Endoscopic transcanal facial nerve decompression in Bell's palsy: A pilot study.

PURPOSE: To explore the surgical effects of endoscopic facial nerve decompression in Bell's palsy. MATERIALS AND METHODS: This retrospective study included 15 patients with Bell's palsy. All had grade VI (House-Brackmann grading system) complete unilateral facial paralysis before surgery and a >95% reduction in amplitude on electroneurography testing compared to the unaffected side. Their MRI results indicated perineural edema in the geniculate ganglion area. Endoscopic decompression surgery was performed soon after they presented at our hospital. The time between onset of facial paralysis and surgery ranged from 25 to 93 days. All patients had no relevant surgical history or ear diseases. RESULTS: At 1-year follow-up, 13 of the 15 (87%) patients had recovered to normal or near-normal facial function (House-Brackmann grade I-II), and all patients had reached House-Brackmann grade III or lower facial function. No obvious air-bone gap or sensorineural hearing loss occurred after surgery, and there were no severe complications or synkinesis. CONCLUSIONS: Endoscopic transcanal facial nerve decompression provides a less traumatic and improved exposure of the geniculate ganglion, and may also help prevent permanent severe facial sequela. Results of intraoperative facial nerve stimulation may be related to the length of time required for recovery. The optimal time of surgery after onset of paralysis needs to be investigated further, to identify a post-drug surgical therapy which may be more acceptable for patients. Patients' response to conservative treatments should be assessed as soon as possible so as not to delay surgery.

Quantitative assessment of Bell's palsy-related facial thermal asymmetry using infrared thermography: A preliminary study.

The temperature distribution of normal human skin is symmetrical. Facial paralysis generally changes this thermal symmetry. The aim of this study is to analyze facial thermal asymmetry during the early onset of Bell's palsy, and to assess the feasibility of the diagnosis of early-onset Bell's palsy using infrared thermography (IRT). Fifteen subjects with Bell's palsy and 15 healthy volunteers were considered in this study. The infrared thermal images of the front, left, and right sides of all the subjects were collected and analyzed. Each group of facial thermograms was divided into 16 symmetrical regions of interest (ROIs) with respect to the left and right sides. Three different temperature difference calculation methods were used to express the degree of thermal symmetry between the left- and right-side ROIs, namely, the mean temperature difference (ΔTroi), maximum temperature difference (ΔTmax), and minimum temperature difference (ΔTmin). Among the facial ROIs, there were significant differences in the thermal symmetries of the frontal region, medial canthus region, and infraorbital region between subjects with and without Bell's palsy (p < 0.05). Based on the results, ΔTroi was more effective than the other two methods for the diagnosis of early-onset Bell's palsy. The area under the ROC curve (AUC) of ΔTroi in the infraorbital region was 0.818; and the sensitivity and specificity were 0.867 and 0.800, respectively. Subjects with early-onset Bell's palsy exhibited thermal asymmetry on the left and right sides of their faces. The diagnosis of early-onset Bell's palsy using IRT is therefore necessary. Nevertheless, more effective thermal symmetry analysis methods will be investigated further in future research.

Investigating the correlation between serum albumin level and the prognosis of Bell's palsy.

ABSTRACT: To investigate the correlation between the serum albumin level and the prognosis of patients with Bell's palsy.We retrospectively analyzed the clinical records of 311 inpatients with Bell's palsy (BP) in our hospital between September 2018 and October 2019. The patients were divided into 2 groups: the recovered group (with the House-Brackmann grade ≤ 2) and the unrecovered group (with the House-Brackmann grade > 2), according to the follow-up results within 3 months after discharge. Blood test indicators (white blood cell count, neutrophil-to-lymphocyte ratio, red cell distribution width, serum albumin level, globulin level) and basic clinical data (age, sex, course of the disease, inpatient days, comorbidity of hypertension, diabetes, and hepatitis B) of the 2 groups were compared to explore whether they were correlated with the prognosis of patients with Bell's palsy.The serum albumin level of patients with BP in the unrecovered group was significantly lower than that of the recovered group (medians [interquartile range], 40.75 [38.40, 43.85] vs 44 [42.10, 46.20], P < .001). Multivariate binary logistic regression revealed that serum albumin (odds ratio 0.772, 95% confidence interval 0.711-0.839, P < .001) was a protective factor for BP prognosis.Serum albumin is a protective factor for the prognosis of BP. Although more prospective clinical controlled trials are needed, our study provides valuable and crucial prognostic information for physicians.

