Changes in the phosphorylation of neurofilament proteins in facial motoneurons following various types of nerve lesion

This report defines the conditions for changes in the phosphorylation state of neurofilaments (NF) after facial nerve lesions. In adult control rats, few phosphorylated neurofilament (pNF) epitopes were stained (using SMI 31 antibodies) in a small subpopulation of facial motoneurons. After various types of mechanical lesion (nerve transection with and without attaching a metal clip to the proximal nerve trunk, nerve crush, combined trigeminal and facial nerve lesions) of the right facial nerve, pNF immunoreactivity transiently increased in most cell bodies of facial motoneurons on the operated side. This pNF 'reaction' started within 2 days after the operation and persisted up to 2 weeks but remained longer in those animals in which axonal regeneration had been prevented or delayed by attaching a metal clip to the proximal nerve stump. After botulinum toxin application into facial muscles (i.e. inhibition of synaptic transmission at motoric endplates) there was no increase in the amount of pNF after 4 and 10 days, but it appeared in facial nuclei 4 weeks after injection on both, the treated and the untreated side, i.e. during functional restitution. Selectively transecting the 'vibrissal part' of the trigeminal nerve induced no obvious changes in the pNF immunoreactivity in facial motoneurons, but a combined trigeminal-facial lesion did. Labeling nonphosphorylated epitopes (using SMI 32 antibodies) showed a slight decrease in immunoreactivity in the neuropil of the facial nucleus 15 days after nerve transection and fixing a metal clip on the proximal nerve stump.

[Therapy of Frey syndrome with botulinum toxin A. Experiences with a new method of treatment]

The effectiveness of botulinum toxin for the treatment of Frey's syndrome is demonstrated. Since December 1993, 14 patients with severe symptomatic gustatory sweating have been treated at the ENT Department, University of Göttingen. Botulinum toxin A (approximately 0.5 U/cm2) was injected intracutaneously into the affected skin area as determined by Minor's starch iodine test. Gustatory sweating in the treated skin area ceased completely within 2 days and did not reappear during the period of following (13 months maximum follow-up). There were no side effects. Findings show that local botulinum toxin injections are a highly effective, safe and minimally invasive treatment for Frey's syndrome. Moreover, this could be a new therapeutic tool for other forms of hyperhidrosis.

Surgical management of benign tumors of the submandibular gland: a follow-up study

PURPOSE

This retrospective study evaluated data pertaining to history, symptoms, diagnosis, and mode of therapy of patients treated for benign tumors of the submandibular gland.

PATIENTS AND METHODS

The records of 38 patients were reviewed. The patients were divided into three groups: pleomorphic adenoma (first operation), pleomorphic adenoma (second operation for recurrence), and other tumors. Follow-up was done by questionnaires sent to the patient and referring doctor.

RESULTS

The vast majority of patients treated (92%) had had either a first or second operation for pleomorphic adenoma. Follow-up revealed that recurrence did not develop in the group of patients with primary surgery. However, one patient undergoing surgery for recurrent pleomorphic adenoma developed two recurrences. Two patients suffered from slight weakness of the lower lip.

CONCLUSION

Tumor recurrence was found only in the cases of second operation after previous surgery for pleomorphic adenoma. Therefore, the first operation should extirpate the entire gland to minimize the risk of recurrence.

Frey's syndrome: treatment with botulinum toxin

The effectiveness of botulinum toxin injections for the management of Frey's syndrome was studied. Botulinum toxin A (approximately 0.5 Units/cm2) was injected intracutaneously into the affected skin area as determined by Minor's starch iodine test. Gustatory sweating in the treated skin area ceased completely within 1 week and has not reappeared (12 months follow up until now in the first treated case). There have been no side effects. It is concluded that local botulinum toxin injections are a highly effective and safe treatment for Frey's syndrome. Additional study is required to evaluate the duration of the therapeutic effect.

[Exulcerating cystadenolymphoma of the parotid gland. A case report]

A recurrent adenolymphoma of the left parotid gland occurring in a 79-year-old woman is reported having caused an extensive ulceration of the epidermis, clinically suggestive of a malignant tumour. The ulcerative tumour process cannot be explained by a particular pattern of growth or a malignant transformation of the adenolymphoma. It is assumed that residual tumour cells of the initially incompletely removed adenolymphoma spread via a long-standing postoperative fistula to the epidermis leading to the uncommon ulceration.

