The Effects of Telerehabilitation-Based Exercise Therapy on Motor and Non-Motor Clinical Outcomes in Adults With Facial Palsy: A Randomized Controlled Trial.

Recent case reports have emphasized the essential clinical contribution of telerehabilitation in the treatment of facial palsy. However, no randomized controlled trial has yet demonstrated the effects of telerehabilitation-based facial exercise therapy. Thus, we aimed to investigate the effectiveness of video exercise-based telerehabilitation on motor and non-motor clinical outcomes in adults with facial palsy. We conducted a randomized controlled trial with 40 peripheral facial palsy patients. Those in the experimental group (EG) received four weeks of telerehabilitation-based video exercises and routine care. Those in the control group (CG) received only routine care. All participants were evaluated with the Facial Disability Index (FDI), the Facial Clinimetric Evaluation Scale (FaCE), Short Form-12 (SF-12), the Hospital Anxiety and Depression Scale (HADS), the House-Brackmann Scale (H-B) and the Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ), both before and after the interventions. Both groups demonstrated a significant improvement in FDI, FaCE, and SF-12 PCS scores (p < .05). In addition, there was a significant improvement only in EG on the SF-12 MCS score (p < .05), and there was a significant gain only in CG on the HADS-Depression score (p < .05). While these results provide a further contribution to our understanding of telerehabilitation benefits in mental health variables related to quality of life for facial palsy patients, we found no EG and CG differences on the physical components of treatment.

Combining early lower eyelid surgery with neuromuscular retraining for synkinesis prevention after facial palsy: the role of the eye in aberrant facial nerve regeneration.

Background: Facial synkinesis (FS) is a distressing sequela of facial palsy (FP) characterized by involuntary, simultaneous movements of facial muscles occurring during voluntary facial expressions. Treatment of synkinesis is challenging, and preventive methods are needed. Aim: This study evaluated the efficacy of physical facial nerve rehabilitation (PFNR) therapy alone vs. PNFR with eyelid surgery to correct lagophthalmos and prevent the onset of synkinesis. Methods: Twenty five outpatients were randomized to receive either PFNR alone (neuromuscular retraining and Kabat proprioceptive neuromuscular facilitation) or PNFR and early (90 days after FP onset) eyelid surgery (involving a conservative oculoplastic correction for lagophthalmos with epiphora or ectropion). Comprehensive otolaryngological assessments and Magnetic Resonance Imaging (MRI) were conducted. Synkinesis progression was measured using Another Disease Scale (ADS) at baseline, 3-, 6-, 12-, and 24-months post-treatment. The data were analyzed with ANOVA, τ-test, Chi-Square analyses. Results: Patients undergoing eyelid surgery with PFNR showed faster (p < 0.001) and better recovery of facial movements (p < 0.05) than patients receiving PFNR alone comparing T0 and T12 (p < 0.0001). No synkinesis were observed in the PFNR plus surgery group while 37% of patients in PFNR alone had synkinesis (p = 0.03). At 24 months, none of the patients in the surgery group presented synkinesis. Conclusion: Combining early surgical treatment of paralytic lagophthalmos or epiphora with PFNR accelerated functional recovery and reduced synkinesis in patients with FP compared to facial rehabilitation alone. Further investigations in larger populations with long-term follow-up are needed. Clinical trial registration: https://clinicaltrials.gov/study/NCT06538103, NCT06538103.

Clinical, myopathological, and genetic features of two Chinese families with Andersen-Tawil syndrome.