Botulinum Toxin Type A to Improve Facial Symmetry in Facial Palsy: A Practical Guideline and Clinical Experience.

Unilateral peripheral facial nerve palsy jeopardizes quality of life, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and depression. Among therapeutical approaches, use of Botulinum toxin type A (BoNT-A) on the nonparalyzed side has shown promising results and improvement of quality of life. Nevertheless, the correct technique is paramount, since over-injection of the muscles can result in lack of function, leading to a "paralyzed" appearance, and even worse, functional incompetence, which may cause greater distress to patients. Therefore, the objective of this article is to provide a practical guideline for botulinum toxin use in facial palsy. To this aim, adequate patient assessment, BoNT-A choice, injection plan and dosage, and injection techniques are covered.

Lower motor neuron facial palsy in a postnatal mother with COVID-19.

COVID-19 is caused by the novel SARS-CoV-2 and is a potentially fatal disease that is of great global public health concern. In addition to respiratory symptoms, neurological manifestations have been associated with COVID-19. This is attributed to the neurotropic nature of coronaviruses. The authors present a case of Bell's palsy associated with COVID-19 in a term primigravida.

COVID-19 myocarditis and postinfection Bell's palsy.

Here we present the case of a 37-year-old previously healthy man who developed fever, headache and a unilateral, painful neck swelling while working offshore. He had no known contact with anyone with COVID-19; however, due to the ongoing pandemic, a nasopharyngeal swab was performed, which was positive for the virus. After transfer to hospital for assessment his condition rapidly deteriorated, requiring admission to intensive care for COVID-19 myocarditis. One week after discharge he re-presented with unilateral facial nerve palsy. Our case highlights an atypical presentation of COVID-19 and the multifaceted clinical course of this still poorly understood disease.

Optimal current intensity for supramaximal stimulation during electroneurography for facial palsy.

OBJECTIVE: To determine the optimal current intensity for supramaximal stimulation during electroneurography (ENoG) for facial palsy. METHODS: Forty patients with unilateral facial palsy (32 Bell's palsy, 7 Ramsay Hunt syndrome, and 1 temporal bone fracture) were enrolled. All patients were initially treated with intravenous steroid injections and examined using ENoG. Compound muscle action potentials (CMAPs) of the orbicularis oris muscle were measured on the paralyzed and healthy sides. Stimulation current intensity was varied every 5 mA from 20 mA to 50 mA using two recording methods (the midline and standard methods). The CMAPs of both sides were monitored to see whether they would saturate under the high current intensity stimulation or not. RESULTS: No obvious saturation of CMAPs was observed in either side with the midline or standard methods. Statistically, a current of 35 mA and above in the healthy side, and 30 mA and above in the paralytic side, resulted in no difference to each side when using the midline recording method. On the other hand, a current of 35 mA and above in the healthy side, and 25 mA and above in the paralytic side, resulted in no difference to each side when using the standard recording method. CONCLUSIONS: These results indicate that a current intensity of at least 35 mA is required to achieve supramaximal stimulation on the healthy side in a patient with unilateral facial nerve palsy. Clinically, for simplicity or standardization purposes, if the same current intensity is introduced bilaterally for ENoG measurements, adopting 40 mA (35 mA plus 10-20%) stimulation would be appropriate for supramaximal stimulation, while being cognizant of the potential effects of artifacts from other muscles.

Buccinator synkinesis treated by botulinum toxin in facial palsy and hemifacial spasms.

