that participants in the age group of 20-31-years were mostly affected due to exposure to cold air and common cold than the other age groups. The main therapeutic approach preferred was physiotherapy (n = 149, 87.1%), followed by corticosteroids and antivirals medications (n = 61, 35.7%), acupressure (n = 35, 20.5%), traditional Saudi herb medicine (n = 32, 18.7%), cauterization by hot iron rod (n = 23, 13.5%), supplementary therapy (n = 2, 1.2%), facial cosmetic surgery (n = 1, 0.6%) and no treatment (n = 1, 0.6%). The most preferred combined therapy was physiotherapy (87.6%) with corticosteroid and antiviral drugs (35.9%), and acupressure (17.6%). Conclusion: The rate of Bell's palsy was approximately 25.7 per 100,000 per year in the Qurayyat region of Saudi Arabia. Exposure to cold air and common cold were the significant risk factors associated with Bell's palsy. Females were predominantly affected by Bell's palsy in the Qurayyat region of Saudi Arabia. Bell's palsy most commonly occurred in the age group 21-30 years. The most favored treatment was physiotherapy following Bell's palsy.

Integrative traditional Korean medicine management, including acupuncture and Chuna-manual therapy, for stroke-related central facial palsy: A study of three case reports.

Central facial palsy, which is a sequela of stroke, is associated with decreased quality of life and psychosocial function. Integrative Korean medicine management, including acupuncture and Chuna-manual therapy, has been used to treat neurological diseases, including facial palsy. We report three cases of central facial palsy patients who had these symptoms over three months after a stroke. They had received rehabilitation treatment for the paralyzed upper and lower extremities. However, as their central facial palsy symptom did not improve, Chuna-manual therapy (SJS nonresistance technique) for facial palsy was started along with acupuncture. Oral region movement improved after four weeks of integrative acupuncture and Chuna-manual therapy. After ten to sixteen weeks of treatment, the facial nerve grading system 2.0 grades improved by one in two cases. In one case, although there was no significant change in the grade, she was satisfied with the results after adding Chuna-manual therapy to acupuncture. There were no adverse events. Integrative management, including acupuncture and Chuna-manual therapy, might be an effective treatment strategy for central facial palsy. Further prospective, controlled studies are warranted.

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.

Tongue strength rehabilitation using biofeedback: a case report. / Reabilitação da força da língua utilizando biofeedback: relato de caso.

This research had the objective of reporting a clinical case in which the rehabilitation of tongue strength with biofeedback strategy was performed. This case report addresses a 20-year-old patient whose orofacial myofunctional evaluation revealed a severe decrease in the force of the anterior third of the tongue and changes in lingual mobility and coordination. The measurement of tongue pressure was performed using the Iowa Oral Performance Instrument (IOPI) during elevation, protrusion and lateralization, and it was verified a reduction in the values ​​obtained in all measured directions, compared with normality patterns. We performed 11 sessions of therapy, with weekly frequency, using a biofeedback strategy that consisted of computer games controlled by the tongue. An instrument embedded in the oral cavity functioned as a joystick as the input method for specific digital games. The patient performed at home the isometric exercises of pressing the tip of the tongue against a spatula, exaggerated retraction of tongue, tongue tapering, and isotonic exercise of touching the commissures and lips alternately, daily. After eight sessions, in relation to the elevation pressure, there was an improvement of 28.6% for the apex and 7.1% for the dorsum. As for protrusion, there was an improvement of 123.5%. In the measurements of left and right lateralization, the values ​​increased 53.8% and 7.4%, respectively. After twelve sessions, it was observed an improvement of 35.7%, 7.4%, 164%, 76.9% and 40.7% in relation to the initial evaluation, for apex elevation, dorsum elevation, protrusion, and lateralization to left and right, respectively. Despite the increase, values ​​recommended in the literature as normal for sex and age were not reached after 12 therapy sessions.