Purpose: To explore the clinical, muscle pathological, and pathogenic gene mutation characteristics of Andersen-Tawil Syndrome (ATS) and enhance the understanding of ATS among clinical practitioners. Methods: Retrospective analysis of clinical data and muscle pathology of two ATS families, along with genetic testing for probands and some family members. Results: In Family 1, spanning four generations, four individuals were affected, while Family 2 had two affected individuals across four generations. All six patients in both families experienced onset in childhood, presenting with periodic paralysis, arrhythmias, and craniofacial skeletal abnormalities. In Family 1, the proband's periodic paralysis was more triggered by low temperature and exercise, occurring several times a year, lasting 4-7 days. All three adult patients in Family 1 had a history of hypokalemia, and the frequency and severity of attacks were reduced after regular oral potassium supplement therapy. Two adult females in Family 1 experienced limb weakness triggered by stress, exertion, and premenstrual period, with milder symptoms than the proband. In Family 2, the proband's periodic paralysis typically occurred the day after excessive exertion, with a frequency of approximately 2-3 months. Two years prior, the proband developed arrhythmias without palpitations or chest tightness. The proband's brother experienced intermittent limb weakness during adolescence, remained untreated, and had sudden death at age 40. Physical examination revealed characteristic features in Family 1 and both probands: small mandible, wide eye spacing, and fifth-digit clinodactyly. Four adult patients were shorter in stature, while the growth status of a pediatric patient was indeterminate. Supplementary tests showed a history of hypokalemia during muscle weakness episodes in Family 1, while Family 2 patients had normal potassium levels during episodes. The long exercise tests were positive in both probands. Muscle MRI showed no significant abnormalities, but muscle pathology revealed rimmed vacuoles and tubular aggregates. Genetic testing identified KCNJ2 gene mutations in two probands and some of their family members, with c.407C > T (p.S136F) heterozygous mutation in Family 1 and c.652C > T (p.R218W) heterozygous mutation in Family 2. Conclusion: Among the clinical symptoms of the patients with Andersen-Tawil Syndrome in this study, not everyone exhibits the full triad of signs: periodic paralysis is the most common initial symptom, craniofacial and digit skeletal abnormalities are characteristic signs, and ventricular arrhythmias pose the most serious potential risk. Given that these typical symptoms were observed in 5 out of 6 patients, clinicians should pay special attention to these typical symptoms, and patients with these symptoms should be followed up over time. Muscle biopsy May reveal pathological changes such as tubular aggregates, but genetic testing for KCNJ gene mutations remains a crucial diagnostic criterion for this syndrome.

Periodic Paralysis in a Child With Thermosensitive Mitochondrial Trifunctional Protein Deficiency.

Mitochondrial trifunctional protein (MTP) deficiency is a fatty acid oxidation disorder associated with a spectrum of phenotypes. Patients with high residual enzyme activity tend to have milder phenotypes, and recently, fever-induced episodic myopathy was reported in association with a thermosensitive form of MTP deficiency. We report a 10-year-old male with recurrent episodes of acute flaccid paralysis involving upper and lower extremities in association with bulbar muscle weakness in the context of febrile illness, a phenotype reminiscent of recurrent periodic paralysis. The episodes started at the age of 3 years and have always been followed by full recovery within 1-2 weeks with no residual weakness. Whole exome sequencing revealed a homozygous c.2132C > T, p.(Pro711Leu) variant in HADHA. The variant leads to mildly reduced long-chain hydroxyacyl-CoA dehydrogenase (LCHAD) and long-chain ketoacyl-CoA thiolase (LCKAT) enzyme activities and reduced MTP protein expression in patient's fibroblasts when cultured at 37°C. Enzyme activities and MTP protein expression diminished when fibroblasts were cultured at 40°C. This is the first published report of confirmed recurrent periodic paralysis as a manifestation of a thermosensitive form of MTP deficiency, and it calls for this condition to be considered when evaluating patients with recurrent periodic paralysis given therapeutic implications.

The effect of home-based neuromuscular electrical stimulation-resistance training and protein supplementation on lean mass in persons with spinal cord injury: A pilot study.

In persons with a spinal cord injury (SCI), resistance training using neuromuscular electrical stimulation (NMES-RT) increases lean mass in the lower limbs. However, whether protein supplementation in conjunction with NMES-RT further enhances this training effect is unknown. In this randomized controlled pilot trial, 15 individuals with chronic SCI engaged in 3 times/week NMES-RT, with (NMES+PRO, n = 8) or without protein supplementation (NMES, n = 7), for 12 weeks. Before and after the intervention, whole body and regional body composition (DXA) and fasting glucose and insulin concentrations were assessed in plasma. Adherence to the intervention components was ≥96%. Thigh lean mass was increased to a greater extent after NMES+PRO compared to NMES (0.3 (0.2, 0.4) kg; p < 0.001). Furthermore, fasting insulin concentration and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) were decreased similarly in both groups (fasting insulin: 1 [-9, 11] pmol∙L-1; HOMA-IR: 0.1 [-0.3, 0.5] AU; both p ≥ 0.617). Twelve weeks of home-based NMES-RT increased thigh lean mass, an effect that was potentiated by protein supplementation. In combination with the excellent adherence and apparent improvement in cardiometabolic health outcomes, these findings support further investigation through a full-scale randomized controlled trial.