OBJECTIVE: To assess botulinum toxin treatment for buccinator muscle synkinesis including: how often the synkinesis was troublesome; who benefitted and how from the treatment; and what were the adverse effects, ideal dosage, and injection site. SUBJECTS AND METHODS: Facial palsy (FP) patients and patients with hemifacial spasms who were attending for multiple site botulinum-toxin treatment for facial sequelae were assessed for buccinator synkinesis. The study group comprises those experiencing buccinator synkinesis with associated bothering symptoms who were willing to try injection also to the buccinator muscle. RESULTS: During 9/2017-12/2019, 126 different patients with facial sequelae were treated with multiple-site botulin-toxin injections by the author. Of them, 83 (66%) received injection also for buccinator synkinesis and 66/82 (80%) wanted to continue with the buccinator injections. The most remarkable results were seen with FP patients biting the mucus membrane of their cheek: usually the biting ceased totally. Patients with powerful hemifacial cheek spasms also experienced cessation of the spasms, contrasting any previous treatments. Adverse effects were mostly mild: slight weakness of the corner of the mouth or additional leakage of saliva or liquids. Only a few patients experienced more pronounced adverse effects. The most posterior contracting part of the buccinator muscle proved to be the best site for the injection. CONCLUSIONS: Buccinator synkinesis was very common and its treatment gave many patients additional relief from facial sequelae symptoms. Professionals treating patients with synkinesis and hemifacial spasms should add well-tolerated buccinator injections to their repertoire of injection sites.

fMRI in Bell's Palsy: Cortical Activation is Associated with Clinical Status in the Acute and Recovery Phases.

BACKGROUND AND PURPOSE: Using functional magnetic resonance imaging (fMRI), we explored cortical activation in patients with acute Bell's palsy (BP) and analyzed its correlates with clinical status in the acute phase, and with 6-month outcome. METHODS: Twenty-four right-handed patients with acute BP within 15 days of onset and 24 healthy controls underwent fMRI during performance of unilateral active (hemi-smiling) and passive lip movement tasks with both the paretic and the normal lip. The degree of paresis was evaluated during the acute stage and at the 6-month follow up using the House-Brackmann (HB) grading scale. Complete recovery was defined as HB grade II or less at the end of the 6-month period. The difference in the HB grade (ΔHB) between the acute stage and the 6-month follow up was used to evaluate clinical improvement. RESULTS: There were 24 patients with unilateral acute BP. HB grades ranged from III to VI. At 6 months, 11 patients (46%) had completely recovered and 12 (50%) were partially improved. Compared with healthy subjects, BP patients had a significantly greater activation of the frontal areas and the insula ipsilateral to the paretic side. In BP patients, there was an inverse correlation between the activation of the ipsilateral hemisphere when moving the paretic side and the degree of paresis at baseline. An association was also observed between activation and clinical outcome (both complete recovery and ΔHB). CONCLUSIONS: In patients with BP, fMRI may represent a useful tool to predict long-term outcome, guide therapeutic approach, and monitor treatment response.

Prognostic factors for the outcome of Bells' palsy: A cohort register-based study.

OBJECTIVES: There is a lack of data on patients' and diagnostic factors for prognostication of complete recovery in patients with Bell's palsy. DESIGN AND SETTING: Cohort register-based study of 368 patients with Bell's palsy and uniform diagnostics and standardised treatment in a university hospital from 2007 to 2017 (49% female, median age: 51 years). MAIN OUTCOME MEASURES: Clinical data, facial grading, electrodiagnostics, motor function tests, non-motor function tests and onset of prednisolone therapy were assessed for their impact on the probability of complete recovery using univariable and multivariable statistics. RESULTS: Median onset of treatment was 1.5 days. 46% of patients had a House-Brackmann scale at baseline of ≥ III. The median recovery time was 2.6 months (95% confidence interval [CI] = 2.1-3.0). 54.9% achieved a complete recovery. If prednisolone therapy started later than 96 hours after onset, the recovery rate decreased significantly. Beyond less severe palsy, no abnormal electroneurography side difference, no pathological spontaneous activity in electromyography and normal stapedius reflex testing were the most powerful tool for prognostication of recovery after Bell's palsy. CONCLUSION: Beyond severity of the palsy, facial electrodiagnostics and stapedius reflex testing are the most powerful tool for prognostication of recovery time after Bell's palsy. Prednisolone therapy should have started at best within a time window of 96 hours after onset to reach the highest probability of complete recovery.

