Differential diagnosis of peripheral facial nerve palsy: a retrospective clinical, MRI and CSF-based study

Peripheral facial palsy in children: Serum Borrelia antibodies may reduce the need for lumbar puncture

AIM

We aimed to investigate the causes of acute peripheral facial palsy (PFP) in Danish children and to explore whether neuroborreliosis-related PFP could be diagnosed without lumbar puncture using clinical symptoms and serum Borrelia burgdorferi (Bb) antibodies.

METHODS

This retrospective population-based cohort study included children undergoing lumbar puncture for PFP between 2019 and 2023 in Denmark's Capital Region. Diagnostic performance measures for neuroborreliosis-related PFP were compared between serum Bb IgG alone and clinical risk scores combining Bb IgG with clinical parameters.

RESULTS

Of the 326 patients with PFP, 137 (42%) were diagnosed with neuroborreliosis and 151 (46%) had Bell's palsy. Positive predictive value for serum Bb IgG alone was 88% (95% CI 79-93) and negative predictive value was 83% (95% CI 75-88). The positive predictive value of a risk score with seven additional parameters was 90% (95% CI 81-95) and negative predictive value 87% (95% CI 80-92).

CONCLUSION

The positive predictive value of serum Bb IgG alone was high in our setting, where nearly half of children with PFP had neuroborreliosis. In high endemic settings, lumbar punctures may be reduced by (i) treating all children with PFP with doxycycline or (ii) treating Bb IgG positive children and performing lumbar puncture in seronegative children.

Plasmablastic Myeloma: An Unusual Cause of Peripheral Facial Paralysis

Peripheral facial paralysis refers to the involvement of the facial nerve (VII cranial nerve) at any point along its path, which starts from its nucleus, located in the pons, and extends to its most distal branches. The etiology is heterogeneous, including viral infections, bacterial infections, trauma, and neoplasms, among others. However, in the majority of cases, the cause is idiopathic, commonly referred to as Bell's palsy. The diagnosis is therefore one of exclusion, based in particular on the physical examination. Naturally, the diagnosis is decisive in directing the therapeutic approach. However, the signs/symptoms of the various primary pathological processes can appear late in the course of the disease. This is why the Physical Medicine and Rehabilitation specialist is particularly important, since, in addition to the initial assessment, he or she monitors the patient more closely and over a longer period of time, together with the team of therapists. New clinical findings and diagnostic tests requested accordingly can dramatically change the initial diagnosis and guide new treatments. We present the clinical case of a 60-year-old man initially diagnosed with Bell's palsy, whose poor clinical evolution and new clinical findings during the rehabilitation program led to the diagnosis of plasmablastic myeloma and a radically different therapeutic approach.

Ramsay Hunt syndrome and concurrent varicella-zoster virus meningitis in Denmark: A nationwide cohort study

Ramsay Hunt syndrome (RHS) is a manifestation of reactivated varicella-zoster virus (VZV) from the geniculate ganglion. Data on clinical features and outcomes of patients with RHS and concurrent VZV meningitis (henceforth RHS meningitis) are limited. Thus, we conducted a nationwide population-based cohort study of all adults hospitalized for RHS meningitis at the departments of infectious diseases in Denmark from 2015 to 2020. Patients with VZV meningitis without cranial nerve palsies were included for comparison. In total, 37 patients with RHS meningitis (mean annual incidence: 1.6/1 000 000 adults) and 162 with VZV meningitis without cranial nerve palsies were included. In RHS meningitis, the median age was 52 years (interquartile range: 35-64), and in addition to peripheral facial nerve palsy (100%), dizziness (46%), and hearing loss (35%) were common symptoms. The triad of headache, neck stiffness, and photophobia/hyperacusis was less common in RHS meningitis than in VZV meningitis without cranial nerve palsies (0/27 [0%] vs. 24/143 [17%]; p = 0.02). At 30 days after discharge, 18/36 (50%) patients with RHS meningitis had persistent peripheral facial nerve palsy, with no statistically significant difference between those treated with and without adjuvant glucocorticoids (6/16 [38%] vs. 12/20 [60%]; p = 0.18). Additional sequelae of RHS meningitis included dizziness (29%), neuralgia (14%), tinnitus/hyperacusis (11%), hearing loss (9%), headache (9%), fatigue (6%), and concentration difficulties (3%). In conclusion, clinical features and outcomes of RHS meningitis were primarily related to cranial neuropathies.

