Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies

Facial and hearing outcomes in transmastoid nerve decompression for Bell's palsy, with preservation of the ossicular chain

Objectives

Facial nerve decompression is a salvage treatment for Bell's palsy patients for whom a poor prognosis is anticipated with standard medical treatment. The transmastoid approach is a frequently performed approach, but it remains unknown if this surgery is effective when the ossicular chain is preserved. This study aimed to determine the efficacy of facial nerve decompression using the transmastoid approach in Bell's palsy.

Design, setting and participants

This retrospective study included patients who had undergone transmastoid facial nerve decompression with ossicular chain preservation and patients who met the criteria for surgery, but received only medical treatment between January 2007 and May 2019, at a single centre.

Main outcome measures

Attainment of House‐Brackmann grade I at 12 months after onset of facial palsy.

Results

The recovery rate to House‐Brackmann grade I in the decompression group in the early phase (≤18 days after onset) was higher than that of the medical treatment group, although the difference was not significant (70% vs 47%, P = .160). However, within this early surgery group, a subgroup of cases with ≥95% facial nerve degeneration demonstrated a significant improvement in recovery rate (73% vs 30%, P = .018). Among surgeries performed in the late phase (≥19 days), only a subgroup with ≥95% facial nerve degeneration was available for analysis, and the difference in recovery rate was not significant compared with medical treatment alone (26% vs 30%, P = 1.00). Post‐surgical hearing evaluation demonstrated that average hearing deterioration was 1.3 dB which was non‐significant, suggesting this procedure does not cause hearing loss.

Conclusions

Transmastoid facial nerve decompression with ossicular chain preservation in the early phase after symptom‐onset is an effective salvage treatment for severe Bell's palsy with ≥95% facial nerve degeneration.

Hematologic parameters as predictive markers in pediatric Bell's palsy

PURPOSE

To analyze various hematological parameters in pediatric population with Bell's palsy (BP) and to determine the most valuable parameter as a prognostic marker.

METHODS

Fifty-nine patients with BP under 18 years were enrolled, and patients were divided into three groups: recovery group (49 cases), non-recovery group (10 cases) and controls (65 healthy children). Age, white blood cell (WBC), hemoglobin (Hbg), mean platelet volume (MPV), red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and C-reactive protein-to-albumin ratio (CAR) were determined and compared between groups. Additionally, the receiver operating characteristics (ROC) analysis was carried out, and the most valuable marker to demonstrate the prognosis among these parameters was investigated.

RESULTS

While mean age was found as 10.69 ± 5.76 years, 28 (47.5%) female and 31 (52.5%) male pediatric patients were determined to be followed up due to BP in our hospital. When such parameters age, mean Hbg, MPV and RDW were examined, no significant difference was detected between groups. However, compared controls with recovery and non-recovery groups, WBC, NLR, PLR and CAR were found to be significantly higher, respectively (p < 0.05). Median CAR and NLR values were found to be significantly higher in non-recovery group, compared to those in recovery group (p = 0.001, p = 0.012, respectively). However, when median WBC and PLR were examined between recovery and non-recovery groups, no significant difference was observed (p > 0.05).

CONCLUSION

High NLR and CAR values in pediatric BP may be related to poor prognosis in such patients. CAR, however, is a more valuable parameter than NLR in terms of indicating poor prognosis.

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.

Diagnostic value of dynamic contrast-enhanced MRI in Bell's palsy: initial experience

AIM

To assess the ability of conventional magnetic resonance imaging (MRI) combined with dynamic contrast-enhanced (DCE)-MRI to accurately identify characteristic imaging findings of Bell's palsy particularly in involved segments.

MATERIALS AND METHODS

A retrospective analysis was performed on MRI images of patients with Bell's palsy in Shanghai Ninth People's Hospital from January 2015 to July 2019. DCE-MRI analysis was performed on a SIEMENS Workstation Extended MR Work Space 2.6.3.5 and by using the T1-weighted volumetric interpolated breath-hold examination (VIBE) sequence. Statistical analyses were performed by using SPSS v. 19.0. The chi-square test was used to compare the accuracy of conventional MRI versus DCE-MRI in imaging the involved segment of the facial nerve.

RESULTS

Combined with the results of the surgery, the accuracy of conventional MRI in imaging the involved segments of the affected facial nerves was 38.5% (5/13), but was 92.3% (12/13) for DCE-MRI. There was a statistically significant difference between the two groups (chi-square value is 8.327, p = 0.004).

CONCLUSION

DCE-MRI is useful to diagnose the involved segments of the affected facial nerve accurately compared to the conventional MRI. This approach has advantages both for the patient, in terms of safety, and for the physician, in terms of the accuracy of the diagnosis.

Modern Management of Facial Nerve Disorders

Facial paralysis is a devastating condition, encompassing a spectrum of disorders, with resultant psychosocial, functional, and aesthetic sequelae. With this in mind, an individualized treatment approach based on the cause, pattern, and duration of palsy is necessary. Treatment options include pharmacologic agents, corneal protective interventions, physical therapy, and surgical procedures. The use of steroids and antivirals in the setting of idiopathic facial paralysis or virus-associated facial paralysis is well supported. Despite the diversity of surgical interventions described, there is a lack of consensus regarding optimal treatment. This article provides an overview of the current management of facial paralysis. Medical, surgical, and physical treatment options are discussed with a review of the relevant literature.

HIV infection, seasonality and younger age predicting incident Bell's palsy among black South Africans

Background

Although South Africa (SA) is facing a high prevalence of HIV infection, there is no literature from this region on a link between Bell’s palsy and HIV. The aim of this study was to identify the occurrence of Bell’s palsy in relation to demographics, seasons and HIV status among black South Africans.

Methods

This retrospective cohort was conducted among adult black patients, without Bell’s palsy in 2003, presenting to the neurology outpatients department at Dr. George Mukhari Academic hospital, Pretoria, South Africa, between 2004 (study baseline) and 2012 (end test). Gender, age, HIV status, and seasons were potential predictors of Bell’s palsy using Cox regression model and Kaplan Meier curves.

Results

From the baseline of 1487 patients, 20.9% (n = 311) experienced Bell’s palsy onset by the end of the study. In univariate analysis, male gender (RR = 2.1 95% CI 1.7–2.5; P <  0.0001), age less than 30 years (RR = 2.9 95% CI 2.4–3.6; P <  0.0001), HIV seropositivity (RR =2.9 95% CI 2.3–4.9; P < 0.0001).