Structural dynamics of synapses and synaptic components

Learning and memory formation are apparently based on cascades of molecular and cellular processes with increasing time constants (ms to days and weeks), but even the most long-lasting effects are transient. Memory traces may permanently modify the behavior (activity patterns, gene expression) of neurons and neuronal networks. Therefore the question is raised whether our current view on the stability of synapses under normal conditions is tenable. Evidence is reviewed suggesting that as direct or indirect effects of modifications in bioelectrical activity and chemical trophicity, synapses may be remodeled and removed within days and weeks, and possibly within hours. Accordingly, species-specific connectivity patterns are not restricted to the standard architecture of the CNS, but (morpho-)genetics allow for a considerable number of alternative wiring patterns, which appear under unusual conditions during ontogenesis and in adulthood. Our present knowledge suggests that, rather than the formation of synapses, they are a selective process. Until now there is no direct method of measuring either synaptic reorganization or the average life span of synapses. Specific cases, however, allow to estimate synapse turnover during ontogenesis, at its lowest possible level. Such data suggest that each synapse is on average remodeled or replaced several to many times during normal developmental, e.g. in the cerebral cortex of Marmoset monkeys at the very least 5 to 10 times (corresponding to 250 million synapses eliminated per hour in area 17!). It is discussed how the consequences of synapse turnover could be utilized by learning processes. Conclusions are followed by an outlook.

Orbicular synkinesis after facial paralysis: treatment with botulinum toxin

Involuntary lid closure not rarely accompanies aberrant regeneration of nerve fibers after different types of facial paralysis. 23 patients with such synkinesis were treated with botulinum toxin injections into the orbicularis oculi muscle. After periocular injections all patients showed much improvement: a period of, on the average, 13 symptom-free weeks was followed by a period of minimal symptoms. There were only minor complications. Whenever repeated treatment is necessary, botulinum toxin proves to be an effective therapy for involuntary lid closure after defective healing following facial paralysis.

Botulinum toxin treatment in patients with hemifacial spasm

Hemifacial spasm is nearly always a unilateral disease of the facial musculature and is characterized by involuntary tonic or clonic cramps that considerably reduce the affected patient's quality of life. In the past, a number of different conservative and operative therapeutic procedures have been applied for the treatment of hemifacial spasm. In many cases these attempts failed to control the disease permanently or resulted in unwanted, sometimes strong, side effects. We report our own experiences with botulinum therapy in 29 patients with hemifacial spasm (78 therapeutic sessions). In our patients the mean duration of an effect after treatment with botulinum toxin was 18.2 weeks. Side effects were rare. Our results since 1990 at the University of Göttingen demonstrate that subcutaneous application of toxin from Clostridium botulinum to involved facial muscles represents a reliable method for successful treatment of hemifacial spasm.

[Prognostic value of electrodiagnosis of Bell's palsy]

Many papers report on a poor rate of complete restitution of Bell's palsy if signs of degeneration can be detected in neuromyography (NMG) or electromyography (EMG). In 119 patients who underwent infusion therapy (as developed by Stennert) 39% showed signs of degeneration in EMG or NMG. Complete restitution was achieved in 93% of these patients. Degeneration was more frequent in elderly patients (< 20 years: 20%, > 60 years: 55%). This did not affect the rate of complete restitution, which was constantly high for every age. If infusion therapy was started within 7 days after onset of the disease, no defects in restitution were observed, which was frequently so if therapy was started later. After one year the rate of complete restitution was about equal in cases with signs of degeneration (91%) and non-degenerative cases (94%). But 80% of the non-degenerative cases showed complete restitution within 3 months after onset of the palsy, whereas 80% of cases with signs of degeneration healed after this date (mean 6.1 months). After oral therapy with cortisol exclusively half of the degenerative cases did not attain complete restitution. After infusion therapy EMG and NMG do not answer the question if a Bell's palsy will heal completely or not but enable us to predict when this will probably be the case.