Alterations in pathogen-specific cellular and humoral immunity associated with acute peripheral facial palsy of infectious origin

BACKGROUND

Peripheral facial palsy (PFP) is a common neurologic symptom which can be triggered by pathogens, autoimmunity, trauma, tumors, cholesteatoma or further local conditions disturbing the peripheral section of the nerve. In general, its cause is often difficult to identify, remaining unknown in over two thirds of cases. As we have previously shown that the quantity and quality of pathogen-specific T cells change during active infections, we hypothesized that such changes may also help to identify the causative pathogen in PFPs of unknown origin.

METHODS

In this observational study, pathogen-specific T cells were quantified in blood samples of 55 patients with PFP and 23 healthy controls after stimulation with antigens from varicella-zoster virus (VZV), herpes-simplex viruses (HSV) or borrelia. T cells were further characterized by expression of the inhibitory surface molecule CTLA-4, as well as markers for differentiation (CD27) and proliferation (Ki67). Pathogen-specific antibody responses were analyzed using ELISA. Results were compared with conventional diagnostics.

RESULTS

Patients with PFP were more often HSV-seropositive than controls (p = 0.0003), whereas VZV- and borrelia-specific antibodies did not differ between groups. Although the quantity and general phenotypical characteristics of antigen-specific T cells did not differ either, expression of CTLA-4 and Ki67 was highly increased in VZV-specific T cells of 9 PFP patients, of which 5 showed typical signs of cutaneous zoster. In the remaining 4 patients, a causal relationship with VZV was possible but remained unclear by clinical standard diagnostics. A similar CTLA-4- and Ki67-expression profile of borrelia-specific T cells was also found in a patient with acute neuroborreliosis.

DISCUSSION

In conclusion, the high prevalence of HSV-seropositivity among PFP-patients may indicate an underestimation of HSV-involvement in PFP, even though HSV-specific T cell characteristics seem insufficient to identify HSV as a causative agent. In contrast, striking alterations in VZV- and borrelia-specific T cell phenotype and function may allow identification of VZV- and borrelia-triggered PFPs. If confirmed in larger studies, antigen-specific immune-phenotyping may have the potential to improve specificity of the clinical diagnosis.

Diagnosis of neuroborreliosis in the context of local seroprevalence: A chart review study and a methodological overview

Background & objectives

In neuroborreliosis (NB) serology might objectively differentiate ongoing from past infection when the intrathecal space is involved. The hierarchy of the parallel serum-CSF (cerebrospinal fluid) methods is seldom discussed and remains elusive in daily practice. We compared the efficacy of certain methods and assessed the prevalence of anti-Borrelia antibodies in the local population.

Methods

We summarized standard two-tier test results in all ELISA-reactive samples of patients with suspected NB (n=152) since 2017 and tested 122 unrelated sera for anti-Borrelia antibodies from central Hungary.

Results

The most common central nervous system symptom was a cranial nerve palsy (27.6% of all subjects). CSF was available in 25 cases. A serum-CSF IgG-matched line immunoassay (LIA) detected intrathecal antibody production correctly in 6 of 8 samples when compared to the ELISA-based antibody-index (AI). Among the 122 random sera the prevalence of specific anti-Borrelia IgG antibodies (on LIA, not including anti-p41) were 6.8% above 30 and 10% above 60 years. Our results enable us to assume the predictive values of serological results according to the pretest probability of neuroborreliosis.

Interpretation & conclusion

Our results suggest that recombinant antigen-based two-tier serology from solely the sera might have sufficient positive predictive value to verify NB in young individuals with characteristic anamnestic data in our region. When parallel serum-CSF testing is warranted, AI should have priority. IgG and albumin concentrations in the both serum and the CSF, the potential time of exposure and the nature and duration of symptoms form the bare minimal set of data for conclusive testing.

Multiple cranial neuropathy due to varicella zoster virus reactivation without vesicular rash: a challenging diagnosis

Ramsay Hunt syndrome is due to reactivation of varicella zoster virus (VZV) dormant in the geniculate ganglion of the facial nerve. The diagnosis is typically based on clinical triad of ipsilateral facial paralysis, otalgia, and vesicles in the auditory canal or the auricle. However, Ramsay Hunt syndrome may occur without skin eruption in up to one third of patients. Moreover, the involvement of other cranial nerves in addition to the facial nerve has been also reported. Herein, we reported a case report of a man who developed a multiple cranial neuropathy caused by VZV reactivation without skin vesicular eruption. The present case underlines a possible diagnostic challenge that clinicians may hit when facing a common disorder such as peripheral facial palsy. Indeed, clinicians must be aware that Ramsay Hunt syndrome may develop without skin vesicular eruption as well it may be complicated by multiple cranial nerve involvement. Antiviral therapy is effective in VZV reactivation for recovery of nerve function.