The highest incidence in winter (30.3% n = 136/450) vs. incidences during other seasons with Intermediate values during Summer (25.3% n = 136/450) and Autumn (20.7% n = 64/308) and the lowest incidence in Spring (23.7% n = 16/353) P < 0.0001) were predictors of Bell’s palsy. In multivariate analysis at adjusting for gender, the most significant and independent predictors of incident Bell’s palsy were HIV seropositivity (HR = 6.3 95% CI 4.8–8.3; P < 0.0001), winter (HR = 1.6 95% CI 1.2–2.1; P < 0.0001) vs. other seasons, and younger age < 30 years (HR = 7.1 95% CI 5.6–9.1; P < 0.0001) vs. older age groups.

Conclusion

Seasonality, younger age and HIV positivity are important and independent risk factors of Bell’s palsy. Education and awareness programs on the possible effects of HIV and seasons on the development of Bell’s palsy are necessary. This would lead to a better understanding and even a possible development of avoidance measures for this condition amongst young black South Africans.

Usefulness of electrophysiology in the prediction of outcome of Bell’s palsy patients

Background

Bell’s palsy (BP) is a common idiopathic cranial mononeuropathy. The electrophysiological tests are one of supportive tools for localizing the site of facial nerve lesion, and to determine the severity and prognosis of the injury. The aim of this study was to evaluate the role of electrophysiology in the prediction of outcome of patients with Bell’s palsy. This study was carried out on 30 adult patients with Bell’s palsy. All study subjects were assessed clinically by Sunnybrook facial nerve grading score (SBS) and electrophysiologically by electroneurography (ENoG), blink reflex (BR), and electromyography (EMG); first evaluation was within 7th to10th day from onset, the second evaluation was done at 20th day, and the follow-up visit was after 1 month to assess the clinical grading system (SBS).

Results

At 1 month, 20 patients (66.7%) had good recovery, while 10 patients (33.3%) had poor recovery according to the Sunnybrook scale. Multiple logistic regression analysis showed that the most significant predictive indicator of BP recovery was ENoG value and R1 latency of BR test. The receiver operating characteristic (ROC) curves showed ENoG degeneration index of 74.6%, considered as a critical cutoff value of non-recovery, with the sensitivity 95% and specificity 90%, and the highest specificity was with blink reflex parameters (R1, R2 latency) 100%.

Conclusion

BR and ENoG were the best predictors of non-recovery of facial function, while EMG findings did not add any prognostic significance. The combination of both tests BR and ENoG, along with clinical findings can be considered a good indication in the acute phase of BP for the possibility to develop palsy residua.

[Sequelae in bell's palsy: Prognostic factors for recovery]

OBJECTIVES

Facial palsy can be assessed using objective and subjective tools. The main purpose of this work was to use these tools to determine at 12 months the percentage of patients with sequelae and to specify the type of sequelae.

MATERIAL AND METHODS

Twenty-three patients with facial palsy were followed in this prospective and longitudinal study. They have been evaluated every 3 months during a year with the House and Brackmann grading scale and the Sunnybrook Facial Grading System. At 12 months, group A was composed of patients with complete recovery and group B, patients with sequelae.

RESULTS

At 3 months, in patients of group B, the House-Brackmann grading scale (P=0.0134), the Sunnybrook Facial Grading System global score (P=0.0283) and dynamic score (P=0.0148) were lower than group A. Moreover, the movement "brow lift" (P=0.0181) seems to be relevant to predict follow-up. Synkinesis on "brow lift" (P=0.0270) and the treatment delay (P=0.0384) increased for group B. Sex, age, paralyzed side and recurrence of facial palsy had no influence.

CONCLUSION

Objective and subjective tools determine thresholds and predictive scores of recovery with sequelae at 1 year. Nevertheless, it is relevant to assess clinically specific facial movements, such as "brow lift", to specify a recovery potential and to predict sequelae a year after the onset of facial palsy. As the treatment delay influences recovery, drug treatment should be recommended as early as possible.

Facial Electromyography Mapping in Healthy and Bell's Palsy Subjects: A High-Density Surface EMG Study

Bell's palsy impairs the symmetry of facial appearance and movement. Detailed examination of facial muscle activities should be important for the diagnosis and treatment of the Bell's palsy. In this study, facial muscle activities in normal and Bell's palsy conditions were measured using a high-density (HD) electromyography (EMG) technique. The EMG signals during active tasks (four different facial expressions) and resting task were collected with a HD array of EMG electrodes from forehead and cheek muscles. To visualize facial EMG activities, the EMG maps were reconstructed from the HD-EMG recordings. The two-dimension (2D) correlation coefficients between right and left sides of facial EMG maps were calculated to evaluate the symmetry of facial muscle activities during these tasks. Our experimental results showed that the 2D correlation coefficients during active tasks were different significantly (P<0.01) between the healthy group(n=4) and Bell's palsy group(n=3). These results demonstrated that the synchronism of facial muscle activities during active tasks in healthy subjects is greater than that in the Bell's palsy subjects. This pilot study suggested that HD-EMG would be a potential technique to assess abnormal asymmetric activities of facial muscles for Bell's palsy.

Raising the Digital Profile of Facial Palsy: National Surveys of Patients' and Clinicians' Experiences of Changing UK Treatment Pathways and Views on the Future Role of Digital Technology

BACKGROUND

Facial nerve palsy leaves people unable to move muscles on the affected side of their face. Challenges exist in patients accessing facial neuromuscular retraining (NMR), a therapy used to strengthen muscle and improve nerve function. Access to therapy could potentially be improved through the use of digital technology. However, there is limited research available on patients' and clinicians' views about the potential benefits of such telerehabilitation based on their lived experiences of treatment pathways.

OBJECTIVE

This study aims to gather information about facial palsy treatment pathways in the United Kingdom, barriers to accessing NMR, factors influencing patient adherence, measures used to monitor recovery, and the potential value of emerging wearable digital technology.

METHODS

Separate surveys of patients with facial palsy and facial therapy specialists were conducted. Questionnaires explored treatment pathways and views on telerehabilitation, were co-designed with users, and followed a similar format to enable cross-referencing of responses. A follow-up survey of national specialists investigated methods used to monitor recovery in greater detail. Analysis of quantitative data was conducted allowing for data distribution. Open-text responses were analyzed using thematic content analysis.

RESULTS

A total of 216 patients with facial palsy and 25 specialist therapists completed the national surveys. Significant variations were observed in individual treatment pathways. Patients reported an average of 3.27 (SD 1.60) different treatments provided by various specialists, but multidisciplinary team reviews were rare. For patients diagnosed most recently, there was evidence of more rapid initial prescribing of corticosteroids (prednisolone) and earlier referral for NMR therapy. Barriers to NMR referral included difficulties accessing funding, shortage of specialist therapists, and limited awareness of NMR among general practitioners. Patients traveled long distances to reach an NMR specialist center; 9% (8/93) of adults reported traveling ≥115 miles. The thematic content analysis demonstrates positive attitudes to the introduction of digital technology, with similar incentives and barriers identified by both patients and clinicians. The follow-up survey of 28 specialists uncovered variations in the measures currently used to monitor recovery and no agreed definitions of a clinically significant change for any of these. The main barriers to NMR adherence identified by patients and therapists could all be addressed by using suitable real-time digital technology.