Clinical Effects of Voice Therapy on Vocal Outcomes in Unilateral Vocal Fold Paralysis: Proof-of-Concept Study for Two SOVT-Based Treatment Protocols.

BACKGROUND: Studies on treatment efficacy in unilateral vocal fold paralysis (UVFP) often lack a predetermined treatment protocol, and little is known about the effects of specific vocal techniques on vocal outcomes and quality of life in UVFP patients. The purpose of this preliminary proof-of-concept study is to investigate the effects and feasibility of two intensive treatment protocols based on water-resistance therapy (WRT) and vocal function exercises (VFE). METHODS: Ten participants with acute or chronic UVFP/paresis were recruited in the study and randomly assigned to the WRT or VFE group. Three of these participants presented with aphonia and could not complete the program as prescribed. The remaining participants completed an intensive therapy program with the assigned vocal technique. Before, during, and after the program, a multidimensional voice assessment was performed. Maximum phonation time, acoustic, perceptual, and patient-reported outcome measures (PROMs) were obtained. RESULTS: WRT and VFE had positive clinical effects on instrumental and auditory-perceptual voice quality, glottal closure, and PROMs, but interindividual variability was high. Studies with larger sample sizes are necessary to confirm or refute these findings. CONCLUSION: The WRT- and VFE-based therapy programs are both feasible and seem to elicit positive clinical changes in UVFP patients. Suggestions on how to improve the programs are provided, as well as considerations for implementation in clinical practice. Follow-up research is needed to examine the efficacy of both programs on group level.

[The key problems of diagnosis and treatment of vocal cord paralysis].

Vocal cord paralysis is a common condition that significantly impairs laryngeal function and can even be life-threatening. Over nearly a century, researchers have conducted extensive animal and clinical studies to achieve accurate diagnosis and restore laryngeal function, making significant progress. Approaches have evolved from mechanically narrowing the glottis to restore phonation, to enlarging the glottis to relieve breathing difficulties, and ultimately to the development of surgical techniques aimed at restoring vocal cord mobility, significantly advancing the field. The publication of expert consensus guidelines on the diagnosis and treatment of vocal cord paralysis has standardized the principles and technical standards for managing this condition. However, a vast amount of related knowledge-including the disease's pathogenesis, diagnostic criteria, surgical principles, and techniques-still requires broader dissemination and further refinement. Advancing this knowledge will guide clinical practice and further enhance the diagnosis and treatment of this condition in China.

[Evaluation of the effect of endoscopic CO2laser arytenoidectomy on re-operation for failed posterior cordotomy].

Objective:To analyze the efficacy of endoscopic CO2 laser arytenoidectomy in treating bilateral vocal cord paralysis. Methods:Ninety-five patients who underwent endoscopic CO2 laser arytenoidectomy for bilateral vocal cord paralysis at the First Affiliated Hospital of Naval Medical University（Changhai Hospital） of Shanghai from January 2009 to December 2022 were included in this study. Among them, 59 patients underwent endoscopic CO2 laser arytenoidectomy as their first glottic enlargement surgery（Group A）, while 36 patients, who had previously undergone two unsuccessful CO2 laser-assisted posterior cordotomies, underwent endoscopic CO2 laser arytenoidectomy as a subsequent surgery（Group B）. Swallowing function, electronic laryngoscopy, perceptual voice evaluation, and objective voice analysis indicators were statistically analyzed before and after surgery to evaluate clinical efficacy. Results:The extubation rate after the first surgery was 84.75% in Group A and 86.11% in Group B, with total extubation rates of 94.92% and 94.44%, respectively. There were no significant differences between the two groups in preoperative and postoperative swallowing function, glottic size, or various voice evaluation indicators（P>0.05）. Within-group comparisons showed that postoperative swallowing function, glottic closure during phonation, perceptual evaluations of G（grade of hoarseness）, A（asthenia）, and B（breathiness） significantly worsened, with increased grades. The maximum transverse diameter of the posterior glottis during inspiration significantly increased, and the VHI-10 score was significantly higher postoperatively. Jitter, shimmer, and the harmonics-to-noise ratio significantly deteriorated, and maximum phonation time significantly shortened（P<0.05）. No significant differences were observed in postoperative R（roughness） and S（strain） compared to preoperative values（P>0.05）. Conclusion:Endoscopic CO2 laser arytenoidectomy can impair voice quality to some extent but effectively alleviates breathing difficulties in patients with bilateral vocal cord paralysis. For patients who did not achieve successful extubation with CO2 laser-assisted posterior cordotomy, endoscopic CO2laser arytenoidectomy is an effective reoperative method, ensuring a high extubation rate while preserving certain voice functions.