Irreversible facial nerve palsy as a revelator ofparotid gland cancer

<br><b>Introduction:</b> Bell's palsy is still the diagnosis of exclusion. In most patients it does not progress, it is unilateral, and selflimiting. Additionally, the majority of patients recover spontaneously within 3 weeks. It is well known that all patients with irreversible facial nerve paresis (FNP) need further examinations to exclude the organic, infectious, metabolic, and autoimmunological causes of the palsy. The goal of the study was to assess the frequency of malignancies hidden under the diagnosis of "Bell's palsy".</br> <br><b>Aim:</b> We aimed to create a diagnostic algorithm to avoid failures concerning patients whose only symptom of parotid gland cancer was irreversible FNP.</br> <br><b>Material and methods:</b> We analyzed 253 consecutive patients with FNP treated in our department in the last 5 years. The subject of the study was "Bell's palsy" cases. All patients with irreversible FNP were reassessed in 6-12 months. We underlined all shortcomings in the diagnostics of those in whom malignancies were found in MRI of the neck and presented the proposal for a diagnostic algorithm to avoid missing such an entity.</br> <br><b>Results:</b> Bell's palsy was observed in 157/253 patients (62.06%), in 36/157 (22.92%) it remained permanent. In 4/36 patients (11.11%) with irreversible FNP, which constituted 2.54% of all "Bell's palsy" cases, parotid gland deep lobe mass was found in MRI. In one patient, infiltration of the skull base was diagnosed. Adenoid cystic carcinoma was confirmed in final histopathology in all cases.</br> <br><b>Conclusions:</b> Our experience has shown that irreversible FNP can be a revelator of the malignant tumor located in the deep lobe of the parotid gland. Contrast-enhanced MRI covering intra- and extracranial segments of the facial nerve should be ordered in all cases of FNP without recovery after 4 months. Repeated imaging should be considered in undiagnosed cases. The main point of our study is to underline that the assessment of the deep lobe of the parotid gland with MRI should be included in the standard diagnostic protocol in all irreversible "Bell's palsy" cases.</br>.

Incidence of Underlying Abnormal Findings on Routine Magnetic Resonance Imaging for Bell Palsy

Importance

There is no consensus on the benefits of routine magnetic resonance imaging (MRI) of the facial nerve in patients with suspected idiopathic peripheral facial palsy (PFP) (ie, Bell palsy [BP]).

Objectives

To estimate the proportion of adult patients in whom MRI led to correction of an initial clinical diagnosis of BP; to determine the proportion of patients with confirmed BP who had MRI evidence of facial nerve neuritis without secondary lesions; and to identify factors associated with secondary (nonidiopathic) PFP at initial presentation and 1 month later.

Design, Setting, and Participants

This retrospective multicenter cohort study analyzed the clinical and radiological data of 120 patients initially diagnosed with suspected BP from January 1, 2018, to April 30, 2022, at the emergency department of 3 tertiary referral centers in France.

Interventions

All patients screened for clinically suspected BP underwent an MRI of the entire facial nerve with a double-blind reading of all images.

Main Outcomes and Measures

The proportion of patients in whom MRI led to a correction of the initial diagnosis of BP (any condition other than BP, including potentially life-threating conditions) and results of contrast enhancement of the facial nerve were described.

Results

Among the 120 patients initially diagnosed with suspected BP, 64 (53.3%) were men, and the mean (SD) age was 51 (18) years. Magnetic resonance imaging of the facial nerve led to a correction of the diagnosis in 8 patients (6.7%); among them, potentially life-threatening conditions that required changes in treatment were identified in 3 (37.5%). The MRI confirmed the diagnosis of BP in 112 patients (93.3%), among whom 106 (94.6%) showed evidence of facial nerve neuritis on the affected side (hypersignal on gadolinium-enhanced T1-weighted images). This was the only objective sign confirming the idiopathic nature of PFP.

Conclusions and Relevance

These preliminary results suggest the added value of the routine use of facial nerve MRI in suspected cases of BP. Multicentered international prospective studies should be organized to confirm these results.

Comparing the Clinical Manifestations of Bell's Palsy between Pre-COVID-19 Pandemic and COVID-19 Pandemic Periods

BACKGROUND

COVID-19 has been shown to affect the onset and severity of various diseases. We examined whether the clinical characteristics of Bell's palsy differed between before and during the COVID-19 pandemic.

METHODS

From January 2005 to December 2021, 1839 patients were diagnosed and treated for Bell's palsy at Kyung Hee University Hospital. These patients were divided into a pre-COVID period group and COVID-19 period group, and the clinical characteristics of the two groups were compared.