CONCLUSIONS

The study findings provide valuable information on facial palsy treatment pathways and views on the future introduction of digital technology. Possible ways in which emerging sensor-based digital technology can improve rehabilitation and provide more rigorous evidence on effectiveness are described. It is suggested that one legacy of the COVID-19 pandemic will be lower organizational barriers to this introduction of digital technology to assist NMR delivery, especially if cost-effectiveness can be demonstrated.

Electrodiagnostic testing in acute facial palsy: Outcomes and comparison of methods

OBJECTIVE

To study the relationship between various electrodiagnostic modalities in acute facial palsy.

SETTING

Academic tertiary care center.

PATIENTS

One-hundred and six patients who presented with traumatic or non-traumatic acute facial paralysis (House-Brackmann, HB, grade 6/6) between 2008 and 2017 and underwent acute electrodiagnostic testing.

INTERVENTION

Electroneurography (ENoG) using nasolabial fold (NLF) or nasalis muscle (NM) methods, and volitional electromyography (EMG) in all patients.

MAIN OUTCOME MEASURES

Percent degeneration of ipsilateral facial nerve compound muscle action potentials (CMAP) on NLF- and NM-ENoG, presence or absence of muscle unit potentials (MUPs) on EMG.

RESULTS

Extent of facial nerve degeneration measured by NLF- and NM-ENoG were highly correlated (r = 0.85, P < .01) on each test and on serial testing. NLF- and NM-ENoG concordantly diagnosed ≥90% degeneration in 44 patients (80%), of whom 32 patients were diagnosed to have 100% degeneration by both methodologies. Absence of MUPs on EMG was 63% sensitive and 92% specific for ≥90% degeneration on ENoG, with a positive predictive value of 90%. For patients with Bell's palsy, percent degeneration on ENoG was also correlated to HB score at 1 year. Surgical decompression resulted in mean HB scores of 2.2 and 3.0 for patients with Bell's palsy and trauma, respectively.

CONCLUSIONS

NM-ENoG may be a valid and comparable method to NLF-ENoG for predicting the recovery of facial nerve function in acute paralysis. Absence of MUPs on EMG is a specific measure of severe degeneration and highly predictive of candidacy for surgical decompression.

LEVEL OF EVIDENCE

Level 3.

Activity limitations and participation restrictions in patients with peripheral facial palsy: a cross-sectional study over a six-year period

BACKGROUND

Peripheral facial palsy is a pathological condition caused by a wide range of etiologies. A damage of VII cranial nerve produces facial disfigurement and limitations in daily life activities, such as drinking, eating and speaking. As a consequence, patients may experience psychological distress and social isolation. To counsel and design a patient-tailored rehabilitation for patients affected by peripheral facial palsy, physical and social limitations should be considered. Moreover, the knowledge of factors associated with disability plays a key role in the early identification and adequate care of patients with higher risk to develop psychological distress and participation restrictions.

AIM

To evaluate activity limitations, psychological distress and participation restrictions of patients affected by peripheral facial palsy seeking for rehabilitation and to identify individual and disease-specific factors associated to disability.

DESIGN

Cross-sectional study.

SETTING

Consultation hour dedicated to facial palsy patients in the outpatient clinic of a Rehabilitation Unit.

POPULATION

One hundred eighty-six outpatients with recent or chronic peripheral facial palsy at the first assessment at our Rehabilitation Unit.

METHODS

Using multiple linear regression models, we evaluated the association between the two subscales of Facial Disability Index (FDI) and the composite score of Sunnybrook Facial Grading System, as well as the association between the two FDI subscales and other clinical and demographic variables.

RESULTS

Activity limitations correlate with the severity of palsy, while psychological distress and participation restrictions do not correlate with the neurological impairment. The correlation between the severity of palsy and both activity limitations and participation restrictions is influenced by palsy etiology. Activity limitations decrease with time from palsy onset, while psychological distress and participation restrictions are more severe in women.

CONCLUSIONS

Beyond severity, also etiology, time from onset and gender influence disability after facial palsy. These factors should be considered in counselling and planning a patient-tailored multidisciplinary rehabilitative treatment.

CLINICAL REHABILITATION IMPACT

Our study highlights the individual and pathology-associated factors related to activity limitations and participation restrictions in patients with peripheral facial palsy. These elements should be considered in the definition of a patient-tailored rehabilitative plan and in the organization of a multidisciplinary care.

Facial Nerve Palsy: Clinical Practice and Cognitive Errors

Facial paralysis is the most common cranial nerve paralysis and the majority of these are idiopathic. Idiopathic facial nerve paralysis, or Bell palsy, typically presents acutely, affects the entire face, may be associated with hyperacusis, a decrease in lacrimation, salivation, or dysgeusia, and typically resolves spontaneously. The diagnosis of idiopathic facial paralysis is made after a thorough history and physical examination to exclude alternative etiologies and follow-up to ensure recovery of facial function. Atypical presentation, recurrent paralysis, additional neurologic deficits, lack of facial recovery in 2-3 months, or a history of head and neck or cutaneous malignancy are concerning for alternative causes of facial paralysis requiring workup. The erroneous use of the eponym Bell palsy to refer to all causes of facial paralysis, regardless of the history and presentation, may result in cognitive errors, including premature closure, anchoring bias, and diagnosis momentum. Hence, we recommend replacing the eponym Bell palsy with idiopathic facial nerve paralysis.

Peripheral facial paralysis as presenting symptom of COVID-19 in a pregnant woman

Acute facial nerve disease leading to peripheral facial paralysis is commonly associated with viral infections. COVID-19 may be a potential cause of peripheral facial paralysis and neurological symptoms could be the first and only manifestation of the disease. We report a case of a term pregnancy diagnosed with COVID-19 after presenting with isolated peripheral facial palsy.

Risk of Leukemia in Children With Peripheral Facial Palsy

Most children with peripheral facial palsy will not have a cause identified. Although leukemia can cause facial nerve palsy, the magnitude of the risk is unknown and recommendations for investigations are variable. We are currently conducting a randomized, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children within the Paediatric Research in Emergency Departments International Collaborative emergency research network. In the course of the assessment for eligibility of the trial, from 644 acute-onset facial palsy presentations we identified 5 children with previously undiagnosed leukemia. We estimate the rate of leukemia in children with acute-onset facial palsy who present to emergency departments to be 0.6% (95% confidence interval 0.2% to 1.6%). In accordance with these cases, we suggest consideration of a screening CBC count for acute-onset peripheral facial palsy presentations in children before initiation of corticosteroid treatment.

