Neuro-ophthalmological approach to facial nerve palsy

Progress in treatment of facial neuritis by acupuncture combined with medicine from the perspective of modern medicine: A review

Facial neuritis is a common clinical disease with high incidence, also known as Bell palsy or idiopathic facial nerve paralysis, which is an acute onset of peripheral facial neuropathy. In modern medicine, there have been obstacles to the effective treatment of facial neuritis. At present, the clinical use of Western medicine treatment is also a summary of clinical experience, the reason is that the cause of facial neuritis is unknown. Facial neuritis belongs to the category of "facial paralysis" in traditional Chinese medicine. For thousands of years, Chinese medicine has accumulated a lot of relevant treatment experience in the process of diagnosis and treatment. At the same time, traditional Chinese medicine, acupuncture and the combination of acupuncture and medicine play an important role in the treatment of facial neuritis. This article discusses the treatment of facial neuritis with acupuncture combined with Chinese medicine, based on the research progress of modern medicine. In this review, we provide an overview of the effectiveness of acupuncture and medication combinations and facial neuritis with current studies investigating acupuncture and medication combinations in the treatment of facial neuritis.

Ocular factors predicting requirement for corneal protective oculoplastic surgery

BACKGROUND

Currently there is no universally agreed schema for predicting ocular morbidity in facial nerve palsy. The House Brackmann Scale has limitations in assessing ocular morbidity from facial nerve palsy. Our aim was to create a scoring system to help quantify ocular morbidity to aid in decision making regarding the need for corneal protective oculoplastic surgery.

METHODS

We conducted a large cohort study observing 606 patients attending the specialist facial palsy clinic in Manchester UK between March 2002 and October 2017. Retrospective multivariate analysis identified clinical predictors for the 316 patients that required oculoplastic surgery. β coefficients generated in the multivariate analysis helped formulate a new facial nerve palsy scoring instrument to predict the need for corneal protective oculoplastic surgery.

RESULTS

The House Brackmann Scale, corneal lagophthalmos and loss of corneal sensation proved clinically significant predictors for requiring corneal protective oculoplastic surgery. The scoring system derived from these factors provided an accurate and repeatable prediction tool demonstrated by validation studies on our patient population. The area under the ROC curve for the multivariate prediction model was 0.769 (0.726, 0.811). A score of 5 points out of a possible 8 was the best cut off score to recommend oculoplastic surgery, giving a sensitivity of 0.750 and a specificity of 0.671.

CONCLUSION

This study demonstrates that corneal lagophthalmos, corneal sensation and the House Brackmann Scale are important in predicting the need for corneal protective oculoplastic surgery. Our scoring tool is an important clinical decision tool for ophthalmic and ENT colleagues.

Evidence-Based Practices in Facial Reanimation Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the causes and preoperative evaluation of facial paralysis. 2. Discuss techniques to restore corneal sensation and eyelid closure, elevation of the upper lip for smile, and depression of the lower lip for lip symmetry. 3. Outline treatment goals, surgical treatment options, timing of repair, and other patient-specific considerations in appropriate technique selection.

SUMMARY

Congenital facial paralysis affects 2.7 per 100,000 children; Bell palsy affects 23 per 100,000 people annually; and even more people are affected when considering all other causes. Conditions that impair facial mimetics impact patients' social functioning and emotional well-being. Dynamic and static reconstructive methods may be used individually or in concert to achieve adequate blink restoration, smile strength and spontaneity, and lower lip depression. Timing of injury and repair, patient characteristics such as age, and cause of facial paralysis are all considered in selecting the most appropriate reconstructive approach. This article describes evidence-based management of facial paralysis.

Efficacy of Autologous Serum Gel in Neurotrophic Persistent Corneal Epithelial Defects Combined with Lagophthalmos

INTRODUCTION

To investigate the efficacy of autologous serum gel in patients with lagophthalmos combined with neurotrophic persistent corneal epithelial defects (PEDs).