RESULTS

There were 1719 patients in the pre-COVID period group and 120 patients in the COVID-19 period group. There were no between-group differences in sex (p = 0.103) or in the presence of underlying hypertension (p = 0.632) or diabetes (p = 0.807). Regarding symptoms, there were no significant between-group differences in otalgia, dizziness, tinnitus, hyperacusis, or hearing loss (p = 0.304, p = 0.59, p = 0.351, p = 0.605, and p = 0.949). There were also no significant between-group differences in electroneurography results (p = 0.398), electromyography results (p = 0.331), House-Brackmann Grade at visit (p = 0.634), or recovery rate after treatment (p = 0.525).

CONCLUSIONS

Contrary to our expectation that Bell's palsy cases during the COVID-19 pandemic would show different clinical features than those occurring before COVID-19, the present study found no differences in clinical features or prognosis.

CSF oligoclonal IgG bands are not associated with ALS progression and prognosis

Introduction

Amyotrophic Lateral Sclerosis (ALS) is characterized by progressive motoneuron degeneration through cell autonomous and non-cell autonomous mechanisms; and the involvement of the innate and adaptive immune system has been hypothesized based on human and murine model data. We have explored if B-cell activation and IgG responses, as detected by IgG Oligoclonal bands (OCB) in serum and cerebrospinal fluid, were associated with ALS or with a subgroup of patients with distinct clinical features.

Methods

IgG OCB were determined in patients affected by ALS (n=457), Alzheimer Disease (n=516), Mild Cognitive Impairment (n=91), Tension-type Headache (n=152) and idiopathic Facial Palsy (n=94). For ALS patients, clinico-demographic and survival data were prospectively collected in the Register Schabia.

Results

The prevalence of IgG OCB is comparable in ALS and the four neurological cohorts. When the OCB pattern was considered (highlighting either intrathecal or systemic B-cells activation), no effect of OCB pattern on clinic-demographic parameters and overall. ALS patients with intrathecal IgG synthesis (type 2 and 3) were more likely to display infectious, inflammatory or systemic autoimmune conditions.

Discussion

These data suggest that OCB are not related to ALS pathophysiology but rather are a finding possibly indicative a coincidental infectious or inflammatory comorbidity that merits further investigation.

Oral health and oral health-related quality of life in patients with chronic peripheral facial nerve palsy with synkineses—A case-control-study

Facial nerve palsy (FP) is the most common cranial nerve lesion, leading to partial or complete immobility of the affected half of face. If food residues on tooth surfaces cannot be removed by natural self-cleaning mechanisms that this is likely to lead to an increase dental plaque formation and the risk of dental, periodontal and general diseases. It was the aim of this study to assess oral health, oral hygiene with the influence of handedness and oral health related quality of life in patients with chronic peripheral FP. This study included 86 people. Patients with FP (n = 43) in an FP-group (FPG) were matched with 43 participants without ever diagnosed FP in a control group (CG). Oral health and oral hygiene were assessed in a clinical examination performed in hospital. Decayed-missing-filled-teeth-index, periodontal-screening-index, approximal plaque index and sulcus bleeding index were used to evaluate dental caries and periodontal health status. Oral health-related quality of life data (OHQoL) was collected with the Oral health impact profile (Germany-14) by interview. Oral health parameters in the FPG were significantly worse than in the CG. The median revealed 14.3% more proximal plaque (p = 0.014), 20.8% more sulcus bleeding (p = 0.002) and more than twice as much caries (p = 0.024). The paretic side compared to the non-paretic side of patients was significantly more affected by inflammatory periodontal diseases (p = 0.032) and had a higher prevalence of caries (p = 0.163). Right-handed patients with right-sided FP performed worse than right-handed patients with left-sided FP (p = 0.004). Patients with FP described a greater limitation of OHQoL than patients without this disease (p < 0.001). In conclusion, facial nerve palsy affects oral health, oral hygiene and OHQoL of patients while handedness influences oral hygiene and oral health.

Facial palsy as a manifestation of COVID-19: A systematic review of cases

Background and Aims

Facial palsy is a rare complication of the COVID-19 infection. Herein, we conducted a systematic review of all published cases of facial palsy post-COVID-19 infection in an attempt to educate the general population and medical practitioners regarding the likely occurrence of facial palsy in COVID-19 patients, its detection, effective treatment plan, and prognosis of the condition.

Methods

We searched PubMed, Google Scholar, and Directory of Open Access Journals (DOAJ) from December 1, 2019 to September 21, 2021.