Ramsay Hunt syndrome: long-term facial palsy outcome assessed face-to-face by three different grading scales and compared to patient self-assessment

Purpose

To determine the long-term facial palsy outcome of Ramsay Hunt Syndrome by face-to-face grading by House–Brackmann Grading System, Facial Nerve Grading System 2.0, and Sunnybrook Facial Grading System concomitantly. To compare the applicability of the grading scales. To compare patients’ self-assessed facial palsy outcome results to gradings performed by the investigator. To compare the face-to-face assessed facial palsy outcome to the initial palsy grade.

Methods

Fifty-seven patients self-assessed their facial palsy outcome and came to a one-time follow-up visit. The palsy outcome was graded by one investigator using the three above-mentioned grading systems concomitantly. The median time from syndrome onset to follow-up visit was 6.6 years.

Result

A good long-term face-to-face assessed palsy outcome was enjoyed by 84% of the patients. Trying to assess only one House–Brackmann grade to represent the palsy outcome was impossible for most patients. Facial Nerve Grading System 2.0 worked better, but needed adjustments and certain sequelae findings needed to be neglected for it to be executable. The Sunnybrook system worked the best. Nearly 20% of the patients assessed themselves differently from the investigator: both better and worse.

Conclusion

The Sunnybrook scale was the most applicable system used. With antiviral medication, the outcome of facial palsy in Ramsay Hunt syndrome starts to resemble that of Bell’s palsy and emphasizes the importance of recognizing the syndrome and treating it accordingly. The results give hope to patients instead of the gloomy prospects that have stigmatized the syndrome.

Mirror Book Therapy for the treatment of Idiopathic Facial Palsy

OBJECTIVE

To determine the utility of treating facial palsy with mirror book therapy in conjunction with facial physical rehabilitation.

METHODS

We randomly selected and reviewed the charts of 25 patients with idiopathic facial palsy. 10 of these patients received facial physical rehabilitation including manual therapy and postural exercises. 15 of these patients received mirror book therapy in conjunction with standard facial rehabilitation. Before and after treatment, patients in both groups were rated using the Facial Grading System (FGS) score, the Facial Disability Index--Physical (FDIP) score, and the Facial Disability Index--Social (FDIS) score. Differences in response to therapy were analyzed.

RESULTS

Patients in the facial physical rehabilitation group without mirror book therapy group showed on average a 20.8% increase in the FGS score, a 19% increase in the FDIP score, and a 14.6% increase in the FDIS score. Patients in the mirror book therapy group showed an average of 24.9% increase in the Facial Grading System (FGS) score, a 21.6% increase in the Facial Disability Index--Physical (FDIP) score, and a 24.5% increase in the Facial Disability Index--Social (FDIS) score.

CONCLUSION

The addition of mirror book therapy to standard facial rehabilitation treatments does significantly improve outcomes in the treatment of idiopathic facial palsy.

Medial Pontomedullary Stroke Mimicking Severe Bell’s Palsy: A Case Report

Introduction: Patients with acute unilateral upper and lower facial palsy frequently present to the emergency department fearing they have had a stroke, but many cases are benign Bell’s palsy. Case Report: We present a rare case of a medial pontomedullary junction stroke causing upper and lower hemifacial paralysis associated with severe dysphagia and contralateral face and arm numbness. Conclusion: Although rare, pontine infarct must be considered in patients who present with both upper and lower facial weakness. Unusual neurologic symptoms (namely diplopia, vertigo, or dysphagia) and signs (namely gaze palsy, nystagmus, or contralateral motor or sensory deficits) should prompt evaluation for stroke.

Development of a smartphone app for neuromuscular facial training

BACKGROUND

Several studies have demonstrated a significant benefit of neuromuscular facial training in the rehabilitation of patients with facial palsy. However, printed instructions for home training are often not of optimum quality and associated with low adherence to therapy. Professional guidance, e.g., by occupational therapists, is regarded as being of high quality, but is associated with a high cost burden, particularly in chronic forms of disease.

OBJECTIVE

The idea to develop a smartphone app for facial training arose from the above-described situation. The aim was to provide structured exercises for the mimic muscles in the sense of neuromuscular training with visual feedback via the front camera of the device.

MATERIALS AND METHODS

A native app architecture in iOS was chosen to implement the graphical and content-related concept. In the Apple Xcode (Apple, Cupertino, CA, US) development environment, the app's code was written in the Swift programming language (Apple) and the graphical user interface was created.

RESULTS

An app prototype was implemented that provides step-by-step instructions on selected mimic exercises via animated smileys. The duration and speed of the exercise can be varied within a limited range. In the development environment, the correct functionality of both physical and virtual devices was successfully tested.

CONCLUSION

App-based facial training offers attractive opportunities to motivate patients for improved adherence to treatment, which could hypothetically lead to a better outcome. Evaluation of this question is planned in a clinical trial after completion of the development.

Neuropathy and pregnancy: An overview

Peripheral nerve injuries are rare in pregnant women. Nevertheless, physiological changes linked to pregnancy may induce nerve lesion. In this review we propose to focus on peripheral nerve disorders the most frequently encountered in pregnant patients. Focal neuropathy or polyneuropathy may appear during pregnancy or at delivery. In other cases, pre-existing neuropathies may deteriorate during pregnancy. In addition to clinical description, we summarised management proposed in the literature.

French Society of ENT (SFORL) guidelines. Management of acute Bell's palsy

AQFThe authors present the guidelines of the French Society of ENT and Head and Neck Surgery (SFORL) regarding the management of Bell's palsy in adults. After a literature review by a multidisciplinary workgroup, guidelines were drawn up based on retrieved articles and group-members' experience, then read over by an independent group to edit the final version. Guidelines were graded A, B, C or "expert opinion" according to decreasing level of evidence. Thorough ENT and neurological clinical examination is recommended in all patients presenting with peripheral facial palsy to confirm diagnosis of Bell's palsy. MRI with gadolinium enhancement should explore the entire course of the facial nerve, if possible within the first month. ENMG should be performed to assess prognosis for recovery. In confirmed Bell's palsy, corticosteroid therapy should be implemented as early as possible (ideally within 72h) at a dose of 1mg/kg/day for 7-10 days. Antiviral therapy should be associated to steroids in patients with severe and early-onset disease and in Ramsay-Hunt syndrome. Isolated antiviral therapy is not recommended. To date, there is no evidence that surgical facial nerve decompression provides benefit.

Oro-facial motor assessment: validation of the MBLF protocol in facial palsy

BACKGROUND

Oro-facial myofunctional praxis assesses the muscular coordination and the degree of motor impairment of the lingual, mandibular and facial muscles necessary for articulation, mimicry and swallowing.

PURPOSE

The objective of this study was to create and validate the MBLF protocol, a French oro-facial myofunctional assessment in order to quantify patient's impairment and to specify the motor and functional deficit for an adapted management.

