Acute facial paralysis: evaluation and early management

Neuromuscular retraining therapy for early stage severe Bell's palsy patients minimizes facial synkinesis

OBJECTIVE

To explore whether early physical interventions, including neuromuscular retraining therapy, can minimize excessive movement or any unwanted co-contraction after a severe Bell's palsy.

DATA SOURCES

From March 2021 to August 2022, the therapist treated Bell's palsy patients for the acute (<3 months, Group A), subacute (3-6 months, Group B) and chronic (> 6 months, Group C) stages of the condition.

METHODS

We explored whether early physical interventions, including neuromuscular retraining therapy, can minimize facial synkinesis after a severe episode of Bell's palsy. Each patient was informed about the potential for synkinesis and the therapist explained that the main purpose of neuromuscular retraining therapy is to learn new patterns to minimize synkinesis. The facial function of Group A was compared to that of Groups B and C using the 'Synkinesis' scale of the Sunnybrook Facial Grading System.

RESULTS

The final facial function score after neuromuscular retraining therapy was significantly associated with both the initial electroneuronographic degeneration rate and initial facial function. Early therapy did not prevent synkinetic movement in 84.7% of the patients. But, there was a significant difference between patients who started early neuromuscular retraining therapy and other groups in final facial function.

CONCLUSION

Synkinesis in Bell's palsy patients can be minimized if physiotherapy commences before synkinesis develops; appropriate neuromuscular retraining therapy timing is essential. A patient with sudden severe Bell's palsy should receive oral steroids as soon as possible, along with physical therapy (including neuromuscular retraining therapy) within 3 months, to minimize synkinesis just before synkinesis onset.

[External otitis: clinical diagnostics and treatment tactics]

OBJECTIVE

To summarize modern data about the epidemiology, etiology, clinical course and diagnosis of otitis externa.

MATERIAL AND METHODS

Materials of scientific publications included in the Cochrane Library, information bases of the RSCI, MEDLINE, PubMed were used as a data source. The choice of material was carried out according to the keywords: otitis externa, etiology, diagnosis, treatment, local treatment.

RESULTS

The role of combined drugs in the main etiopathogenetic mechanisms of the external ear inflammatory process is shown.

CONCLUSION

Analysis of published data from clinical trials indicates the importance of a fixed antibacterial agents and anesthetic combination in increasing the effectiveness of topical therapy for otitis externa.

Operator Experience and Fracture Location Affects the Rate of Facial Nerve Injury in Condylar Fractures: An Analysis of 89 Cases

PURPOSE

The purpose of this study was to measure the frequency and identify risk factors for facial nerve injury (FNI) in the open treatment of condylar neck and subcondylar fractures.

MATERIALS AND METHODS

A prospective cohort study was conducted over 5 years on patients who were treated surgically for mandibular condylar fractures using the retomandibular transparotid approach (RMTA). The primary result was FNI occurrence (yes/no). The predictor variables were demographic, fracture location, and pattern (dislocation, present or not), as well as surgeon experience. Post-treatment functional facial nerve changes were initially assessed in the operating room as the patient regained consciousness and documented thereafter within, the 1st and 3rd weeks, and 3rd and 6th months. Appropriate statistics were computed and, SPSS version 16 was used to analyze the data. χ² test and Fisher exact test were used to assess significance (P ≤ 0.05).

RESULTS

Eighty-nine patients with 102 condylar fractures (63 subcondylar and 26 condylar neck), with a mean age of 28.5±7.5 years and 91% men were evaluated. There were 15 subjects (16.8%) with FNI and among them 6 subjects had persistent facial weakness for 6-8 weeks that completely resolved within 3 months, with no permanent facial nerve paralysis. The marginal mandibular (n = 7), buccal (n = 6), and zygomatic (n = 2) were the facial nerve branches involved. Risk factors for FNI were operator' inexperience, fracture-dislocation, and condylar neck fracture to the site and location of the fracture. Multivariate logistic regression showed that the location of the fracture at neck level (0.030∗), fracture dislocation (<0.001∗), and operator's inexperience (0.003∗) were significant risk factors for postoperative facial nerve injury (P ≤ 0.05).

CONCLUSIONS

If conducted properly, the RMTA is a safe method for treating condylar fractures with rare major complications; however, fracture dislocation, fractured condylar neck, and operator' in-experience were significantly associated with increased risk of developing transient postoperative FNI.