Results

We included 49 studies bearing accounts of 75 cases who had facial palsy. The mean age of patients was 42.9 ± 19.59 years, with a male-to-female ratio of 8:7. The majority of the cases were reported from Brazil (n = 14), USA (n = 9), Turkey (n = 9), and Spain (n = 9). Noticeably, 30.14% of COVID-19 patients were diagnosed with Guillain-Barré syndrome. In total, 22.97% of patients complained of bilateral facial paralysis (n = 17), whereas ipsilateral paralysis was observed in 77.03% (n = 57). These were common complaints of Lagophthalmos, otalgia, facial drooping, dysarthria, and compromised forehead wrinkling. The treatment regimen mainly included the use of corticosteroids (n = 51) (69.86%), antivirals (n = 23) (31.51%), IVIG (n = 18) (24.66%), antibiotics (n = 13) (17.81%), antiretroviral (n = 9) (12.33%), and antimalarial (n = 8) (10.96%) medications. In all, 35.62% of patients (n = 26) adhered to a combination of antiviral and corticosteroid-based therapy. Positive treatment outcomes were observed in 83.58% (n = 56) of cases. In contrast, 10 patients (14.93%) showed nonsignificant recovery, out of which 3 (4.48%) died from the disease.

Conclusion

The association of facial palsy with COVID-19 is controversial and therefore requires further investigation and published work to confirm a causal relationship. However, physicians should not overlook the likelihood of facial palsy post-COVID-19 infection and treat it accordingly.

Lyme neuroborreliosis as a cause of sudden sensorineural hearing loss and facial palsy

We present a case of sudden sensorineural hearing loss and rapidly progressive facial palsy in a female patient in her 40s with no, apparently, notable past medical or surgical history. Investigations revealed a positive serology for B. burgdoferi and the MRI allowed us to identify suggestive signs of Lyme meningitis with multiple cranial nerve involvement. After diagnosis, the patient was treated with intravenous ceftriaxone with a full recovery of sensorineural deafness and facial palsy. This case report highlights the importance of collecting a complete medical history in all cases of facial palsy and sudden hearing loss while presenting an infrequent clinical presentation of early disseminated Lyme disease with neuroborreliosis.

Enhancement of cranial nerves in Lyme neuroborreliosis: incidence and correlation with clinical symptoms and prognosis

PURPOSE

Symptoms of cranial neuritis are a common presentation of Lyme neuroborreliosis (LNB). Imaging studies are scarce and report contradictory low prevalence of enhancement compared to clinical studies of cranial neuropathy. We hypothesized that MRI enhancement of cranial nerves in LNB is underreported, and aimed to assess the prevalence and clinical impact of cranial nerve enhancement in early LNB.

METHODS

In this prospective, longitudinal cohort study, 69 patients with acute LNB were examined with MRI of the brain. Enhancement of cranial nerves III-XII was rated. MRI enhancement was correlated to clinical findings of neuropathy in the acute phase and after 6 months.

RESULTS

Thirty-nine of 69 patients (57%) had pathological cranial nerve enhancement. Facial and oculomotor nerves were most frequently affected. There was a strong correlation between enhancement in the distal internal auditory canal and parotid segments of the facial nerve and degree of facial palsy (gamma = 0.95, p < .01, and gamma = 0.93, p < .01), despite that 19/37 nerves with mild-moderate enhancement in the distal internal auditory canal segment showed no clinically evident palsy. Oculomotor and abducens nerve enhancement did not correlate with eye movement palsy (gamma = 1.00 and 0.97, p = .31 for both). Sixteen of 17 patients with oculomotor and/or abducens nerve enhancement had no evident eye movement palsy.

CONCLUSIONS

MRI cranial nerve enhancement is common in LNB patients, but it can be clinically occult. Facial and oculomotor nerves are most often affected. Enhancement of the facial nerve distal internal auditory canal and parotid segments correlate with degree of facial palsy.

Scalp Nodules and Facial Droop in an Infant

A previously healthy, term, 5-week-old girl initially presented to her primary care physician with a solitary, enlarging scalp nodule. The infant was otherwise well without additional signs or symptoms of illness. Over the next several weeks, the nodule continued to grow, and additional lesions appeared on her scalp. An ultrasound of the primary nodule revealed a hypoechoic structure favored to represent a serosanguinous fluid collection. After evaluation by general surgery and dermatology, she underwent a scalp biopsy of the largest lesion. While biopsy specimen results were pending, her parents noted that she was developing increased irritability, difficulty closing her right eye, and facial weakness. She was referred to the emergency department where a right-sided facial droop involving the brow and forehead was noted. The skin biopsy specimen results, along with subsequent laboratory studies and imaging, led to the final diagnosis.

Facial Nerve Palsy as a Neurological Manifestation of COVID-19

Facial nerve palsy is the most frequent acute mononeuropathy and it is often of viral etiology, although many other causes have been identified. It has recently been described as a potential manifestation of COVID-19. We report the case of a patient with recent history of diarrhea and malaise that was admitted to the hospital presenting right facial paresis with orbicular muscle involvement. Nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the real-time reverse transcription polymerase chain reaction and magnetic resonance imaging showed no structural changes. During the hospital stay, the patient showed clinical improvement, and no other symptoms were observed. This case presentation suggests a possible association between neuropathies and SARS-CoV-2 infection.