METHODS

The MBLF was validated against the Sunnybrook Facial Grading System (criterion validity). The construct validity was tested by comparing healthy subjects (n = 102) from patients with facial palsy (n = 60). Internal and external consistency of face symmetry were reported. Normative data was provided.

RESULTS

There was a statistically significant correlation between the MBLF protocol and the Sunnybrook Facial Grading System [F(59) = 310.51, p < 0.001, R² = 0.843]. Significant differences were observed in Student's t test between healthy volunteers and patients with facial palsy [t(74.13) = 14,704, p < 0.001, r = 0.863]. A significant effect of the severity grades of facial palsy on the MBLF_TOTAL scores was found [F(158) = 268.469, p < 0.001]. The more severe the facial palsy, the lower the motor scores were.

CONCLUSION

This MBLF French validation provides a baseline for comparing and quantifying the performance of subjects. The MBLF protocol is valid for assessing facial symmetry in peripheral facial palsy. A prospective study is needed to validate its role in dynamic evaluation of facial palsy.

Misdiagnosis of Bell's palsy: Case series and literature review

Although Bell's palsy is a common etiology for isolated facial paralysis, it is important clinicians perform a complete neurologic examination to avoid misdiagnosis. Multiple cranial neuropathy is often caused by tumor or infection.

Facial Palsy: A Retrospective Study of 416 Cases Based on Electrodiagnostic Consultation

Background:

Facial nerve palsy (FP) is a frequent neurological condition caused mostly by Bell´s Palsy (BP).

Objectives:

The main objective of this study is to describe electrophysiological parameters in a retrospective 28-year review of 416 cases of FP based on electrodiagnostic consultation.

Methods:

In total, 520 exams from 416 patients over a 28-year period were reviewed. Sex, age, etiology, comorbidities, and variables from electroneurography and needle electromyography were analyzed. Cases were grouped as BP (70.7%), injury (16.4%), iatrogenic (10.3%) and Ramsay Hunt syndrome (RHS) (2.6%).

Results:

The mean age was 41 years (3-82), 53.4% female. Diabetes was the most frequent comorbidity. Estimated Axon Loss (EAL), >90%, was found in 50% of the cases, mainly in the iatrogenic group. The amplitude drop of the Compound Muscle Action Potentials (CMAPs) was proportional in the Orbicularis Oculi, Orbicularis Oris and Nasalis muscles. The absence of CMAPs was more frequent in the iatrogenic group and less frequent in the BP one. Bell´s palsy associated with diabetes was more severe. The R1 latency (blink reflex) was significantly longer in the BP group (P>0.001). Synkinesis due to the misdirection of regenerating axons was much more frequent in the BP and RHS groups.

Conclusion:

Bell´s palsy was the most common cause. The EAL was equal in all facial branches. Facial nerve inexcitability was more frequent in the iatrogenic/injury groups. The R1 latency was found to be prolonged in the BP group and the only good prognosis indicator in a few cases. Misdirection reinnervation was more frequent in BP and RHS groups. There was no sex or side predominance.

Concurrent Treatment With Intratympanic Dexamethasone for Moderate-Severe Through Severe Bell's Palsy

OBJECTIVE

To determine whether early intervention with intratympanic steroid injection, known as concurrent intratympanic steroid therapy, is effective as a supplement to systemic steroid therapy for treating moderate-severe to severe Bell's palsy.

DESIGN

An open-label historical control trial.

SETTING

Tertiary referral center.

PARTICIPANTS

A total of 35 Bell's palsy patients presenting with House-Brackmann grade IV or higher were treated with intratympanic steroid therapy concurrent with standard systemic treatment and compared with 108 patients treated with standard systemic therapy alone started within 7 days of onset.

INTERVENTIONS

In the concurrent intratympanic steroid therapy group, patients received both 410 mg of prednisolone (standard dose) and 1.65 mg of intratympanic dexamethasone for 10 consecutive days. Patients in the control group received the standard dose, or more, of systemic prednisolone. Both groups were additionally treated with valacyclovir.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was restoration of a House-Brackmann score of grade I.

RESULTS

The rate of recovery to House-Brackmann Grade I was higher for the concurrent intratympanic steroid therapy group than for the control group (94% vs 73%, p = 0.008). The adjusted odds ratio was 5.47 (95% confidence interval: 1.18-25.21, p = 0.029).

CONCLUSIONS

The recovery rate was higher for concurrent intratympanic steroid therapy treatment than for standard-of-care control treatment, regardless of whether steroid with lower or equivalent glucocorticoid action was administered. This result suggests that concurrent treatment with intratympanic steroid therapy is a potentially beneficial supplement to systemic steroid administration.

High-dose Corticosteroids for Adult Bell's Palsy: Systematic Review and Meta-analysis

OBJECTIVES

To compare the efficacy and safety of high-dose corticosteroids (initial prednisolone [PSL] of 100 mg or more daily) and standard-dose corticosteroids (initial PSL of 50-60 mg) in patients with Bell's palsy.

STUDY DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, Cochrane Central Register of Controlled Trials, Ichushi-Web, Web of Science, and CINAHL, combined with data from ClinicalTrials.gov.

STUDY SELECTION

Published and unpublished cohort studies comparing high- and standard-dose corticosteroids in adult patients with Bell's palsy were included.

DATA EXTRACTION

Study characteristics (study design, patient's number), patient characteristics (sex, age, disease severity, prescription of antivirals), and outcomes (nonrecovery, any adverse effects).

DATA SYNTHESIS

From the 1,974 identified articles, 8 studies were met eligible criteria. Of the included studies, the initial dose in high-dose corticosteroids regimens varied from 120 mg to 200 mg PSL daily. Compared with standard-dose corticosteroids, high-dose corticosteroids were associated with a significantly decreased nonrecovery at 6 months after disease onset (odds ratio 0.42, 95% confidence interval 0.22-0.80; very low quality) in patients with Bell's palsy. No severe adverse effects were observed in patients receiving high- or standard-dose corticosteroids.

CONCLUSION

High-dose corticosteroids reduce nonrecovery in patients with Bell's palsy. The dose of high-dose corticosteroids was varied and further prospective study is needed to identify an adequate dose of corticosteroids in these patients.

Predictive Value of VIBE using Subtraction to Evaluate Idiopathic Facial Palsy after Starting Therapy

Purpose To determine the predictive value of 3-dimensional spoiled gradient-echo volumetric interpolated breath-hold examination (VIBE) using subtraction to evaluate the short-term effect of therapy for facial palsy.