[Analysis of the efficacy of non-surgical treatment mainly focus on voice therapy and it's influencing factors in patients with unilateral vocal fold paralysis].

Objective:Retrospective analysis of the efficacy and it's influencing factors of non-surgical treatment mainly focus on voice therapy for patients with unilateral vocal fold paralysis. Methods:The retrospective study includes 57 patients who were diagnosed with unilateral vocal fold paralysis and presented with hoarseness as their main complaint at the Department of Voice Medicine, Zhongshan Hospital of Xiamen University from August, 2021 to August, 2023. Judging the efficacy of non-surgical treatment mainly focus on voice therapy through changes in acoustic, aerodynamic, and laryngoscopic parameters; Analyze the relationship between patients' age, gender, duration of disease, cause of nerve injury, type of nerve injury, side of nerve injury and efficacy of non-surgical treatment. Results:After non-surgical treatment mainly focused on voice therapy, there were statistically significant differences（P<0.01） in the changes of vocal fold bow, glottal gap, glottal compression, loudness, Jitter, Shimmer, IC, and NC parameters. There is a statistically significant correlation between the duration of the disease and changes in glottal gap, Shimmer, and IC（P<0.05）, the side of nerve injury can affect changes of glottal gap and NC（P<0.05）. Conclusion:Non-surgical treatment mainly focused on voice therapy has a good efficacy on patients with unilateral vocal fold paralysis. The duration of the disease and the side of nerve injury may affect the efficacy.

[A meta-analysis on the improvement of vocal function in unilateral vocal cord paralysis by reinnervation of the recurrent laryngeal nerve].

Objective:To conduct a systematic description and meta-analysis of the treatment of unilateral vocal cord paralysis（UVCP） with recurrent laryngeal nerve reinnervation through literature search, and to analyze the therapeutic effect of recurrent laryngeal nerve reinnervation on improving vocal function in UVCP. Methods:Electronic databases Pubmed, Web of Science, EMBASE, Cochrane Library, CNKI, and Wanfang databases were searched using relevant keywords and screened in strict accordance with the inclusion and exclusion criteria, and quality evaluations were conducted. Reported treatment outcomes were measured by relevant data extracted from literature, such as auditory perception assessment（GRBAS）, voice handicap index（VHI）, maximal phonation time（MPT）, jitter, shimmer, and noise harmonic ratio（NHR）, etc. Meta-analysis was performed by Revman5.3 and heterogeneity was analyzed using fixed effects or random effects models. Results:Eight articles were included in this study, all of which showed that the postoperative maximum phonation time of patients was significantly prolonged compared to preoperative, while the postoperative GRBAS score, Jitter, Shimmer, and NHR decreased compared to preoperative with statistical significance. Conclusion:The innervation of the internal laryngeal muscle was obtained through the reinnervation of the recurrent laryngeal nerve, which effectively improved the patient's vocal function and had a good long-term therapeutic effect. Although there was no difference in the efficacy of surgical methods for reconstructing the recurrent laryngeal nerve, the anastomosis between ansa cervicalis nerve and the recurrent laryngeal nerve is more ideal. Further randomized controlled studies with longer follow-up periods and larger samples will increase the credibility of their effectiveness.