Recurrent facial palsy: The prognostic value of electrophysiological tests according to recurrence interval.

OBJECTIVE: The prognostic value of nerve excitability tests (NET) and electroneurography (ENoG) for recurrent peripheral facial palsy is poorly understood. This study aimed to evaluate the association between NET/ENoG results for the current palsy and recovery. METHODS: We extracted data on patients who were referred to our hospital (2005-2017). Adult patients with recurrent peripheral facial palsy who underwent NET and ENoG within 3 weeks of onset were retrospectively analyzed (n = 26). Favorable recovery was defined as the achievement of either House-Brackmann grade I/II or the same level of facial movement as before the current palsy. We evaluated the predictive NET/ENoG results by making comparison between the favorable recovery group and the unfavorable recovery group, which were subdivided based on the length of time after the previous palsy. RESULTS: In terms of patients with a >4-year recurrent interval, 8 out of 12 patients achieved favorable recovery. Compared to the favorable recovery group, the unfavorable recovery group had significantly higher NET results (9.03 mA vs. -1.08 mA, p = 0.017). Also, the unfavorable recovery group had significantly higher NET results in patients with a >2-year recurrent interval (9.03 mA vs. 1.06 mA, p = 0.036). However, other test results (NET in ≤4-year recurrent interval/all 26 patients, and ENoG in >4-year recurrent interval/≤4-year recurrent interval/all 26 patients) did not differ significantly between patients with favorable and unfavorable recovery. CONCLUSION: NET might be a useful prediction method in patients with at least a few years interval between the previous and the current palsy.

Implantable wireless device for study of entrapment neuropathy.

BACKGROUND: Disease processes causing increased neural compartment pressure may induce transient or permanent neural dysfunction. Surgical decompression can prevent and reverse such nerve damage. Owing to insufficient evidence from controlled studies, the efficacy and optimal timing of decompression surgery remains poorly characterized for several entrapment syndromes. NEW METHOD: We describe the design, manufacture, and validation of a device for study of entrapment neuropathy in a small animal model. This device applies graded extrinsic pressure to a peripheral nerve and wirelessly transmits applied pressure levels in real-time. We implanted the device in rats applying low (under 100 mmHg), intermediate (200-300 mmHg) and high (above 300 mmHg) pressures to induce entrapment neuropathy of the facial nerve to mimic Bell's palsy. Facial nerve function was quantitatively assessed by tracking whisker displacements before, during, and after compression. RESULTS: At low pressure, no functional loss was observed. At intermediate pressure, partial functional loss developed with return of normal function several days after decompression. High pressure demonstrated complete functional loss with incomplete recovery following decompression. Histology demonstrated uninjured, Sunderland grade III, and Sunderland grade V injury in nerves exposed to low, medium, and high pressure, respectively. COMPARISON WITH EXISTING METHODS: Existing animal models of entrapment neuropathy are limited by inability to measure and titrate applied pressure over time. CONCLUSIONS: Described is a miniaturized, wireless, fully implantable device for study of entrapment neuropathy in a murine model, which may be broadly employed to induce various degrees of neural dysfunction and functional recovery in live animal models.

Effect of pulse waveforms on movement amplitudes and perceived discomfort in electric muscle stimulation in unresolved facial nerve palsy.

Studies on the effects of the pulse waveform used in electrical muscle stimulation on the activations and perceived discomfort of the waveform have been mainly executed on limb muscles with variable results, however, knowledge of these effects on facial muscles is currently lacking. We studied two waveforms, square wave and sinusoidal wavelet, for the activation of the frontalis muscle in 9 individuals with unresolved facial nerve palsy. Both waveforms produced a movement that was greater in amplitude compared with the maximal voluntary movement of the affected side in 8 participants and at least as great as the healthy side's maximal voluntary movement in 4 participants. Both waveforms were equally successful in producing movements, and there was no significant difference in perceived discomfort ratings between the two waveforms. These findings will be useful for the future development of neuroprosthetic applications for reanimating facial muscles using electrical stimulation. Trial registration: ClinicalTrials.gov NCT03496025, registration date March 19, 2018.