Materials and Methods We included 97 patients with idiopathic facial palsy (52 male, 45 female; aged 50.7 ± 19.4 years) who underwent MR imaging with a contrast agent after starting therapy. The mean interval between onset and therapy was 1.55 ± 1.69 days, between therapy and MR imaging was 3.19 ± 2.78 days, and between MR imaging and assessment of the therapeutic effect was 3.50 ± 0.71 days. The degree of therapeutic effect was determined using a 4-grade scale based on the House–Brackmann scale for grading facial nerve function. Two radiologists reviewed VIBE with pre- and postcontrast subtraction using the 4-point scale. We evaluated the diagnostic performance and compared the degree of therapeutic effect and enhancement of facial nerves that were divided into 5 segments bilaterally.

Results We identified 98 facial palsy initially and significant enhancement in 55 facial nerves after the start of therapy and residual palsy in 87. Sensitivity for all facial palsy was 62.0 %, specificity was 90.9 %, positive predictive value was 98.2 %, negative predictive value was 23.3 %, and accuracy was 65.3 %. Eleven patients recovered completely, 1 showed significant enhancement, and the remaining 10 did not show significant enhancement of the facial nerve.

Conclusion VIBE has a potential to predict the prognostic outcome and assess facial palsy after the start of therapy.

Key points: 

Citation Format

[Development of a smartphone app for neuromuscular facial training. German Version]

BACKGROUND

Several studies have demonstrated a significant benefit of neuromuscular facial training in the rehabilitation of patients with facial palsy. However, printed instructions for home training are often not of optimum quality and associated with low adherence to therapy. Professional guidance, e.g., by occupational therapists, is regarded as being of high quality, but is associated with a high cost burden, particularly in chronic forms of disease.

OBJECTIVE

The idea to develop a smartphone app for facial training arose from the above-described situation. The aim was to provide structured exercises for the mimic muscles in the sense of neuromuscular training with visual feedback via the front camera of the device.

MATERIALS AND METHODS

A native app architecture in iOS was chosen to implement the graphical and content-related concept. In the Apple Xcode (Apple, Cupertino, California, US) development environment, the app's code was written in the Swift programming language (Apple) and the graphical user interface was created.

RESULTS

An app prototype was implemented that provides step-by-step instructions on selected mimic exercises via animated smileys. The duration and speed of the exercise can be varied within a limited range. In the development environment, the correct functionality of both physical and virtual devices was successfully tested.

CONCLUSION

App-based facial training offers attractive opportunities to motivate patients for improved adherence to treatment, which could hypothetically lead to a better outcome. Evaluation of this question is planned in a clinical trial after completion of the development.

Main prognostic factors and physical therapy modalities associated with functional recovery in patients with peripheral facial paralysis

ABSTRACT Patients with peripheral facial paralysis (PFP) have some degree of recovery. The aim of this study was to evaluate prognostic factors and physical therapy modalities associated with functional recovery in patients with PFP. This is a cohort study with 33 patients. We collected the following variables of patients who underwent treatment at the rehabilitation center: age, sex, risk factors, affected side, degree of facial paralysis (House-Brackmann scale), start of rehabilitation, and therapy modality (kinesiotherapy only; kinesiotherapy with excitomotor electrotherapy; and kinesiotherapy with excitomotor electrotherapy and photobiomodulation therapy). The outcomes were: degree of facial movement (House-Brackmann) and face scale applied 90 days after treatment. Degree of PFP was associated with functional recovery (RR=0.51, 95% CI: 0.51-0.98; p=0.036). The facial movement was associated with the time to start rehabilitation (r=−0.37; p=0.033). Lower facial comfort was observed among women, worse ocular comfort was associated with diabetes mellitus, worse tear control with prior PFP, and worse social function with the degree of PFP. Our results indicate that the all modalities present in this study showed the same result in PFP. Recovery of PFP was associated with degree of nerve dysfunction, the length of time to onset of rehabilitation, female sex, hypertension, diabetes mellitus, and previous PFP, all of which were associated with worse outcomes on the face scale.

Quality of Life in Bell's Palsy: Correlation with Sunnybrook and House-Brackmann Over Time

OBJECTIVES

To compare patient-graded facial and social/well-being function with physician-graded facial function in Bell's palsy over time.

STUDY DESIGN

A prospective follow-up study at two tertiary otorhinolaryngological centers.

METHODS

A total of 96 patients, 36 women and 60 men, aged 18-77 years, were included. Facial Clinimetric Evaluation (FaCE) scale and Facial Disability Index (FDI) scores were compared with Sunnybrook and House-Brackmann scores.

RESULTS

Inclusion was on mean day 7 (96 patients) and follow-up on days 53 (81 patients) and 137 (32 patients). Initially, correlations between FaCE total score, FaCE domains, FDI physical function, FDI social/well-being function and Sunnybrook and House-Brackmann scores were low to fair, except for FaCE facial movement (r = 0.55). Correlations between FaCE total score and Sunnybrook score were very good to excellent at visits 2 (r = 0.83) and 3 (r = 0.81). Women scored FaCE social and FDI social/well-being function lower than men, despite similar Sunnybrook scores.

CONCLUSION

In early stages of Bell's palsy, there were low to fair correlations between FaCE/FDI (except for facial movement) and Sunnybrook score. This implies that the design of the quality of life (QoL) instruments is less suited for the acute phase. The high correlations at follow-ups suggest that the questionnaires can be used for evaluation of QoL over time. Our results indicate that women experience more facial palsy-related psychosocial dysfunction.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E612-E618, 2021.

A closer look at the paralyzed face; a narrative review of the neurobiological basis for functional and aesthetic appreciation between patients with a left and a right peripheral facial palsy

BACKGROUND

The facial nerve or n. facialis (NVII) is the seventh cranial nerve and it is responsible for the innervation of the mimic muscles, the gustatory organ, and the secretomotor function to the salivary, lacrimal, nasal and palatine glands. Clinical presentation of Facial Palsy (FP) is characterized by unilateral facial asymmetry and may present with a change in taste, decreased saliva production, and dysarthria. A facial palsy has a notable effect on the facial appreciation by both the patient and the environment and also affects quality of life and emotional processing. There appear to be differences in the appreciation of people with a left and right facial palsy.

PURPOSE OF THIS REVIEW

The purpose of the review is to give an overview of the anatomy of the facial nerve, neuro-anatomy of face processing, and hemispheric specialization and lateralization. Further,an overview is given of the clinical studies that translated the neuro-anatomical and neurobiological basis of these concepts into clinical studies. What this review adds: This review emphasizes the neurobiological evidence of differences in face processing between the left and right cerebral hemisphere, wherein it seems that the right hemisphere is superior in emotional processing. Several theories are proposed; 1) a familiarity hypothesis and 2) a left-right hemispheric specialization hypothesis. In clinical studies, promising evidence might indicate that, in patients with FP, there is indeed a difference in how left and right FP are perceived. This might give differences in decreased quality of life and finally in occurrence of depression. Further research must aim to substantiate these findings and determine the need for altering the standard therapeutic advice given to patients.