Astrocytes as rapid sensors of peripheral axotomy in the facial nucleus of rats

Facial nerve transection leads to functional and structural reactions in lesioned motor neurones and surrounding glial cells. Data from this study provide evidence that the most rapid reaction described so far consists of an increase in immunoreactivity of connexin-43 (cx-43), the predominant gap junction protein in astrocytes. The ipsilateral facial nucleus is selectively marked as early as 0.75 to 1.5 hours after axotomy, while the unlesioned side as well as the unoperated controls remain faintly stained. Thus, enhanced coupling capacity of astrocytes by gap junctions appears to be a sensitive indicator of modified neuronal-glial interaction in the CNS.

Facial nerve lesions lead to increased immunostaining of the astrocytic gap junction protein (connexin 43) in the corresponding facial nucleus of rats

After peripheral transection of the facial nerve, immunostaining of astrocytic gap junction protein changed in the corresponding brainstem nucleus of the rat. Enhanced connexin-43 immunoreactivity was restricted to the ipsilateral facial nucleus and to astrocytes surrounding lesioned motoneurons. This reaction is focally distinct, and marks only a part of the astrocytic network indicating a local plasticity of intercellular coupling. These results suggest that astrocytes work as sensors of signals which either depend on the integrity of neighboring neurons or inform about neuronal disorders.

[Psychosocial problems and coping with illness by patients with defective healing after facial paralysis]

Twenty patients with defective healing following idiopathic or infection-induced facial paralysis (group 1) and 14 patients with defective healing after excision of an acoustic neuroma and subsequent hypoglossal-facial nerve anastomosis (group 2) were questioned as to their psychosocial conditions. The principle gueries involved the impact of facial impairment on social activities, behavior in public, professional performance and communication, as well as strategies in coping with disfigurement. One third of the patients (with a majority in group 2) experienced stigmatization and a feeling of embarrassment or anxiety in public. Many patients minimized facial expressions and communication in order to hide their paralyses. In particular, patients in group 2 frequently had to change their employment and had great problems in accepting their conditions. Additional problems had with a clinical diagnosis of "acoustic neuroma" involved greater stress and more pronounced social withdrawal than experienced by the patients with idiopathic pareses.

[Electrophysiologic studies of the pattern of lesions of mimetic muscles in Bell's palsy]

This paper reports on 379 investigations of patients with the diagnosis of Bell's palsy. The computerized analysis was carried out retrospectively with the programme FANDOS (6). In most electrophysiological measurements five standard muscles (frontalis muscle, orbicularis oculi muscle, levator labii muscle, zygomaticus muscle, orbicularis oris muscle) were investigated with electromyography (EMG); further, neuromyography was performed. In 77.3% of the cases electromyographically incomplete and 22.7% complete palsies were found. The distribution of the reduced innervation patterns and the degeneration of the muscles did not show a preferred lesion of certain muscles. In about sixty per cent of all cases in at least four muscles a homogeneous electromyographic pattern of the lesion in the mimic musculature could be detected. Degeneration potentials, however, were mostly found in one muscle only. In order to provide a differentiated analysis of the electromyographical state of a facial paresis an "EMG-index" was introduced that allows a general judgement of the "degree of palsy" in all five investigated muscles. An analysis of the time dependence of the "EMG-index" over the course of two weeks following onset of the palsy showed no variation during this time period. This proves that the complete status of the palsy is reached early after onset and that a deterioration or improvement is rarely seen within this time interval.

[Involuntary lid closure caused by defective healing of facial paralysis and its treatment with botulinum toxin]

Unvoluntary lidclosure with movement of the mouth is not so rare in aberrant regeneration of nerve fibers after Bell's palsy. There was no therapy until now. 10 patients with this disease were treated with botulinum-toxin injections into the orbicularis muscle. For an average time of 11 weeks after injection there was a complete absence of synkinesis, followed by a time of 9 weeks of less complaints. Thus 2-3 injections might be sufficient treatment within a year. Complications worth mentioning, especially due to the reduced force of lidclosure, were not observed.

