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

Management of facial nerve trauma

PURPOSE OF REVIEW

To present the current literature on management of facial nerve disorder secondary to trauma, with a focus on the utility of electrodiagnostic testing in this setting.

RECENT FINDINGS

Patients with facial palsy related to temporal bone fractures should be started on high-dose corticosteroids as early as possible. Recent literature on the benefit of surgical intervention in the setting of temporal bone fracture is mixed. Some studies support early surgical decompression whereas others have found no benefit compared with conservative treatment.

SUMMARY

The management of facial nerve trauma is based on location and extent of injury. Extratemporal trauma and transected nerve should be treated with surgical exploration and tension-free coaptation ideally within 72 h. There are no guidelines for intratemporal facial nerve trauma. Surgical decompression compared with medical management is debated in the literature without consensus and more large studies are needed.

Predictive Value of the Neutrophil-to-Lymphocyte Ratio and C-Reactive Protein in Patients with Idiopathic Facial Nerve Palsy

Objective

This study aims to investigate the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) in patients with idiopathic facial nerve palsy.

Methods

The clinical data of patients with idiopathic facial nerve palsy were retrospectively analyzed. After three months of follow-up, patients were divided into good prognosis and poor prognosis, and the correlation between NLR, CRP and idiopathic facial nerve palsy was analyzed.

Results

Negative correlation of NLR with Portmann score in idiopathic facial nerve palsy (r=-0.788, P<0.05); In contrast to the group with poor prognosis, patients in good prognosis group had low levels of body mass index (BMI), NLR, and C-reactive protein (CRP), and high Portmann score (P<0.05); Multivariate logistic regression analysis showed Portmann score (OR=1.268, 95% CI (1.005-1.616)), NLR (OR=0.262, 95% CI (0.128-0.533)) and CRP levels (OR=0.949, 95% CI (0.895-0.989)) were risk factors of poor prognosis for patients with idiopathic facial nerve palsy. The area under the receiver operator characteristic (ROC) curve of NLR and CRP levels in predicting poor facial nerve function was 0.764 and 0.697, the specificity was 85.5% and 75.0%, and the sensitivity was 74. 0% and 76.0%, respectively. The ROC curve of the combined diagnosis was 0.829, the specificity was 80.7%, and the sensitivity was 82.0%.

Conclusion

Elevated NLR and CRP are associated with a poor prognosis of idiopathic facial nerve palsy and can serve as an indicator for clinical prognosis, and can be widely used in clinical.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Cross-cultural adaptation of the Korean Synkinesis Assessment Questionnaire: A validation study

Objective

The Synkinesis Assessment Questionnaire (SAQ) is a reliable tool to assess synkinesis symptoms; however, it is yet to be validated in Korea. Thus, this study aimed to translate and validate the Korean SAQ.

Methods

This validation study was set in a clinic in Seoul, Korea, that provides general integrative medicine services. A total of 100 participants with facial palsy were enrolled. Participants completed the SAQ, House-Brackmann grade (HB grade), Sunnybrook Facial Grading System (SB), and Facial Disability Index (FDI). The forward-backward translation method was followed. Of the 100 participants, 31 underwent a second assessment for test-retest reliability. Internal consistency and test-retest reliability were evaluated using Cronbach's alpha coefficient. The construct validity of the Korean version of the SAQ was tested using Spearman's rank correlation coefficient.

Results

The internal consistency score for the SAQ was 0.789, and the test-retest reliability score was 0.787. According to Spearman's rank correlation coefficient, the SAQ correlations to the synkinesis subdomain of SB score, total SB score, HB grade, and physical function domain in the FDI score were 0.366 (p < .001), -0.386 (p < .001), 0.315 (p = .001), and -0.269 (p = .007), respectively. All values were statistically significant.

Conclusions

The Korean SAQ is a valid and reliable tool used to evaluate synkinesis in patients with facial palsy.

Level of Evidence

Level 3.

An electrophysiological prognostic diagnosis for facial palsy

Two electrophysiological tests for facial palsy-electroneurography (ENoG) and nerve excitability test (NET)-were reviewed. ENoG has advantages over NET in that it reflects the percentage of degenerated facial nerve fibers and can provide an accurate prognosis. However, as disadvantages, ENoG requires large, expensive equipment, and such supramaximal electrical stimulation can be quite painful for patients. NET is less painful due to weak stimulation with just enough current to meet the threshold, and the required equipment is compact and inexpensive to procure. However, it is impossible to calculate the percentage of degenerated nerve fibers, and NET is inferior to ENoG in terms of accurate prognostic prediction for facial palsy. The appropriate timing for both ENoG and NET is 7 to 10 days after the onset. While ENoG has proven more popular than NET because of its accuracy for prognostic prediction, we should not predict the prognosis of facial palsy based solely on the results of electrophyisiolgical examinations; a comprehensive evaluation including the facial muscle grading system is essential.

Long-term Outcome After Acute Peripheral Facial Palsy

PURPOSE

To analyze long-term outcomes in a large cohort of patients with acute peripheral facial palsy (APFP).

METHODS

Hospital-based, cross-sectional study. Data were abstracted from the electronic medical record. Time to recovery was assessed with Kaplan-Meier survival analyses. Binary logistic regression analysis was used to identify factors associated with outcome.

RESULTS

Three hundred seventy-two patients with APFP seen at a tertiary hospital between February 2015 and March 2021 were analyzed. Seasonal variation of APFP peaked in the early fall (September 29) and had a peak-to-low ratio of 1.36 (R 2 = 0.329, p < 0.001). Patients who tested positive for Lyme disease (10%) had an earlier peak (July 16) compared with those who were negative (October 15). Eighty-seven percent of patients had complete recovery (averaging 64 ± 61 days). Patients, with higher House-Brackmann (H-B) grades at presentation took longer to recover, were more likely to have aberrant regeneration and had lower final rates of recovery compared with those with lower H-B grades (χ 2 = 12.03, p < 0.001). Of the patients with residual palsies, 70% had evidence of aberrant regeneration, and nearly half of those had hemifacial spasm.

CONCLUSIONS

Most patients with APFP achieve complete recovery within 1 year, including those positive for Lyme. More severe palsy at presentation portends a worse outcome.

A Telerehabilitation Approach to Chronic Facial Paralysis in the COVID-19 Pandemic Scenario: What Role for Electromyography Assessment?

There is a lack of data on patient and diagnostic factors for prognostication of complete recovery in patients with peripheral facial palsy. Thus, the aim of this study was to evaluate the role of a telerehabilitave enhancement through the description of a case report with the use of short-wave diathermy and neuromuscular electrical stimulation combined to facial proprioceptive neuromuscular facilitation (PNF) rehabilitation in unrecovered facial palsy, in a COVID-19 pandemic scenario describing a paradigmatic telerehabilitation report. A 43-year-old woman underwent a facial rehabilitation plan consisting of a synergistic treatment with facial PNF rehabilitation, short-wave diathermy, and neuromuscular electrical stimulation (12 sessions lasting 45 min, three sessions/week for 4 weeks). Concerning the surface electromyography evaluation of frontal and orbicularis oris muscles, the calculated ratio between amplitude of the palsy side and normal side showed an improvement in terms of movement symmetry. At the end of the outpatient treatment, a daily telerehabilitation protocol with video and teleconsultation was provided, showing a further improvement in the functioning of a woman suffering from unresolved facial paralysis. Therefore, an adequate telerehabilitation follow-up seems to play a fundamental role in the management of patients with facial palsy.