Analysis between Retromandibular and Periangular Transmasseteric Approach for Fixation of Condylar Fracture - A Prospective Study

Introduction:

Condylar fractures make up for an average of 17.5%–52% of all mandibular fractures. The aim of the present study was to compare the ease, success, and complications between retromandibular and periangular transmasseteric approaches when used for open reduction and internal fixation of condylar fractures.

Materials and Methods:

A total 20 cases with condylar fracture, ten each for retromandibular and periangular transmasseteric approach, were included in the study. Patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Postoperative occlusion, maximum mouth opening, range of movement, facial nerve function, visibility, convenience of plating, and time taken for exposure, fixation, and closure were recorded. Incidence of complications such as wound dehiscence, wound infection, hematoma, sialocele formation, Frey's syndrome, and hypertrophic scars were also evaluated.

Results:

The mean exposure time in the retromandibular approach was 10 min 31 s and 9 min 17 s in the periangular transmasseteric approach. The incidence of facial nerve injury was 2 of 10 patients in the retromandibular group and 3 of 10 patients in the periangular transmasseteric group, all of which resolved within 6 months. The incidence of sialocoele was 2 of 10 in the retromandibular group. The time taken for exposure of the fracture site was statistically significant between the two approaches (P = 0.048) with longer time required for retromandibular approach.

Discussion:

It can be summarized that both the approaches are comparable and well suited for surgical management of condylar fractures. It was observed that in displaced condylar neck fractures, greater difficulty was experienced in the periangular transmasseteric approach than the retromandibular approach.

Does a Retromandibular Transparotid Approach for the Open Treatment of Condylar Fractures Result in Facial Nerve Injury?

PURPOSE

The retromandibular transparotid approach (RMA) to condylar fractures of the mandible provides excellent access, but can increase the risk of complications. The aim of this study was to estimate the frequency of facial nerve paralysis (FNP) and associated postoperative complications after open reduction and rigid internal fixation (ORIF) of subcondylar fractures through the RMA.

MATERIALS AND METHODS

This was a retrospective cohort study of patients with condylar fractures requiring ORIF through the RMA. The inclusion criteria were 1) a medical record of surgical treatment of a subcondylar fracture by RMA; 2) preoperative and postoperative radiographs; 3) mental status permitting an adequate neuromotor examination; 4) absence of a post-injury or pretreatment functional facial nerve deficit; and 5) regular postoperative follow-up longer than 6 months with documentation of complications, functional results, and fixation stability. The predictive variables were age, gender, fracture site, fracture pattern, concomitant fractures, etiology, and plate types. The outcome variable was FNP. Univariate, bivariate, and multiple logistic regression statistics were computed.

RESULTS

Fifty patients with 55 displaced mandibular subcondylar fractures (35 men, 15 women; mean age, 44.5 yr; range, 17 to 87 yr) met the inclusion criteria. The condylar fracture involved the neck in 35 patients (63.6%) and the base in 20 patients (36.4%). The fracture pattern was deviation in 11 patients (20.0%), displacement in 23 (41.8%), and dislocation in 21 (38.2%). Precise ORIF with double-buttress fixation resulted in immediate functional recovery in all patients. Seven fractures (12.7%) were associated with FNP that resolved completely within 6 months. Further statistical analysis showed that dislocated and displaced condylar neck fractures were significant risk factors for postoperative FNP (P < .05). Other postoperative complications were minimal.

CONCLUSION

The RMA for subcondylar fractures is feasible and safe. Dislocated condylar neck fractures are associated with a highly increased risk of temporary postoperative FNP as a surgical complication.

The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends

Background

Recent advances in Bell’s palsy (BP) were reviewed to assess the current trends in its management and prognosis.

Material/Methods

We retrieved the literature on BP using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Key words and phrases used during the search included ‘Bell’s palsy’, ‘Bell’s phenomenon’, ‘facial palsy’, and ‘idiopathic facial paralysis’. Emphasis was placed on articles and randomized controlled trails (RCTs) published within the last 5 years.

Results

BP is currently considered the leading disorder affecting the facial nerve. The literature is replete with theories of its etiology, but the reactivation of herpes simplex virus isoform 1 (HSV-1) and/or herpes zoster virus (HZV) from the geniculate ganglia is now the most strongly suspected cause. Despite the advancements in neuroimaging techniques, the diagnosis of BP remains one of exclusion. In addition, most patients with BP recover spontaneously within 3 weeks.