[Efficacy analysis of ansa cervicalis anterior root-recurrent laryngeal nerve anastomosis in the treatment of unilateral vocal cord paralysis].

Objective:Investigates the application and clinical efficacy of ansa cervicalis anterior root-recurrent laryngeal nerve（RLN） anastomosis in the treatment of unilateral vocal fold paralysis（UVFP）. Methods:A prospective study was conducted with 92 UVFP patients admitted to our department from January 2018 to January 2022 who received ansa cervicalis anterior root-RLN anastomosis. The course of nerve injury ranged from 6 to 24 months. Videostroboscopy, voice subjective auditory perceptual assessment（GRBAS）, Voice Handicap Index（VHI-10）, voice objective acoustic analysis and laryngeal electromyography（EMG） were used to evaluate the efficacy of the operation. Results:Videostroboscopy showed that although the movement of vocal cords did not return to normal 12 months after operation, their volume and muscle tension were significantly improved and their positions were adducted to the median or near-median. Also the glottic closure, vocal cord position, vocal cord edge, symmetry and regularity of vocal cord vibration were significantly improved than pre-operation（P<0.01）. The five indexes of GRBAS（Grade, Roughness, Breathiness, Asthenia, Strain） and VHI-10, as well as voice acoustic parameters（Jitter, Shimmer, NHR） post-operation were significantly reduced, while the maximum phonation time（MPT） was significantly longer（P<0.01）. The results of laryngeal EMG indicated that the maximum voluntary motor unit recruitment（VMUR） post-operation was significantly recovered（P<0.01）, which confirmed that the affected laryngeal muscle obtained effective nerve reinnervation. Conclusion:Ansa cervicalis anterior root-RLN anastomosis can effectively improve the voice function of patients which is safe and satisfactory. It is an ideal method for the treatment of unilateral RLN injury.

[The current status and development of nerve repair techniques for bilateral vocal cord paralysis].

The related research of nerve repair for bilateral vocal cord paralysis（BVCP） can be traced back to a century ago. There is still no standardized surgical therapeutic schedule and the evaluation of curative effect, due to the variability and complexity of laryngeal nerve innervation. Otolaryngologists have been constantly weighing and improving the surgical plan in relieving airway obstruction, maintaining vocal function and reducing cough to protect the normal physiological function of the larynx. Different medical institutions have great differences in the treatment methods. Many studies and literatures were published on the treatment of BVCP, yet have few related works on the application of it's nerve repair technology presently. The research progress of nerve repair technology for BVCP were described, along with its developing trend, aiming to lay the foundation for the future technical exploration and development.

[Study on the efficacy of posterior cordotomy with partial arytenoidectomy in bilateral vocal fold paralysis].

Objective:The aim of this study is to investigate the efficacy of posterior cordotomy with partial arytenoidectomy in bilateral vocal fold paralysis（BVFP）. Methods:Medical records of 37 patients with BVFP were retrospectively collected, and they were all admitted to the Department of Otolaryngology-Head and Neck Surgery, West China Hospital of Sichuan University, from Jan. 2019 to Dec. 2023. Preoperative and postoperative evaluations of respiratory function, voice quality, and swallowing function were conducted. Results:Postoperatively, 32 out of 37 patients achieved significant relief in breathing difficulties. Out of 29 patients with tracheostomy, 26（89.7%） were successfully decannulated. One month postoperative follow-up revealed a decline in voice quality for 33 patients（89.2%）, and 5 cases（13.5%） reported a decrease in swallowing function. However, by three months postoperatively, both voice quality and swallowing function showed significant improvement. Conclusion:Posterior cordotomy with partial arytenoidectomy is an effective surgical method for BVFP, and significantly improve respiratory difficulty despite its impact on voice quality, with no significant impairment to swallowing function, shows significant clinical value.

Acceptance and willingness of patients with chronic facial nerve palsy for an implantable device that assists with eye closure.