[Magnetic stimulation in patients with essential blepharospasm]

In 31 patients with an essential blepharospasm investigations were undertaken with transcranial cortical and cisternal magnetic stimulation of the facial nerve. Cortical stimulation was performed contralaterally, whereas cisternal stimulation was ipsilateral; the latencies and amplitudes of the potentials were determined. However, the extracranial part of the facial nerve was stimulated in the region of the stylomastoid foramen for neuromyography electrically. In most measurements the response potentials in the orbicularis oculi muscle and the levator labii muscle were determined. Cisternal stimulation yielded normal latencies, whereas cortical stimulation showed an increase of latency in some blepharospasm patients. A difference between the orbicularis oculi muscle and the levator labii muscle as known in patients with hemifacial spasm (20) could not be observed. The mean values of all latencies after cortical stimulation were normal. The method of transcranial magnetic stimulation is an important part of the complete investigation of patients with facial hyperkinesias as shown here in blepharospasm patients.

The effects of botulinum toxin on hemifacial spasm: an electrophysiologic investigation

Forty-one patients with unilateral or bilateral facial spasm were studied by electrophysiologic examination. All patients received local treatment with botulinum toxin. In the patients and controls, the measurements of the blink reflex revealed changes that (1) may indicate a central origin of the spasm in some cases, and (2) make it likely that the trigeminal nerve influences the facial nucleus and is thus involved in the regulation of the spasm.

[Squamous cell carcinoma in the area of the parotid gland. Metastasis or primary tumor?]

A total of 61 patients with a histological diagnosis of squamous cell carcinoma of the parotid gland were studied. The patients were classified into three categories. There were 34 patients with a metastasis to the parotid gland from a squamous cell carcinoma elsewhere within the head and neck who presented on average 2.1 years (range 3 months to 7 years) after diagnosis of the primary tumour; in one case a salivary gland tumor presented 32 years after irradiation of a squamous cell carcinoma of the temple. Six patients had histological evidence of a metastasis within the parotid gland, but no evidence of a primary tumour. Twenty-one patients presented with a primary epidermoid carcinoma of the parotid gland. Two patients showed a primary squamous cell carcinoma of the parotid arising in myoepithelial sialadenitis.

[Botulinum toxin treatment of synkinesia following facial paralysis]

We report ten patients with unilateral synkinesias after facial palsy treated with botulinum toxin injections. All patients suffered from extensive mass movements around the eye. After periocular injections all patients showed much improvement: a period of 11 weeks free of symptoms was followed by a 9-week period of minimal symptoms. There were no important complications. The use of botulinum toxin injections is an effective therapy for mass movements after defect healing of facial palsy.

[Esophageal caustic injury in childhood. A critical elucidation with indication for esophagoscopy]

From 1983 through 1988, esophagoscopies were performed in 41 children because of suspected caustic esophageal injury. Of these 41 children, 11 had endoscopically significant esophageal burns and were treated with steroids and antibiotics. Of these 11 patients, two had no chemical burns of the facial skin, mouth, or pharyngeal mucosa. The authors therefore believe that esophagoscopy must not be omitted in cases of suspected caustic ingestion.

[Magnetic stimulation in patients with facial hemispasm]

A total of 28 patients with a hemifacial spasm were examined using transcranial magnetic stimulation. The potentials were evoked cortically and cisternally; latencies and amplitudes of each potential were measured in the levator labii muscle and in the orbicularis oculi muscle. After cortical stimulation, differences in latencies were found between the healthy and the diseased side of the levator labii muscle. Prolonged latencies were measured more frequently on the diseased side (cortical stimulation). The method of magnetic stimulation is an important addition to electrophysiological diagnostic procedures in facial hyperkinesias. Cortical stimulation combined with measurements of the blink reflex and neuromyography may allow separate parts of the route of the whole facial nerve and supranuclear structures to be examined.

[Relevance of combined electrodiagnosis in facial hyperkinesia]

We present a combined electrophysiological diagnostic procedure for patients with facial hyperkinesia. With the new method of magnetic stimulation a central cortical stimulation is possible to represent the total way of the facial nerve. The combination of magnetic stimulation with other methods such as the blink reflex may lead to topodiagnostic statements in facial hyperkinesias.