Conclusions

Corticosteroids are currently the drug of choice when medical therapy is needed. Antivirals, in contrast, are not superior to placebo according to most reliable studies. At the time of publication, there is no consensus as to the benefit of acupuncture or surgical decompression of the facial nerve. Long-term therapeutic agents and adjuvant medications for BP are necessary due to recurrence and intractable cases. In the future, large RCTs will be required to determine whether BP is associated with an increased risk of stroke.

Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach

The objective of this study was to evaluate any damage to the facial nerve after a retromandibular transparotid approach for open reduction and internal fixation (ORIF) of a subcondylar fracture. We studied 38 patients with 44 subcondylar fractures (3 bilateral and 38 unilateral) treated by ORIF through a retromandibular transparotid approach. All patients were followed up for 6 months. Postoperative function of the facial nerve was evaluated within 24h of operation, and at 1, 3, and 12 weeks, and 6 months. Variables including type of fracture, degree of mouth opening, postoperative occlusion, lateral excursion of the mandible, and aesthetic outcome were also monitored. Nine of the 44 fractures resulted in transient facial nerve palsy (20%). Branches of the facial nerve that were involved were the buccal (n=7), marginal mandibular (n=2), and zygomatic (n=1). In the group with lateral displacement, 2/15 showed signs of weakness, whereas when the fracture was medially displaced or dislocated 7/23 showed signs of weakness. Of the 9 sites affected, 7 had resolved within 3 months, and the remaining 2 resolved within 6 months. The mean (range) time to recovery of function was 12 weeks (3-6 months). There was no case of permanent nerve palsy. The retromandibular transparotid approach to ORIF does not permanently damage the branches of the facial nerve. Temporary palsy, though common, resolves in 3-6 months. Postoperative occlusion, mouth opening, and lateral excursion of the mandible were within the reference ranges. We had no infections, or fractured plates, or hypertrophic or keloid scars.

When the bell tolls on Bell's palsy: finding occult malignancy in acute-onset facial paralysis

PURPOSE

This study reports 4 cases of occult parotid malignancy presenting with sudden-onset facial paralysis to demonstrate that failure to regain tone 6 months after onset distinguishes these patients from Bell's palsy patients with delayed recovery and to propose a diagnostic algorithm for this subset of patients.

MATERIALS AND METHODS

A case series of 4 patients with occult parotid malignancies presenting with acute-onset unilateral facial paralysis is reported.

RESULTS

Initial imaging on all 4 patients did not demonstrate a parotid mass. Diagnostic delays ranged from 7 to 36 months from time of onset of facial paralysis to time of diagnosis of parotid malignancy. Additional physical examination findings, especially failure to regain tone, as well as properly protocolled radiologic studies reviewed with dedicated head and neck radiologists, were helpful in arriving at the diagnosis.

CONCLUSION

An algorithm to minimize diagnostic delays in this subset of acute facial paralysis patients is presented. Careful attention to facial tone, in addition to movement, is important in the diagnostic evaluation of acute-onset facial paralysis.

Facial nerve paralysis

Emotions are communicated through facial expression. Happiness, confusion, and frustration can be expressed with a slight smile, eyebrow shift, or wrinkled nose. Injury to the facial nerve and subsequent inability of perform volitional mimetic movement can provoke anxiety. This article explores the causes, treatment, and prevention of facial nerve paralysis.

Regional spread of nonneurogenic tumors to the skull base via the facial nerve

OBJECTIVE

This study examined the clinical and pathologic features of regional spread of nonneurogenic neoplastic disease to the intratemporal segments of the facial nerve.

STUDY DESIGN

Retrospective review.SETTING Three tertiary referral centers.

PATIENTS

Six patients with neoplastic disease of nonneurogenic origin involving segments of the facial nerve within the temporal bone.

INTERVENTIONS

All patients underwent surgery with curative intent. Five patients received adjuvant radiation, and two received adjuvant radiation and chemotherapy.

MAIN OUTCOME MEASURES

Histopathology, site of primary tumor, intratemporal location of regional spread along the facial nerve, degree of facial paralysis, and presence of residual disease.

