Botulinum toxin A treatment in facial palsy synkinesis: a systematic review and meta-analysis

Approaches to the Management of Synkinesis: A Scoping Review

Postparalysis facial synkinesis (PPFS) can develop in any facial palsy and is associated with significant functional and psychosocial consequences for affected patients. While the prevention of synkinesis especially after Bell's palsy has been well examined, much less evidence exists regarding the management of patients with already established synkinesis. Therefore, the purpose of this review is to summarize the available literature and to provide an overview of the current therapeutic options for facial palsy patients with established synkinesis. A systematic literature review was undertaken, following the Preferred Reporting Items of Systematic Reviews and Meta-analyses 2020 guidelines. MEDLINE via PubMed and Cochrane Library were searched using the following strategy: ([facial palsy] OR [facial paralysis] OR [facial paresis]) AND (synkinesis) AND ([management] OR [guidelines] OR [treatment]). The initial search yielded 201 articles of which 36 original papers and 2 meta-analyses met the criteria for inclusion. Overall, the included articles provided original outcome data on 1,408 patients. Articles were divided into the following treatment categories: chemodenervation (12 studies, 536 patients), facial therapy (5 studies, 206 patients), surgical (10 studies, 389 patients), and combination therapy (9 studies, 278 patients). Results are analyzed and discussed accordingly. Significant heterogeneity in study population and design, lack of control groups, differences in postoperative follow-up, as well as the use of a variety of subjective and objective assessment tools to quantify synkinesis prevent direct comparison between treatment modalities. To date, there is no consensus on how PPFS is best treated. The lack of comparative studies and standardized outcome reporting hinder our understanding of this complex condition. Until higher quality scientific evidence is available, it remains a challenge best approached in an interdisciplinary team. An individualized multimodal therapeutic concept consisting of facial therapy, chemodenervation, and surgery should be tailored to meet the specific needs of the patient.

Five decades of the use of botulinum toxin in ophthalmology

Botulinum toxin (BoNT) has been known for over 50 years. It has conquered many areas of medicine and has become indispensable in contemporary medicine. Now, BoNT is used to treat at least 26 conditions in six medical specialties. Although the use of BoNT began in strabology, it became the gold standard for many ophthalmologic pathologies. The present review of the literature focuses on the use of BoNT in ophthalmology and treatment of the following conditions: blepharospasm, facial hemispasm, facial palsy, spastic entropion, strabismus, endocrine orbitopathy, convergence spasm, and facial trauma. We conclude that nearly half a century of experience in utilizing BoNT in ophthalmology ensured a satisfactory level of effectiveness and safety for patients with many pathologies. Areas of future research include the application of BoNT in new selected indications, the development of the route of application without injections, and the development of long-acting BoNT forms for patients who require repeated long-term treatment.

[Five-year follow-up after neurosurgery complicated by facial neuropathy]

BACKGROUND

Botulinum toxin A (BTA) injections are effective for facial neuropathy. However, there is insufficient number of studies devoted to long-term management of these patients.

OBJECTIVE

To evaluate the effectiveness and safety of BTA therapy in patients with facial neuropathy after neurosurgical interventions.

MATERIAL AND METHODS

The study included 86 patients with facial neuropathy after surgical treatment of posterior cranial fossa and cerebellopontine angle tumors. All ones were divided into 2 groups: group I (main) - 57 patients with BTA prescribed early after facial nerve injury, group II (control) - 29 people undergoing exercise therapy, as well as special exercises and acupressure of painful muscle cords. The Sunnybrook Facial Grading Scale (SFGS) was used to assess facial symmetry and synkinesis, the Facial Disability Index (FDI scale) - to assess the quality of life. Overall duration of the study was 5 years (control points: 6 months, 1, 2, 3 and 5 years).

RESULTS

The SFGS scores after 1, 2, 3 and 5 years were significantly better in the main group (resting symmetry p<0.01, voluntary movement symmetry p<0.01, synkinesis p<0.01, general condition of facial muscles p<0.01). Scores of physical and social functioning were significantly higher in the main group after 1 (p<0.01), 2 (p<0.01), 3 (p<0.01) and 5 years (p<0.01) after surgery. There was no need to change BTA dosage over 5 years. Thus, this form of BTA may be the most effective for synkinesis of facial muscles.

CONCLUSION

Correction of synkinesis caused by facial neuropathy requires long-term follow-up and long-term treatment. BTA is effective and may be recommended for long-term treatment of these patients.

Dipeptidyl peptidase-4 inhibitors alleviate cognitive dysfunction in type 2 diabetes mellitus

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) are commonly at high risk for developing cognitive dysfunction. Antidiabetic agents might be repurposed for targeting cognitive dysfunction in addition to modulation on glucose homeostasis. This study aimed to evaluate the impact of dipeptidyl peptidase-4 inhibitors (DPP-4i) on cognitive function in T2DM.

METHODS

PubMed, Embase, Cochrane Library and Web of Science were systematically searched from inception to September 30, 2023. Weighted mean differences were calculated using the Mantel-Haenszel (M-H) fixed or random effects model based on the degree of heterogeneity among studies. Heterogeneity was evaluated using a Chi-squared test and quantified with Higgins I2. Sensitivity analysis was performed with the leave-one-out method, and publication bias was evaluated according to Begg's and Egger's tests.

RESULTS

Six clinical trials involving 5,178 participants were included in the pooled analysis. Administration of DPP-4i generally correlated with an increase of Mini-Mental State Examination (MMSE) scores (1.09, 95% CI: 0.22 to 1.96). DPP-4i alleviated cognitive impairment in the copying skill subdomain of MMSE (0.26, 95% CI: 0.12 to 0.40). Treatment with DPP-4i also resulted in an increase of Instrumental Activities of Daily Living (IADL) scores (0.82, 95% CI: 0.30 to 1.34). However, DPP-4i produced no significant effects on Barthel Activities of Daily Living (BADL) scores (0.37, 95% CI: -1.26 to 1.99) or other test scores.

CONCLUSIONS

DPP-4i treatment favourably improved cognitive function in patients with T2DM. Further trials with larger samples should be performed to confirm these estimates and investigate the association of different DPP-4i with cognitive function among diabetic patients.

TRIAL REGISTRATION IN PROSPERO

CRD42023430873.