Bell's Palsy in Pregnancy.

IMPORTANCE: The incidence and severity of Bell's palsy are increased in pregnancy, with most cases arising in the third trimester or postpartum period. It has been indicated that pregnancy-related Bell's palsy has worse long-term outcomes, such as complete facial paralysis, compared with nonpregnant women and males. OBJECTIVE: This article outlines the existing literature diagnosis, treatment, and prognosis of Bell's palsy, specifically looking at the implications during pregnancy. The aim is to provide a reference for physicians treating Bell's palsy in pregnant patients. EVIDENCE ACQUISITION: Existing literature on neuropathies during pregnancy, clinical presentation, and treatment of Bell's palsy was reviewed through a MEDLINE and PubMed search. Referenced articles were reviewed and used as primary source materials as appropriate. RESULTS: Multiple clinical tests of motor function are used to establish the diagnosis of Bell's palsy including Wartenberg's lid vibration test, an abnormal eyelash occlusion test, and asymmetry with voluntary and spontaneous smiling. Optimal treatment for Bell's palsy remains controversial. While early treatment with corticosteroids for 10 days is highly recommended, the simultaneous use of antiviral therapy is frequently performed but has less supporting evidence. Pregnancy itself and delay in treatment initiation are associated with persistent nerve palsy, whereas treatment started within 3 days of symptom onset is usually associated with full recovery. Recurrence of Bell's palsy in pregnancy is rare. CONCLUSIONS AND RELEVANCE: To date, there is limited literature in the diagnosis and treatment of Bell's palsy during pregnancy. The prognosis of Bell's palsy in pregnancy is worse than in nonpregnant individuals. Early treatment with steroids is recommended, but not without risk.

Latency shift in compound muscle action potentials during electroneurography in facial palsy.

OBJECTIVE: Electroneurography (ENoG) reliably predicts the prognosis of facial palsy. However, the results of ENoG are dependent on the location, where the wave is detected, as a compound muscle action potential (CMAP) arising from the facial muscles. To minimize errors in prognostic prediction, we analysed the latencies of facial CMAPs. MATERIALS AND METHODS: Fifty-seven patients with unilateral peripheral facial palsy and 24 healthy volunteers were enrolled. Amplitudes, negative peak latencies (NPL), and rise latencies (RL) of CMAPs were measured on the paralysed and healthy sides in patients and in healthy volunteers. The relationships of these latencies with ENoG values and the lowest House-Brackmann (H-B) scores were also analysed. RESULTS: The amplitude of CMAP on the paralysed side was smaller, and NPL and RL were longer, than those on the healthy side in patients and healthy volunteers (p < 0.01). In patients, there was no difference in NPL between the ENoG < 40% group and the ENoG ≥ 40% group. Conversely, there was a significant difference in RL between the ENoG < 40% group and ENoG ≥ 40% group (p = 0.03). No relationships were observed between NPL or RL and the lowest H-B score. CONCLUSIONS: NPL and RL of CMAP on the paralysed side were equivalent or longer than those on the healthy side. During ENoG for facial palsy, CMAP should be measured on the healthy side first, and then detected (and the amplitude measured) on the paralysed side with reference to CMAP latency on the healthy side, to reduce errors in detecting facial CMAPs.

Automated objective and marker-free facial grading using photographs of patients with facial palsy.