RESULTS

Five cases of malignancy were reported: one case of parotid adenoid cystic carcinoma, one case of parotid mucoepidermoid carcinoma, two cases of squamous cell carcinoma of the skin, and one case of an unidentified carcinoma. Perineural spread was histologically found in all cases of malignant disease. In addition, one case of benign pleomorphic adenoma of the parotid gland that circumferentially involved an intratemporal segment of the facial nerve was reported. Facial paralysis was present in five of six (83%) of cases. Four patients had unresectable malignant disease, and two died despite multimodality therapy.

CONCLUSIONS

The facial nerve provides a route for the spread of neoplastic disease into the temporal bone, and perineural invasion is an important mechanism of invasion and motility of malignant disease. Nonneurogenic intratemporal tumors of the facial nerve are a rare but significant cause of facial paralysis.

The facial nerve. Current trends in diagnosis, treatment, and rehabilitation

Facial paralysis is a potentially devastating disorder with numerous implications. Multiple entities must be considered in its etiology, and recent advances in microbiology, radiographic imaging, electrodiagnostic testing, and microsurgery have provided great insight into the pathophysiology, diagnosis, treatment, and rehabilitation of the facial nerve. Recent DNA PCR testing has shed new insight into the potential cause for Bell's palsy. This article focuses on the evaluation, differential diagnosis, medical treatment, and rehabilitation of facial nerve pathology with primary emphasis on facial paralysis. Surgical management is also discussed, including reanimation of the paralyzed face.

Traditional pharmacology and medicine in Africa. Ethnopharmacological themes in sub-Saharan art objects and utensils

Drawing from the general description that ethnopharmacology studies the human use of crude drugs and poisons in a traditional context, ethnopharmacological themes in native art can be defined as themes visualizing different features of traditional medicines and poisons, such as natural sources, methods of preparation, containers, usage and implements, target diseases and effects. This review documents that native African art objects and utensils are a goldmine of such ethnopharmacological themes by focusing on the following subjects: (a) objects related to the use of medicines (sources as well as tools for their collection, preparation and keeping); (b) objects related to the use of poisons (e.g. for ordeals, hunting and fishing); (c) objects related to the use of psychotropic agents (e.g. alcoholic beverages, kola nuts, smoking and snuffing materials); (d) pathological representations (e.g. treponematoses, leprosy, smallpox, swollen abdomen, scrotal enlargement, goiter and distorted faces); and (e) portrayals of certain types of treatment (e.g. topical instillations, perinatal care, and surgery). To avoid the impression that ethnopharmacology has little else to offer than armchair amusement, an epilogue outlines the medical relevance of this interdisciplinary science for Western and African societies.

Simultaneous leukaemic infiltrate and cholesteatoma in the same temporal bone

Leukaemic relapse in the ear is very rare. We report a case of relapse of acute lymphoblastic leukaemia in the left ear. The patient presented with an aural polyp and ipsilateral facial palsy. The temporal bone showed simultaneous leukaemic infiltrate and cholesteatoma. To our knowledge, this is the first case reported with such pathology.

Inflammatory diseases of the ear

The inflammatory diseases of external and middle ear are one of the commonest conditions encountered by the pediatric physician. Inner ear inflammations are less common and need special and urgent attention. Special management in each case requires detailed history, examination, necessary investigations and appropriate referral to otolaryngologist when necessary. The article is aimed to help formulate a plan in managing the inflammatory conditions of ear. Otalgia constitutes the most prominent of the symptoms in external and middle ear inflammations whereas vertigo, tinnitus and sensory hearing loss form the symptom complex for inner ear infections. It is necessary to understand the basic pathophysiology of the inflammatory condition to be able to institute a targetted treatment. The audiometry impedance studies, microbiology of discharge and occasionally ABR and CT scan from the mainstay of investigative workup. The treatment is specific and based on the precise diagnosis. It often requires the help of an otolaryngologist. Decisions may have to be made with regards to the need for any surgical intervention particularly in acute otitis media, an external canal abscess or an acute mastoiditis. A case of chronic otitis media with facial palsy or vertigo (labyrinthitis being a possibility) needs urgent intervention.

Eye, ear, nose, and throat

Patients present to the emergency department with a number of eye, ear, nose, and throat (ENT) problems. This article updates some very common problems; identifies a few pearls on nasal foreign body removal, ophthalmologic medication, and epistaxis; and reviews a few pitfalls in identifying malignancies and sore throats.