High frequency of paediatric facial nerve palsy due to Lyme disease in a geographically endemic region

INTRODUCTION

Idiopathic facial nerve palsy (FNP) is an uncommon but important presentation in children, with Lyme disease known to be a common cause. The UK county of Hampshire is a high incidence area of Lyme disease. We conducted a retrospective review of the investigation and management of paediatric FNP at a large University hospital, including serologic testing and treatment of Lyme disease.

METHODS

We conducted a retrospective chart review of children under 18 presenting between January 1st^, 2010 and December 31st^, 2017 with a diagnosis of FNP. Patients with clear non-Lyme aetiology at presentation were excluded. Data was collected on demographics, initial presentation, investigations including Lyme serology, and management.

RESULTS

A total of 93 children were identified, with an even proportion of male to female and median age 9.3 years (IQR 4.6-12 years). A history of rash was present in 5.4%, tick bite in 14% and recent travel to, or residence in the New Forest in 22.6%. Lyme serology was performed in 81.7% of patients, of which 29% were positive. Antibiotics were prescribed for 73.1% of patients, oral steroids for 44% and aciclovir for 17.2%.

CONCLUSION

Lyme disease is a significant cause of FNP in this endemic area of the UK, and there was a large degree of variability in management prior to national guideline publication. Areas with endemic Lyme disease should consider introducing local guidelines supporting routine investigation and management for FNP, including empiric treatment for Lyme disease in accordance with NICE guidelines to improve care and reduce variability.

Histological characteristics of intra-temporal facial nerve paralysis in temporal bone malignancies

OBJECTIVE

To describe the histopathologic findings and clinical presentation of intra-temporal facial nerve invasion in primary and metastatic malignancies of the human temporal bone (TB).

MATERIALS AND METHODS

Retrospective analysis of all medical records of patients diagnosed with peripheral facial nerve palsy (PFnP) of a malignant origin was performed. Temporal bones underwent standard processing for histologic examination. Hematoxylin and eosin (H&E)-stained slides were examined by light microscopy. The histologic findings were compared to premortem clinical data.

RESULTS

Eighteen TBs were identified in 16 patients. The male to female ratio was 9:7. The median (range) age of death was 56.5 years (27 months to 75 years). The median time interval from facial nerve injury to death was 5.5 months. There were 11 carcinomas and seven sarcomas identified. Primary TB malignancies were identified in seven TBs (39%), and the rest (11 TBs, 61%) were of metastatic origin. Complete facial nerve paralysis (House-Brackmann [HB] grade VI), was the most common clinical presentation affecting nine patients (10 TBs, 56%). Neural involvement was multifocal in nature (16 of 18 TBs, 89%). The most commonly involved cranial nerve (CN) VII segment was the meatal segment (13 TBs, 72%), followed by the labyrinthine, tympanic, and vertical segments (nine, eight, and six TBs, respectively).

CONCLUSION

PFnP can be the result of local, regional, or distant malignancy, and is associated with poor survival. The facial nerve can serve as a route of tumor progression intracranially. Whereas every segment of CNV II can be violated by tumors, not all PFnP are related to direct tumor invasion.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E358-E367, 2020.

Facial nerve paralysis in 64 equids: Clinical variables, diagnosis, and outcome

BACKGROUND

Facial nerve paralysis (FNP) in equids is not well described in the veterinary literature.

OBJECTIVE

To investigate the causes of FNP and associations among clinical variables, diagnosis, and outcome.

ANIMALS

Sixty-four equids presenting with FNP between July 2000 and April 2019. Cases of postanesthetic FNP were excluded.

METHODS

Medical records were retrospectively reviewed. Variables were evaluated for associations with outcomes (diagnosis and case outcome) using logistic regression.

RESULTS

The most common cause of FNP was trauma (n = 20). Additional diagnoses included central nervous system (CNS) disease (n = 16), idiopathic (n = 12, 4 of which had adequate diagnostic investigation and were considered "true" idiopathic, and 8 of which were considered "not investigated" idiopathic), temporohyoid osteoarthropathy (n = 10), otitis media-interna (n = 3), lymphoma (n = 1), iatrogenic as a consequence of infiltration of local anesthetic (n = 1), and clostridial myositis (n = 1). Follow-up was available for 55 (86%) cases. Twenty-nine (53%) equids had full resolution of FNP, 14 (25%) were euthanized, 6 (11%) partially improved, and 6 (11%) were unchanged or worse.

CONCLUSIONS AND CLINICAL IMPORTANCE

If FNP is the consequence of CNS disease, successful treatment of the primary disease likely leads to resolution of FNP. Most cases of FNP in equids are traumatic in origin. True idiopathic cases are uncommon.

Efficacy of low-level laser therapy on management of Bell's palsy: a systematic review

The aim of this study is to evaluate the efficacy of low-level laser therapy (LLLT) in patients with Bell's palsy (BP) through a systematic review method. We systematically searched international databases including PubMed, Scopus, and Web of Science to find eligible articles without language limitation. All relevant randomized controlled trials (RCTs) that compared the efficacy of the LLLT with placebo laser, exercise, massage, or no intervention on BP patients were included. Four studies (out of 259) had met our inclusion criteria involving 171 patients and were entered to the systematic review. Full texts of the selected studies were retrieved and critically appraised using Physiotherapy Evidence Database (PEDro) scale. The patients of all trials were in sub-acute (less than 1 week) stage. Both of LLLT and control groups showed significant improvement after trials. Two authors reported significant differences between the groups after 6 weeks of laser application (830 nm, 100 mW). In converse, two other authors did not identify any effectiveness following 4 weeks and 15 days of LLLT application with 670 and 830 nm wavelength, sequentially. There is clear lack of information lead to get and evidence-based suggestion for the LLLT application on Bells' palsy; however, the LLLT irradiation with 830 nm and 100 mW power for a period of 6 weeks might be beneficial on recovery for the patients with sub-acute Bell's palsy. There were no reported adverse effects during treatment and/or follow-up sessions.

Training lip force by oral screens. Part 3: Outcome for patients with stroke and peripheral facial palsy

The aim of this study was to investigate whether training with an oral screen can improve oral motor function in patients with stroke and peripheral palsy. The participants in the study were eight patients with orofacial dysfunction after stroke, included 7–14 months after onset, and seven patients with peripheral palsy, included 14–28 months after onset. A customized oral screen in acrylic was made for each participant. The screen had a tube around the handle to allow air to pass when measurements were made of the perioral muscle force. When measuring the ability to suck, the hole was sealed with wax. The participants trained with the oral screen two times daily for 5 min. Measurements were made at baseline, after 1 month and thereafter every third month until no further improvement was achieved. Measurements were made with two different instructions, to squeeze and to suck. In the stroke group, muscles around the mouth improved when pouting and smiling; these participants also achieved statistically significant changes when sucking. For the peripheral palsy group, little improvement could be seen when pouting and smiling. However, these patients reported less or no drooling, and the measurements for sucking increased significantly for six of the seven patients. The first recorded significant change was seen in the stroke group after 4 weeks training and in the group with peripheral palsy after 6 weeks. Training with a custom‐made oral screen can significantly improve perioral muscle force and the ability to create negative intraoral pressure. The patients reported less leakage in saliva, drink, and food as well as fewer bite injuries and less food accumulation.