METHODS

This is retrospective, case-series study enrolled 15 patients with lagophthalmos complicated by neurotrophic PEDs refractory to medical treatment including autologous serum eye drops. They were treated with autologous serum gel in conjunction with conservative treatment. The following information was collected from medical records: demographics, underlying diseases, and past ocular history. PEDs healing time was evaluated with visual acuity, visual analog scale (VAS) scores, esthesiometer scores, and the areas of the epithelial defects.

RESULTS

Six men and nine women with a mean age of 63.3 ± 9.9 years were included. The most common cause of the neurotrophic PEDs and lagophthalmos in this group was postherpetic infection (46.7%) and cerebral hemorrhage (26.7%) each. Two months following treatment with autologous serum gel, there was a reduction in the area of the epithelial defects (from 19.2 ± 9.9 to 0.6 ± 1.5 mm²) and a significant improvement in best-corrected visual acuity (BCVA) (from 0.8 ± 0.5 to 0.5 ± 0.4 logMAR) and VAS scores (from 5.1 ± 1.1 to 2.1 ± 0.6) in 13 eyes (87%). Among the 11 completely healed eyes, the mean epithelial healing time was 3.2 ± 1.8 weeks.

CONCLUSIONS

Autologous serum gel reduces symptoms and promotes corneal epithelialization of refractory neurotrophic PEDs in patients with lagophthalmos. Therefore, it may be well tolerated and a beneficial addition in the management of neurotrophic PEDs in patients with lagophthalmos.

Ramsay Hunt syndrome with multiple cranial neuropathy: a literature review

BACKGROUND

Ramsay Hunt Syndrome (RHS) is a neurotological disorder involving the reactivation of the varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve (Sweeney and Gilden in J Neurol Neurosurg Psychiatry 71:149-154, 2001). The characteristic presentation involves ipsilateral lower motor neuron type facial paresis, auricular pain with or without hearing impairment, and vesicular lesions of the external auditory canal and outer ear. Involvement of the facial and vestibulocochlear nerve is typical in RHS, whilst multiple cranial neuropathies are rare and associated with poorer prognosis and systemic complications (Arya et al. in Am J Case Rep 19:68-71, 2017; Shinha and Krishna in IDCases 2:47-48, 2015; Shim et al. in Acta Otolaryngol 131:210-215, 2011; Coleman et al. in J Voice 26:e27-e28, 2012; Morelli et al. in Neurol Sci 29:497-498, 2008;). Likely mechanisms involved in the pathogenesis of cranial polyneuropathy include direct peri-neural and trans-axonal spread of viral inflammation between contiguous cranial nerves and haematogenous dissemination between nerves with shared blood supply. Impairments in speech, swallowing, hearing, and oculo-protection can contribute to morbidity and requires a multidisciplinary approach to patient care.

METHODS

We present a rare case of RHS with multiple cranial neuropathies followed by a comprehensive review of current literature with regard to the pathophysiology, diagnostic workup, and the management strategies employed in these patients.

CONCLUSION

RHSs with multiple cranial neuropathies are important to recognise as they are associated with significant morbidity and poor prognosis. A multidisciplinary approach to patient management is required to address the several complications that can arise from cranial nerve deficits, especially in regard to speech and swallow.

Neuro-Ophthalmic Complications of Vestibular Schwannoma Resection: Current Perspectives

Vestibular schwannomas (VSs), also called acoustic neuromas, are benign intracranial neoplasms of the vestibulocochlear (VIII) cranial nerve. Management options include “wait-and-scan,” stereotactic radiosurgery and surgical resection. Due to the proximity of the VIII nerve to the facial (VII) nerve in the cerebello-pontine angle, the VII nerve is particularly vulnerable to the effects of surgical resection. This can result in poor eye closure, lagophthalmos and resultant corneal exposure post VS resection. Additionally, compression from the tumor or resection can cause trigeminal (V) nerve damage and a desensate cornea. The combination of an exposed and desensate cornea puts the eye at risk of serious ocular complications including persistent epithelial defects, corneal ulceration, corneal vascularization, corneal melting and potential perforation. The abducens (VI) nerve can be affected by a large intracranial VS causing raised intracranial pressure (a false localizing sign) or as a result of damage to the VI nerve at the time of resection. Other types of neurogenic strabismus are rare and typically transient. Contralaterally beating nystagmus as a consequence of vestibular dysfunction is common post-operatively. This generally settles to pre-operative levels as central compensation occurs. Ipsilaterally beating nystagmus post-operatively should prompt investigation for post-operative cerebrovascular complications. Papilledema (and subsequent optic atrophy) can occur as a result of a large VS causing raised intracranial pressure. Where papilledema follows surgical resection of a VS, it can indicate that cerebral venous sinus thrombosis has occurred. Poor visual function following VS resection can result as a combination of all these potential complications and is more likely with larger tumors.