Esta pesquisa teve o objetivo de relatar um caso clínico em que foi realizada a reabilitação da força lingual com estratégia de biofeedback. Trata-se de uma paciente de 20 anos de idade, cuja avaliação miofuncional orofacial evidenciou diminuição grave de força do terço anterior da língua e alterações na mobilidade e na coordenação linguais. A quantificação da pressão lingual foi realizada por meio do Iowa Oral Performance Instrument durante a elevação, a protrusão e a lateralização, tendo se verificado redução nos valores obtidos em todas as direções medidas em comparação aos padrões de normalidade. Foram realizadas 11 sessões de terapia, com frequência semanal, utilizando estratégia de biofeedback que consistia em jogos computacionais acionados pela língua. Um instrumento encaixado na cavidade oral funcionava como um joystick, sendo método de entrada para jogos digitais específicos. Em casa, a paciente realizou exercícios isométricos de pressão de ponta de língua contra espátula, retração exagerada de língua, afilamento lingual e isotônico de tocar comissuras e lábios alternadamente, diariamente. Após oito sessões, em relação à pressão na elevação, houve melhora de 28,6% para o ápice e 7,1% para o dorso. Quanto à protrusão, houve melhora de 123,5%. Nas medidas de lateralizações esquerda e direita, os valores aumentaram 53,8% e 7,4%, respectivamente. Após 12 sessões, percebeu-se melhora, em relação à avaliação inicial, de 35,7%, 7,4%, 164%, 76,9% e 40,7%, para elevação de ápice, de dorso, protrusão, lateralizações esquerda e direita, respectivamente. Apesar do aumento, valores preconizados na literatura, como normalidade para o sexo e a idade, não foram atingidos com 12 sessões.

Reabilitação da força da língua utilizando biofeedback: relato de caso / Tongue strength rehabilitation using biofeedback: a case report

RESUMO Esta pesquisa teve o objetivo de relatar um caso clínico em que foi realizada a reabilitação da força lingual com estratégia de biofeedback. Trata-se de uma paciente de 20 anos de idade, cuja avaliação miofuncional orofacial evidenciou diminuição grave de força do terço anterior da língua e alterações na mobilidade e na coordenação linguais. A quantificação da pressão lingual foi realizada por meio do Iowa Oral Performance Instrument durante a elevação, a protrusão e a lateralização, tendo se verificado redução nos valores obtidos em todas as direções medidas em comparação aos padrões de normalidade. Foram realizadas 11 sessões de terapia, com frequência semanal, utilizando estratégia de biofeedback que consistia em jogos computacionais acionados pela língua. Um instrumento encaixado na cavidade oral funcionava como um joystick, sendo método de entrada para jogos digitais específicos. Em casa, a paciente realizou exercícios isométricos de pressão de ponta de língua contra espátula, retração exagerada de língua, afilamento lingual e isotônico de tocar comissuras e lábios alternadamente, diariamente. Após oito sessões, em relação à pressão na elevação, houve melhora de 28,6% para o ápice e 7,1% para o dorso. Quanto à protrusão, houve melhora de 123,5%. Nas medidas de lateralizações esquerda e direita, os valores aumentaram 53,8% e 7,4%, respectivamente. Após 12 sessões, percebeu-se melhora, em relação à avaliação inicial, de 35,7%, 7,4%, 164%, 76,9% e 40,7%, para elevação de ápice, de dorso, protrusão, lateralizações esquerda e direita, respectivamente. Apesar do aumento, valores preconizados na literatura, como normalidade para o sexo e a idade, não foram atingidos com 12 sessões.

ABSTRACT This research had the objective of reporting a clinical case in which the rehabilitation of tongue strength with biofeedback strategy was performed. This case report addresses a 20-year-old patient whose orofacial myofunctional evaluation revealed a severe decrease in the force of the anterior third of the tongue and changes in lingual mobility and coordination. The measurement of tongue pressure was performed using the Iowa Oral Performance Instrument (IOPI) during elevation, protrusion and lateralization, and it was verified a reduction in the values ​​obtained in all measured directions, compared with normality patterns. We performed 11 sessions of therapy, with weekly frequency, using a biofeedback strategy that consisted of computer games controlled by the tongue. An instrument embedded in the oral cavity functioned as a joystick as the input method for specific digital games. The patient performed at home the isometric exercises of pressing the tip of the tongue against a spatula, exaggerated retraction of tongue, tongue tapering, and isotonic exercise of touching the commissures and lips alternately, daily. After eight sessions, in relation to the elevation pressure, there was an improvement of 28.6% for the apex and 7.1% for the dorsum. As for protrusion, there was an improvement of 123.5%. In the measurements of left and right lateralization, the values ​​increased 53.8% and 7.4%, respectively. After twelve sessions, it was observed an improvement of 35.7%, 7.4%, 164%, 76.9% and 40.7% in relation to the initial evaluation, for apex elevation, dorsum elevation, protrusion, and lateralization to left and right, respectively. Despite the increase, values ​​recommended in the literature as normal for sex and age were not reached after 12 therapy sessions.

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.

Unilateral acne after facial palsy.

We describe a case of unilateral acne which appeared after an episode of facial nerve palsy. An 18-year-old female patient presented with papules and pustules predominantly located on the side where the facial paralysis occurred. The patient suffered right facial paralysis, which was treated with prednisone and kinesiotherapy with massages, electrostimulation, and infrared light. Two weeks later, acne lesions appeared in the area affected by the paralysis. As suggested in other cases of paralysis, including cases of Parkinson's disease and spinal cord injury, an increased sebum excretion rate and the immobility of the affected area are most likely what caused the unilateral acne lesions.