Mimics of perineural tumor spread in the head and neck

Perineural spread (PNS) is an important potential complication of head and neck malignancy, as it is associated with decreased survival and a higher risk of local recurrence and metastasis. There are many review articles focused on the imaging findings of PNS. However, a false-positive diagnosis of PNS can be just as harmful to the patient as an overlooked case. In this manuscript, we delineate and classify various imaging mimics of PNS. Mimics can be divided into the following categories: normal variants (including vascular structures and failed fat suppression), infections, inflammatory disease (including granulomatous disease and demyelination), neoplasms, and post-traumatic/surgical changes. Knowledge of potential mimics of PNS will prevent false-positive imaging interpretation, and enable appropriate oncologic management.

Diagnostic value of dynamic contrast-enhanced magnetic resonance imaging in Bell's palsy

BACKGROUND

Bell's palsy (BP) is the most common form of acute facial nerve disorder and is characterized by rapid onset peripheral facial palsy of unknown etiology.

PURPOSE

To explore the diagnostic value of dynamic contrast-enhanced (DCE) magnetic resonance imagine (MRI) in patients with BP particularly in involved segments.

MATERIAL AND METHODS

A retrospective analysis was performed on the patients with BP who underwent routine MRI examinations and volumetric interpolated breath-hold examination (VIBE) sequence-based DCE-MRI before surgery in our department from January 2015 to July 2020. DCE-MRI data postprocessing was performed on Siemens Workstation Extended MR Work Space 2.6.3.5. Statistical analyses were performed using SPSS®v.19.0. The inter-observer reliability was evaluated with kappa identity test and McNemar's test.

RESULTS

Twenty-three patients were included. On conventional contrast-enhanced MRI, the two observers were inconsistent in their diagnosis of lesion segments of facial nerve (Kappa 0.426, P = 0.009). Compared to the results of the surgery, the diagnostic consistency of both observers was general (Kappa 0.476, P < 0.001 and Kappa 0.430, P < 0.001, respectively). The diagnostic results of DCE-MRI for lesion segments of the facial nerve were consistent between the two observers (Kappa 0.929, P < 0.001). Compared to the results of the surgery, the diagnostic consistency of both observers was good (Kappa 0.753, P < 0.001 and Kappa 0.731, P < 0.001, respectively).

CONCLUSION

Compared to conventional MRI, DCE-MRI has good stability and repeatability in the diagnosis of the lesion segments of the facial nerve as well as a good specificity and accuracy.

Adjunctive Corticosteroids for Lyme Neuroborreliosis Peripheral Facial Palsy - a prospective study with historical controls

BACKGROUND

Lyme neuroborreliosis peripheral facial palsy (LNB PFP) and idiopathic peripheral facial palsy, Bell's palsy (BP), are the most common causes of facial palsy in borrelia-endemic areas and are clinically similar. Early treatment with corticosteroids has been shown to be effective in Bell's palsy and antibiotics improve outcome in LNB, but there is a lack of knowledge on how the addition of corticosteroids to standard antibiotic treatment affects outcome in LNB PFP.

METHODS

This prospective open trial with historical controls was conducted at two large hospitals in western Sweden between 2011 and 2018. Adults presenting with LNB PFP were included in the study group and were treated with oral doxycycline 200 mg b.i.d. for 10 days and prednisolone 60 mg o.d. for 5 days, then tapered over 5 days. The historical controls were adult patients with LNB PFP included in previous studies and treated with oral doxycycline. Both groups underwent a follow-up lumbar puncture and were followed until complete recovery or for 12 months.

RESULTS

Fifty-seven patients were included, 27 in the study group and 30 in the control group. Two patients (6%) in the study group and 6 patients (20%) in the control group suffered from sequelae at end follow up. There was no statistically significant difference between the groups, neither in the proportion of patients with sequelae, nor in the decline in CSF mononuclear cell count.

CONCLUSIONS

Adjunctive corticosteroids neither improve nor impair the outcome for patients with Lyme neuroborreliosis peripheral facial palsy treated with doxycycline.

Assessment of anti-HSV antibodies in patients with facial palsy in the course of neuroborreliosis

AIM

There are many causes of facial nerve palsy. The most common causes are neuroborreliosis (NB), idiopathic paralysis or Herpes simplex virus (HSV) reactivation. The aim of this study was to characterize patients with facial palsy in the course of NB and to determine whether HSV-1 reactivation takes place during the acute phase of NB.