PURPOSE: An automated, objective, fast and simple classification system for the grading of facial palsy (FP) is lacking. METHODS: An observational single center study was performed. 4572 photographs of 233 patients with unilateral peripheral FP were subjectively rated and automatically analyzed applying a machine learning approach including Supervised Descent Method. This allowed an automated grading of all photographs according to House-Brackmann grading scale (HB), Sunnybrook grading system (SB), and Stennert index (SI). RESULTS: Median time to first assessment was 6 days after onset. At first examination, the median objective HB, total SB, and total SI were grade 3, 45, and 5, respectively. The best correlation between subjective and objective grading was seen for SB and SI movement score (r = 0.746; r = 0.732, respectively). No agreement was found between subjective and objective HB grading [Test for symmetry 80.61, df = 15, p < 0.001, weighted kappa = - 0.0105; 95% confidence interval (CI) = - 0.0542 to 0.0331; p = 0.6541]. Also no agreement was found between subjective and objective total SI (test for symmetry 166.37, df = 55, p < 0.001) although there was a nonzero weighted kappa = 0.2670; CI 0.2154-0.3186; p < 0.0001). Based on a multinomial logistic regression the probability for higher scores was higher for subjective compared to objective SI (OR 1.608; CI 1.202-2.150; p = 0.0014). The best agreement was seen between subjective and objective SB (ICC = 0.34645). CONCLUSIONS: Automated Sunnybrook grading delivered with fair agreement fast and objective global and regional data on facial motor function for use in clinical routine and clinical trials.

Infectious causes of peripheral facial nerve palsy in children-a retrospective cohort study with long-term follow-up.

The aim of this study was to analyze the clinical and laboratory characteristics of children with peripheral facial nerve palsy (pFP) with a focus on identifying infectious etiology and long-term outcome. We conducted an ICD-10-based retrospective chart review on children hospitalized with pFP between January 1, 2006, and December 31, 2016. Furthermore, a telephone-based follow-up survey was performed. A total of 158 patients were identified, with a median age of 10.9 years (interquartile range 6.4-13.7). An infectious disease was associated with pFP in 82 patients (51.9%); 73 cases were classified as idiopathic pFP (46.2%). Three cases occurred postoperatively or due to a peripheral tumor. Among the infectious diseases, we identified 33 cases of neuroborreliosis and 12 viral infections of the central nervous system (CNS), caused by the varicella-zoster virus, human herpesvirus 6, herpes simplex virus, enterovirus, and Epstein-Barr virus. Other infections were mainly respiratory tract infections (RTIs; 37 cases). Children with an associated CNS infection had more often headache and nuchal rigidity, a higher cerebrospinal fluid cell count, and a longer length of hospital stay. Long-term follow-up revealed an associated lower risk of relapse in CNS infection-associated pFP. Among all groups, permanent sequelae were associated with female sex, a shorter length of hospitalization, and a lower white blood cell count at presentation. pFP is frequently caused by an CNS infection or is associated with concurrent RTIs, with a potential impact on the short- and long-term clinical course.

Measurement of the depth of facial nerve at the level of stylomastoid foramen using MR imaging in Bell's palsy.

OBJECTIVES: To investigate whether the depth of the facial nerve from the skin surface as it exits the stylomastoid foramen differs between the paralyzed and unaffected sides in patients with Bell's palsy. METHODS: Forty-three patients (23 females, 20 males; mean age 43.8 ±â€¯15.2 years) diagnosed with Bell's palsy between January 2014 and June 2017 were retrospectively reviewed and those who had a cranial MR imaging performed within 10 days upon admission to hospital were included in the study. The axial postcontrast CUBE sequence was utilized for the measurement of the facial nerve depth. Age, gender, and body mass index (BMI) as well as concomitant chronic diseases, were also noted. The severity of facial paralysis was graded using the House-Brackmann (HB) scoring system. RESULTS: The facial nerve depth was significantly lower on the paralytic side compared to the unaffected side (32.9 ±â€¯5.4 mm vs. 36.9 ±â€¯5.1 mm, respectively; p = 0.007). The facial nerve depth on the paralytic side was not statistically different in the female patients compared to male patients (31.2 ±â€¯4.6 mm vs. 34.7 ±â€¯5.7 mm, respectively; p = 0.270). The facial nerve depth on the paralytic side was not correlated with patients' age (r = 0.288; p = 0.999), BMI (r = 0.215, p = 0.999), and HB scores (r = 0.031; p = 0.999). CONCLUSION: In our study cohort of patients with Bell's palsy, the facial nerve in the paralytic side is located more superficially as it exits the stylomastoid foramen when compared to the contralateral side. Therefore, the depth of the facial nerve may potentially play a key role in the etiology of Bell's palsy, which should be further evaluated.