BACKGROUND: Patients with facial nerve palsy often experience lagophthalmos (incomplete eye closure), which can lead to exposure keratitis. The Bionic Lid Implant for Natural Eye Closure (BLINC) is a medical device designed to mimic the more natural blink kinetics than traditional lid loading techniques. AIMS: This study aimed to evaluate potential factors that might influence the design of the BLINC device and willingness of participant to undergo the implant placement surgery. METHODS: Patients attending a multidisciplinary facial nerve clinic were invited to complete a survey addressing patient acceptance of the BLINC device implantation. RESULTS: Seventy-two patients were mailed the survey, of which 50 returned completed surveys (69%). The most important factor identified by participants was the device function (81% ranked as very important) and the least important factor was cost (16% ranked as very important). Median acceptable device function time was 5 years (range 1-10 years). Ten participants (20%) indicated willingness to be the first to trial BLINC. Women were more likely to rate visual appearance as important (OR 3.32, CI 1.14-9.62, p = 0.028), and less likely to rate user friendliness as important (OR 0.16, CI 0.04-0.52, p = 0.0021). Older participants were more likely to rate the length of recovery period as important (OR 1.04, CI 1.01-1.08, p = 0.006). Participants with complete eye closure were less likely to be willing to trial the implant (OR 0.08, CI 0.00-0.53, p = 0.006, whilst patients with eye irritation were more willing to trial the implant (OR 7.20, CI 1.12-142, p = 0.036). CONCLUSION: Certain patient demographics impact patient aesthetic and functional preferences and the willingness to trial the BLINC device.

Invasive fungal otitis media with peripheral facial paralysis.

Invasive fungal otitis media is clinically rare and diagnosis often delayed. We report a 65-year-old female with Aspergillus fumigatus otitis media complicated by mastoiditis and peripheral facial paralysis. Complete mastoidectomy and type II tympanoplasty, with oral administration of voriconazole for more than 3 months resulted in a successful outcome.

Understanding neurotropic enteric viruses: routes of infection and mechanisms of attenuation.

The intricate connection between the gut and the brain involves multiple routes. Several viral families begin their infection cycle in the intestinal tract. However, amongst the long list of viral intestinal pathogens, picornaviruses, and astroviruses stand out for their ability to transition from the intestinal epithelia to central or peripheral nervous system cells. In immunocompromised, neonates and young children, these viral infections can manifest as severe diseases, such as encephalitis, meningitis, and acute flaccid paralysis. What confers this remarkable plasticity and makes them efficient in infecting cells of the gut and the brain axes? Here, we review the current understanding of the virus infection along the gut-brain axis for some enteric viruses and discuss the molecular mechanisms of their attenuation.

Outbreak Response to Circulating Vaccine-Derived Poliovirus in Three Northern Regions of Ghana, 2019.

Background: Circulating Vaccine-Derived Poliovirus Type 2 (cVDPV2) was isolated in sewage and later in stool samples from children with acute flaccid paralysis (AFP) in northern Ghana. Method: A multidisciplinary and multisectoral team investigated this outbreak and reported on epidemiological and laboratory investigations. Sewage/wastewater samples were collected from the environment, while stool samples were collected from AFP/contact children under 5 years of age. The samples were processed for virus isolation, and positive isolates were sequenced. We also conducted a descriptive investigation involving a review of records, active case search, and Monovalent Oral Polio Vaccine 2 campaigns. Additionally, we interviewed caregivers about the vaccination status of their children, as well as their knowledge on polio prevention. Water quality, sanitation, hygiene practices, and health-seeking behaviours were also assessed. Results: A total of 18 cVDPV2 were confirmed in the three regions of Ghana during the outbreak in 2019-2020. All strains were genetically linked to a Nigerian cVDPV2 strain NIE-KWS-KSB-18-006HC29 that circulated in 2018. Evaluation of the surveillance system shows that officers have good knowledge of AFP and know how to collect samples, package them, and ship them to the laboratory. Few communities had access to potable water. Open defecation was common, and the water supply, sanitation, and hygiene practices of the communities were poor. Conclusion: The cVDPV2 outbreak represents the first time cVDPV2 has circulated in the country since Ghana embarked on the polio eradication program in 1996. However, with quality mOPV2 mop-up campaigns, a nationwide IPV catch-up campaign coupled with enhanced surveillance measures, transmission was interrupted.