METHODS

A retrospective analysis of 66 patients with facial nerve palsy was performed. In 38 patients, facial palsy was caused by Borrelia burgdorferi sl infection. Immunological tests for HSV-1, tick-borne encephalitis virus and B burgdorferi sl in serum and cerebrospinal fluid (CSF) were performed.

RESULTS

In this analysis, 55.2% of NB patients had right nerve palsy and 21% bilateral palsy; 15.8% of patients had erythema migrans (EM). Lymphocytic meningitis was diagnosed in 92% of patients and Bannwarth's syndrome was diagnosed in 47% of patients. IgM anti-HSV-1 antibodies were detected in four patients with NB and two patients with facial nerve palsy of other origin. IgM anti-HSV-1 antibodies were detected in the CSF of three patients (7.9%) with NB, and one of them had bilateral VII paresis and EM simultaneously. Treatment with ceftriaxone or doxycycline led to complete recovery.

CONCLUSIONS

Neuroborreliosis should always be considered as a cause of peripheral facial nerve palsy. Peripheral facial nerve palsy is a significant symptom in the course of NB, especially in patients accompanied by meningitis. Pathomechanism of facial nerve paresis has not been well explained so far and may depend on two independent mechanisms in NB, including HSV-1 reactivation.

Intrathecal antibody kinetics in neuroborreliosis: A report on three cases and a literature review

Borreliosis is a common affliction in northern countries and its neurological manifestations often mislead trained clinicians. We present three cases of Lyme neuroborreliosis, with intrathecal synthesis of specific antibodies, lymphocytic meningitis and magnetic-resonance imaging (MRI) findings. Our description aims at illustrating the natural history of the infection, highlighting persistent intrathecal synthesis of anti-Borrelia antibodies months after treatment completion, and its clinical significance. We then review the literature on MRI findings in neuroborreliosis and the kinetics of intrathecal synthesis of specific anti-Borrelia antibodies.

Mastoid effusion on temporal bone MRI in patients with Bell's palsy and Ramsay Hunt syndrome

This study aimed to investigate the incidence of mastoid effusion on temporal bone magnetic resonance imaging (MRI) in patients with Bell’s palsy (BP) and Ramsay Hunt syndrome (RHS), and evaluate the usefulness of mastoid effusion in early differential diagnosis between BP and RHS. The incidence of mastoid effusion on 3.0 T—temporal bone MRI, which was conducted within 10 days after the onset of acute facial nerve palsy, was compared between 131 patients with BP and 33 patients with RHS. Findings of mastoid cavity on temporal bone MRI were classified into three groups as normal mastoid, mastoid effusion, and sclerotic change, and the incidence of ipsilesional mastoid effusion was significantly higher in RHS than BP (P < 0.001). Tympanic membrane was normal in 7 of 14 RHS patients with mastoid effusion, and injected without middle ear effusion in 7 patients. This study highlights significantly higher incidence of ipsilesional mastoid effusion in RHS than BP, and suggests that the presence of mastoid effusion may provide additional information for differential diagnosis between RHS and BP.

Positive Tests for Lyme Disease and Emergency Department Visits for Bell's Palsy Patients

BACKGROUND

Etiologies for Bell's palsy include herpes viruses and Lyme disease, with highest incidence in the colder and warmer months, respectively. In New Jersey, a Lyme-endemic area, the months with the most Lyme disease (80% of cases) are May through October ("Lyme months").

OBJECTIVE

Our aim was to determine whether positive tests for Lyme disease and visits are greater in the Lyme months than the rest of the year for patients with Bell's palsy in New Jersey emergency departments (EDs).

METHODS

We conducted a retrospective chart review from two New Jersey suburban EDs with consecutive patients from February 1, 2013 to January 31, 2018.We identified patients having Bell's palsy using the emergency physician diagnosis. We tabulated positive Lyme tests and visits for Bell's palsy by month of year. We calculated the ratio of positive tests and visits between the Lyme months and the rest of the year along with 95% confidence intervals (CIs).

RESULTS

There were 442 visits for Bell's palsy, 359 (81%) of these patients were tested for Lyme disease and 57 (16%) of the tests were positive. The Lyme months had 7.1 (95% CI 3.5-14.4) times more positive tests and 1.3 (95% CI 1.1-1.4) times more Bell's palsy visits than the rest of the year. Both measures peaked in July.

CONCLUSIONS

In a Lyme-endemic area, positive Lyme tests and ED visits for Bell's palsy are greatest in the Lyme months, peaking in July. This finding can help guide testing and treatment for patients in the ED with Bell's palsy during various months of the year.

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.

