[Diagnostics of diseases and the function of the facial nerve]

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.

Modern concepts in facial nerve reconstruction

Background

Reconstructive surgery of the facial nerve is not daily routine for most head and neck surgeons. The published experience on strategies to ensure optimal functional results for the patients are based on small case series with a large variety of surgical techniques. On this background it is worthwhile to develop a standardized approach for diagnosis and treatment of patients asking for facial rehabilitation.

Conclusion

A standardized approach is feasible: Patients with chronic facial palsy first need an exact classification of the palsy's aetiology. A step-by-step clinical examination, if necessary MRI imaging and electromyographic examination allow a classification of the palsy's aetiology as well as the determination of the severity of the palsy and the functional deficits. Considering the patient's desire, age and life expectancy, an individual surgical concept is applicable using three main approaches: a) early extratemporal reconstruction, b) early reconstruction of proximal lesions if extratemporal reconstruction is not possible, c) late reconstruction or in cases of congenital palsy. Twelve to 24 months after the last step of surgical reconstruction a standardized evaluation of the therapeutic results is recommended to evaluate the necessity for adjuvant surgical procedures or other adjuvant procedures, e.g. botulinum toxin application. Up to now controlled trials on the value of physiotherapy and other adjuvant measures are missing to give recommendation for optimal application of adjuvant therapies.

[CT and MR imaging of the facial nerve]

Modern imaging techniques used for depicting the facial nerve include multi-slice spiral computed tomography (CT) and high-field magnetic resonance imaging (MRI). CT is the gold standard for imaging the osseous structures of the temporal bone. As a result of its excellent soft tissue contrast, MRI enables identification of the facial nerve itself. Due to high spatial resolution and the possibility to generate multiplanar reconstructions, both CT and MRI facilitate an exact evaluation of anatomical structures in all three spatial planes. The present article provides an overview of relevant anatomical structures, a thorough knowledge of which is the basic prerequisite to understanding pathologies and interpreting radiological findings correctly. Furthermore, basic techniques and strategies for imaging the facial nerve using CT and MRI are explained in general. The articles concludes with specific requirements for the radiological diagnosis of dysplasia, neoplasms and trauma, as well as vascular and inflammatory diseases.

[Rehabilitation options for lesions of the facial nerve]

Patients with permanent facial palsies cannot hide their conditions. As a consequence, these patients suffer from massive psychological stress. To achieve satisfactory reconstruction of mimic function, experience with a variety of surgical techniques and adjuvant nonsurgical treatments is necessary. This report provides information on the present repertoire of surgical and conservative options, emphasizing their fields of indications, limitations, and possible combinations.

Prognoseabschätzung der peripheren Fazialisparese

BACKGROUND

In this retrospective study, we assessed the long-term prognostic value of the minimal nerve excitability test (NET) by comparing the results it yielded with the House-Brackmann (HB) index in patients with the most common types of facial paralysis, Bell's palsy and traumatic facial palsy.

PATIENTS AND METHODS

Three hundred and fifty patients aged 9-85 years (mean age 42.4 years; 156 male and 194 female), all of whom were treated initially with the same steroid therapy, entered on study. Patients in whom decompression surgery had been performed were excluded so as to avoid falsely optimistic prognoses. The 350 study patients were divided into two groups: group 1 was made up of 250 with Bell's palsy and group 2, of 100 with nonpenetrating traumatic facial palsy following temporal bone fracture. The NET was conducted repeatedly in all patients for 3 weeks from the start of day 3 of treatment, the value recorded on day 14 being used in the evaluation. For each patient, the result of the NET was recorded as 'normal', 'diminished' or 'without response' according to the difference between the two sides of the face. The final HB grading was determined after 1 year to check for the agreement between the electrical prognosis and the clinical outcome and thus the reliability of the prognosis indicated by the NET.

RESULTS

The results indicate that a normal NET forecast a satisfactory outcome that could be classed as HB I-II in almost all the patients in both groups. Among patients who had no response on NET, 85% of those with Bell's palsy and 90% of those with traumatic facial palsy failed to recover nerve function. Diminished nerve excitability proved to be a sign of a relatively favourable prognosis: 74% of patients in each group recovered normal facial function.

CONCLUSION

The NET is a method of investigation that is easily applied and can make a positive contribution to the assessment of prognosis in Bell's palsy and in traumatic facial palsy, reflecting the functional state of the facial nerve reliably in most of cases.