The Double Bell's: Unraveling Idiopathic Bilateral Facial Paralysis in a 31-Year-Old.

Bell's palsy, an acute, idiopathic, and typically unilateral facial nerve paralysis, represents a common cause of sudden facial weakness. The aetiology is often attributed to viral infections. This case report discusses the presentation, diagnosis, and management of a rare case of idiopathic bilateral Bell's palsy. We present a case of a 31-year-old male who presented to the emergency department with a one-week history of progressive bilateral facial weakness following initial neck and jaw pain. Despite the resolution of pain, the patient experienced complete facial paralysis on both sides, including the inability to raise eyebrows, close eyes fully, and numbness over the lips. The patient presented with no complaints of headache, trauma, vision changes, or recent travel history. Examination and routine blood tests yielded normal results, and a head CT scan showed no abnormalities. As a result, the diagnosis of idiopathic bilateral Bell's palsy was confidently confirmed. This case highlights the clinical presentation, diagnostic approach, and management of a rare bilateral facial palsy, emphasizing the importance of a comprehensive evaluation and considering Bell's palsy in differential diagnoses of acute facial weakness.

The Role of Continuous Positive Airway Pressure in Acute Bilateral Vocal Cord Paresis or Paralysis Post-Thyroidectomy.

OBJECTIVES: Acute post-thyroidectomy bilateral vocal cord paresis or paralysis (BVCP) is often managed with observation, botulinum toxin injection or tracheostomy. However, only a few cases discuss obstructive sleep apnea (OSA) in the context of BVCP with limited exploration of home sleep test (HST) and continuous positive airway pressure (CPAP) as post-operative assessment and management tools. This study suggests CPAP as a less invasive approach while awaiting vocal cord recovery. METHODS: A retrospective chart review was conducted on 2 female patients who presented with dyspnea and sleep-disordered breathing (SDB) symptoms post-thyroidectomy. Both patients underwent laryngoscopy and HSTs, followed by CPAP prescription. RESULTS: Case 1 (body mass index [BMI]: 32.6 kg/m2) and Case 2 (BMI: 20.1 kg/m2), aged 66 and 77 respectively, presented with post-surgery dyspnea and SDB symptoms. Laryngoscopy revealed left vocal cord paresis and right vocal cord paralysis in both cases. Although tracheostomy could provide definitive treatment, both cases were deferred for non-invasive options, which led to HST, confirming moderate OSA (PAT-derived apnea-hypopnea index (pAHI): 18/hour and 27.1/hour) leading to CPAP recommendation. In Case 2, 5 weeks of CPAP use resulted in dramatic improvements in her sleep quality, with continued benefits at 3-month follow-up. CONCLUSION: These cases underscore the value of considering sleep studies and CPAP as adjunctive tools in acute post-thyroidectomy BVCP management while awaiting vocal motion recovery. This report also further supports that BVCP sufficiently narrows the glottic airway, predisposing patients to OSA.

Bilateral Recurrent Laryngeal Nerve Injury Following Botulinum Toxin Injection at the Cricopharyngeus Muscle: Diagnosis, Anatomic Considerations, and ICU Management.

Bilateral vocal cord paralysis poses life-threatening risks to patients who do not undergo prompt diagnostic intervention and airway management. Although developing bilateral vocal cord paralysis is extremely rare, if injury does occur, it is more frequently due to surgical resection sequelae in the neck. This case is particularly unique as we present a patient with a history of stage III laryngeal carcinoma status post chemotherapy in remission, who developed respiratory distress three days following an upper endoscopy procedure for an esophageal stricture at the level of the cricopharyngeus muscle, where he received a botulinum injection. This manuscript discusses the anatomy, clinical practices of botulinum toxin, nerve innervation, and mechanisms of injury for patients who develop bilateral recurrent laryngeal nerve injury. In addition, this manuscript details vocal cord positioning and how the positioning of the cords during laryngoscopy investigation can lead to diagnostic confirmation. With few reported cases of bilateral recurrent laryngeal nerve injury secondary to botulinum toxin particularly at the cricopharyngeus level, this report should serve as a guide for future clinicians regarding the risks of using this toxin, the risks of local spread, and management.