CT and MR neuroimaging findings in patients with Lyme neuroborreliosis: A national prospective cohort study

BACKGROUND

We aimed to describe the use and findings of cranial computerized tomography (CT-head), spine and brain magnetic resonance imaging (MRI-spine/MRI-brain) in Lyme neuroborreliose (LNB).

METHODS

Patients with LNB were identified using a nationwide, population-based prospective cohort of all adults treated for neuroinfections at departments of infectious diseases in Denmark from 2015 to 2019. Multivariate logistic regression analyses assessed associations between clinical characteristics and MRI-findings consistent with LNB.

RESULTS

We included 368 patients (272 definite LNB and 96 probable LNB), 280 scans were performed in 198 patients. Neuroimaging was associated with older age (59 vs. 57, p = 0.03), suspicion of other diseases (77% vs. 37%, p < 0.0001), no history of tick bites (58% vs. 43%, p = 0.01), physical/cognitive deficits prior to admission (15% vs 5%, p = 0.006), peripheral palsy (10% vs. 2%, p = 0.0008), encephalitis (8% vs. 1%, p = 0.0007) and cognitive impairment (8% vs. 2%, p = 0.03) compared with those without neuroimaging. Normal or incidental findings were common (93/98 CT-head and 154/182 MRI). 1/98 CT-head, 19/131 MRI-brain and 6/51 MRI-spine had findings consistent with LNB. Symptoms ≥45 days was associated with MRI-findings consistent with LNB (adjusted odds ratio (aOR) 4.2, 95%confidence interval 1.2-14.4, p = 0.02).

CONCLUSION

In this Danish cohort including 368 LNB-patients, use of neuroimaging was common and often performed in older comorbid patients without previous tick-bite intended to investigate alternative diagnoses. The results were in general without pathology and neuroimaging cannot exclude LNB or replace lumbar puncture. MRI is of value when investigating alternative neurological diseases and may support suspicion of LNB in cases with meningeal/leptomeningeal/neural enhancement.

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.

Acute Peripheral Facial Palsy: Recent Guidelines and a Systematic Review of the Literature

BACKGROUND

This study reviews recent literature on facial palsy guidelines and provides systematic reviews on related topics of interest.

METHODS

An electronic database search was performed to identify recent guidelines dealing with facial nerve palsy, systematic reviews and recent meta-analysis published between 2011 and 2019 (inclusive). The literature search used the search terms "Bell's palsy," "Ramsay-Hunt syndrome," "Facial palsy," "Facial paralysis," "Facial paresis," "Guideline," "Meta-analysis," "Systematic review," and "Randomized controlled trial." Only studies written in English were used.

RESULTS

The characteristics of treatment trends for facial palsy have been reviewed over the past decade. The most prominent change noted may be the shift from the conventional House-Brackmann facial nerve grading system to the Sunnybrook and eFACE systems. In addition, the results of serial meta-analyses indicate increasing agreement with the use of surgical decompression of the facial nerve. Beyond steroids or combined steroid-antiviral treatment, various novel drugs and treatments have been tried. For long-standing facial paralysis and postparetic synkinesis sequelae after facial palsy, facial reanimation has been highlighted and the necessity of new paradigms have been raised.

CONCLUSION

For peripheral facial paralysis, various changes have been made, not only in the facial nerve grading systems, but also in medical treatments, from surgical procedures to rehabilitation, during the last decade.

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.

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.

The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell's Palsy)

BACKGROUND

Peripheral facial nerve palsy is the most com- mon functional disturbance of a cranial nerve. 60-75% of cases are idiopathic.

METHODS

This review is based on a selective literature search proceeding from the current, updated German-language guideline on the diagnosis and treatment of idiopathic facial nerve palsy.

RESULTS

The recommended drug treatment consists of prednisolone 25 mg bid for 10 days, or 60 mg qd for 5 days followed by a taper to off in decrements of 10 mg per day. This promotes full recovery (number needed to treat [NNT] = 10; 95% confidence interval [6; 20]) and lessens the risk of late sequelae such as synkinesia, autonomic disturbances, and contractures. Virostatic drugs are optional in severe cases (intense pain or suspicion of herpes zoster sine herpete) and mandatory in cases of varicella-zoster virus (VZV) infection. Corneal protection with dexpanthenol ophthalmic ointment, artificial tears, and a nocturnal moisture- retaining eye shield has been found useful in practice. In cases of incomplete recovery with residual facial weakness, both static and microsurgical dynamic methods can be used to restore facial nerve function.

CONCLUSION

Because 25-40% of cases of facial nerve palsy are not idiopathic, differential diagnosis is very important; key diagnostic methods include a clinical neurological examin- ation, otoscopy, and a lumbar puncture for cerebrospinal fluid examination. High-level evidence supports corticosteroid treatment for the idiopathic form of the disorder.