Unilateral acne after facial palsy

Abstract: We describe a case of unilateral acne which appeared after an episode of facial nerve palsy. An 18-year-old female patient presented with papules and pustules predominantly located on the side where the facial paralysis occurred. The patient suffered right facial paralysis, which was treated with prednisone and kinesiotherapy with massages, electrostimulation, and infrared light. Two weeks later, acne lesions appeared in the area affected by the paralysis. As suggested in other cases of paralysis, including cases of Parkinson's disease and spinal cord injury, an increased sebum excretion rate and the immobility of the affected area are most likely what caused the unilateral acne lesions.

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.

Lagophthalmos after facial palsy: current therapeutic options.

As the facial nerve carries sensory, motor and parasympathetic fibres involved in facial muscle innervation, facial palsy results in functional and cosmetic impairment. It can result from a wide variety of causes like infectious processes, trauma, neoplasms, autoimmune diseases, and most commonly Bell's palsy, but it can also be of iatrogenic origin. The main ophthalmic sequel is lagophthalmos. The increased surface exposure increases the risk of keratitis, corneal ulceration, and potentially loss of vision. Treatment options are wide; some are temporary, some permanent. In addition to gold standard and traditional therapies and procedures, new options are being proposed aiming to improve not only lagophthalmos but also the quality of life of these patients.

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.

Bell's palsy in Singapore: a view from the patient's perspective.

INTRODUCTION: Bell's palsy is a well-recognised disease with robust research on its possible aetiologies and epidemiology, but scant information on patients' concerns and concepts regarding the condition is available. We aimed to evaluate the ideas, concerns and expectations of patients with Bell's palsy in Singapore. METHODS: A cross-sectional study was conducted at a single tertiary-care hospital in Singapore. Participants were all patients with newly diagnosed Bell's palsy referred to the otolaryngology department either from the emergency department or by general practitioners. Participants were given a self-administered questionnaire and their facial nerve palsies were graded by the consultant doctor. RESULTS: A total of 52 patients were recruited, of which 41 were available for analysis. 78.0% of patients were concerned that they were having a stroke upon presentation of the symptoms. Other beliefs about the cause of the disease included overwork or stress (36.6%), something that the patient had eaten (9.8%) and supernatural forces (2.4%). About 50% of patients had tried some form of complementary or alternative therapy other than the steroids/medicines prescribed by their general practitioner or emergency physician. While 39.0% of patients agreed that the Internet had helped them understand more about their condition in addition to the information provided by the physician, 9.8% of them specifically disagreed with this statement. CONCLUSION: We have found that patients with Bell's palsy in Singapore are not very knowledgeable about the disease. Although the Internet is a useful resource, a physician's explanation of the disease and its natural progression remains of utmost importance.

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.

A clinical pilot study comparing traditional acupuncture to combined acupuncture for treating headache, trigeminal neuralgia and retro-auricular pain in facial palsy.

Traditional acupuncture (TA) and ear acupuncture (EA) are used for treatment of headache, trigeminal neuralgia, and retro-auricular pain. The purpose of this study is to develop effective treatment using combined acupuncture (CA) which consists of TA and EA and to set clinical protocols for future trials. Participants were divided into TA (n = 15) control and CA (n = 34) experimental groups. Obligatory points among Korean Five Element Acupuncture and optional individual points along with symptom points were used in the TA group. The CA group was exposed to ear points of Fossion and TA. Acupuncture treatment consisted of six mandatory sessions per patient over 3 weeks and extended to 12 sessions. Pain was assessed using the visual analogue scale. We compared TA to CA and researched their relevant publications. No significant difference was observed between the two groups (p = 0.968) which showed pain-alleviating tendency. Pain alleviation was significantly different after the fifth and sixth sessions (p = 0.021, p = 0.025), with headache being the most significantly relieved (F = 4.399, p = 0.018) among the diseases. When assessing pain intensity, both the Headache Impact Test and the Migraine Disability Assessment Scale should be adopted for headache and the fractal electroencephalography method be used in pain diseases. In the future, studies should consist of TA, EA, and CA groups; each group having 20 patients. Treatment number should to be no less than 10 sessions. Korean Five Element Acupuncture should be a compulsory inclusion along with individual points being optional inclusion in TA. EA could be selected from Nogier, Fossion and so forth. In conclusion, acupuncture treatment, whether TA or CA, showed pain alleviation in headache, trigeminal neuralgia, and retro-auricular pain, but no significant difference was seen between groups. Prospective, well-controlled, and relevant protocols using multimodal strategies to define the role of TA, EA, and CA are needed.

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.