Prognostic role of homeostasis model assessment and oral glucose tolerance test in nondiabetic patients with Bell’s palsy

Background/aim

We aimed to reveal the incidence and predictive role of insulin resistance and distorted oral glucose tolerance test in nondiabetic patients with Bell’s Palsy (BP).

Materials and methods

Eighty-six patients with BP and 28 control subjects; all with normal blood glucose levels and no history of diabetes, were enrolled in the study. We investigated insulin resistance (IR) in all subjects, in terms of HOMA-IR greater than 2.7. Sixty-two of the patients also underwent an oral glucose tolerance test (OGTT).

Results

The mean HOMA-IR value was significantly increased in patients, compared to the control group (3.2 vs 1.6; P < 0.01). IR was detected more in BP patients than in controls (P < 0.05). The patients with higher HOMA-IR values had more severe facial dysfunction at the initial presentation and complete recovery time took longer than the patients with normal HOMA-IR value (75 days vs 42 days; P < 0.05). Following a 2h-OGTT, impaired glucose tolerance and newly diagnosed DM were found in 60% of the patients. Recovery time was significantly longer in prediabetics and newly diagnosed diabetic patients than in patients with normal glycemia (68 days, 52 days, and 32 days, respectively; P < 0.01).

Conclusion

There is a strong linkage between HOMA-IR value and BP prognosis so HOMA-IR value may have a significant role of predicting BP prognosis at presentation.

Clinical Presentations and Outcome Studies of Cranial Nerve Involvement in Herpes Zoster Infection: A Retrospective Single-Center Analysis

Varicella-zoster virus (VZV) infection can cause chickenpox and herpes zoster. It sometimes involves cranial nerves, and rarely, it can involve multiple cranial nerves. We aimed to study clinical presentations of cranial nerve involvement in herpes zoster infection. We included patients who had the diagnosis of herpes zoster infection and cranial nerve involvement. The diagnosis was confirmed by typical vesicles and a rash. We excluded patients who had cranial neuralgias or neuropathies but without typical skin lesions (zoster sine herpete or post-herpetic neuralgia). We included 330 patients (mean age, 55.0 ± 17.0 years) who had herpes zoster with cranial nerve involvement, including 155 men and 175 women. Most frequently involved cranial nerves were the trigeminal nerve (57.9%), facial nerve (52.1%), and vestibulocochlear nerve (20.0%). Other involved cranial nerves included the glossopharyngeal nerve (0.9%), vagus nerve (0.9%), oculomotor nerve, trochlear nerve, and abducens nerve (each 0.3%, respectively). One hundred and seventy patients (51.5%) had only sensory symptoms/signs; in contrast, 160 patients (48.5%) had both sensory and motor symptoms/signs. Of those 160 patients, sensory preceded motor symptoms/signs in 64 patients (40.0%), sensory and motor symptoms/signs occurred simultaneously in 38 patients (23.8%), and motor preceded sensory symptoms/signs in 20 patients (12.5%). At one month after herpes zoster infection, vesicles and rash disappeared in 92.6% of patients; meanwhile facial palsy showed a significant improvement in 81.4% of patients (p < 0.05). Cranial motor neuropathies are not infrequent in herpes zoster infections. Multiple cranial nerve involvement frequently occurred in Ramsay Hunt syndrome. We found a significantly increased seasonal occurrence of cranial nerve zoster in spring rather than summer. Cranial motor nerves were affected while the hosts sometimes had a compromised immune system.

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.

Concentrations of Serum Cyclophilin A in Patients With Bell Palsy

BACKGROUND

Cyclophilin A (CyPA) is the responder protein to stimuli that cause inflammation. To date, no association among CyPA and Bell palsy has been reported.

METHODS

The concentrations of Serum CyPA were measured in 90 healthy participants and 92 patients with Bell palsy. Serum samples of patients and the control group were compared on the basis of CyPA levels. Facial latency and amplitude values on electromyography were evaluated and compared with serum CyPA concentrations.

RESULTS

A total of 28, 37, 19, and 8 patients had grade 3, 4, 5, and 6 facial palsy cases, respectively. Comparing the control group and the patient group showed significant differences in CyPA values (P < 0.001). Cyclophilin A value can be evaluated as a marker with high disease discrimination capability. The results also showed that at low CyPA, the average recovery time was shorter than that of high CyPA (41.6 ± 5.7 days vs 62.8 ± 10.2 days, P = 0.036). We found no statistically significant relationship between electromyography parameters and CyPA level. (Facial latency: r: -0.014, P: 0.948; facial amplitude r: -0.081, P: 0.713).

CONCLUSION

Serum CyPA concentrations increased in response to inflammation in Bell palsy patients. However, CyPA could not be used as an early prognostic marker in Bell palsy, low CyPA indicates the shorter average recovery time than that of high CyPA.

The association between Bell's palsy and rheumatoid arthritis: A longitudinal study

This study aimed to evaluate the relationship between Bell's palsy and rheumatoid arthritis in a national sample cohort from Korea.Data were collected for individuals ≥20 years old from 2002 to 2013 in the Korean National Health Insurance Service-National Sample Cohort. We extracted data for patients with rheumatoid arthritis (n = 7628) and 1:4-matched controls (n = 30,512) and analyzed the occurrence of Bell's palsy in both groups. Matching was performed based on age, sex, income, and region of residence. Rheumatoid arthritis was diagnosed according to International Classification of Disease-10 (ICD-10) codes (M05-M06) and the prescription of biological agents and/or disease-modifying antirheumatic drugs. Bell's palsy patients were diagnosed according to ICD-10 code H912 and treatment ≥2 times with steroids. Adjusted hazard ratios (HRs) were calculated using stratified Cox proportional hazard models for the Charlson comorbidity index and 95% confidence intervals (CIs). Subgroup analyses based on age and sex were also performed.The rates of Bell's palsy were similar between the rheumatoid arthritis group (0.5% [38/7628]) and the control group, with no significant difference (0.4% [124/30,512], P = .270). The adjusted HR for Bell's palsy was 1.12 (95% CI, 0.78-1.62) in the rheumatoid arthritis group (P = .540). In the subgroup analyses according to age and sex, the relationship between Bell's palsy and rheumatoid arthritis did not reach statistical significance.The risk of Bell's palsy was not increased in patients with rheumatoid arthritis.