When paediatric facial nerve paralysis is not a Bell's palsy: A case of cerebellopontine angle tumour

Facial nerve paralysis in children is a rare clinical condition that can lead to serious complications. Due to their rare occurrence, tumours, especially in the cerebellopontine angle, may be overlooked. We report a case of cerebellopontine angle tumour in an 8-year-old boy who presented with a right-sided lower motor neuron type of facial nerve palsy. Further examination showed a mild bilateral nystagmus. However, misled by the initial diagnosis of Bell's palsy, there was a delay in performing diagnostic magnetic resonance imaging of the brain, which showed a large mass in the cerebellopontine. Subsequently, six weeks after his initial presentation, the boy succumbed to the disease. This case illustrates that careful clinical examination, even in a seemingly simple case, is imperative to avoid diagnostic errors.

Imaging of the post-operative orbit and associated complications

Dedicated post-operative radiological evaluation following ophthalmologic procedures is relatively uncommon. However, given the ever-growing ophthalmologic procedural advancements and the increasing utilization of neuroimaging for myriad indications, the orbits are often imaged incidentally in a delayed post-procedural state. Regardless of the clinical scenario, it is important for neuroradiologists and other specialists commonly exposed to orbital imaging to be aware of both expected and abnormal post-operative imaging findings because misinterpreted normal features or unrecognized complications can result in vision-threatening delays in treatment or mismanagement. In this review article, we discuss many common ophthalmologic procedures, their indications, and most likely complications. We also provide illustrative operative photographs and radiological imaging examples. By understanding the surgical intent, recognizing the devices that are commonly used, and developing familiarity with the appearance of post-operative complications, pitfalls in interpretation can be avoided and patient outcomes ultimately improved.

Role of Topical Cenegermin in Management of a Cornea Transplant in a Functionally Monocular Patient with Neurotrophic Keratitis and Facial Nerve Palsy: A Case Report

Background

NK is one of the most challenging ocular conditions to treat and it can represent a devastating complication of acoustic neuroma surgery due to the profound corneal anesthesia and concomitant exposure keratopathy caused by seventh nerve palsy. In such cases, cornea surgery should be considered with extreme caution due to the high risk of devastating complications. The purpose of the study is to report the efficacy of a novel human recombinant nerve growth factor (rhNGF)-based ophthalmic treatment in a functionally monocular patient with a recurrence of severe neurotrophic keratitis (NK) on a corneal graft.

Case Presentation

A 24-year-old woman who underwent acoustic neuroma surgery was referred for the assessment of a lagophthalmos and a paracentral corneal ulcer refractory to medical treatment. The patient presented with a large descemetocele, diagnosed as stage 3 NK that required multilayer amniotic membrane transplantation (AMT) and a following optical penetrating keratoplasty (PK). The recurrence of NK on the graft was successfully treated with a cycle of rhNGF (cenegermin 20 µg/mL) eye drops. Due to the complications of a further NK recurrence after treatment discontinuation, a second AMT and PK approach was chosen. A second cycle of treatment with cenegermin was immediately initiated after PK to prevent further recurrences. No postoperative complications were observed and we report a stable situation at 1 year of follow-up.

Conclusion

The case presented here is, to our knowledge, the first report of a treatment with cenegermin for a NK recurrence after PK and suggests that such early medical approach could be evaluated to prevent postoperative complications.

The Efficacy of Electro-Acupuncture Added to Standard Therapy in the Management of Bell Palsy

OBJECTIVE

To investigate the comparative efficacy of electro-acupuncture when added to standard therapy in patients with Bell palsy in terms of clinical and neurophysiologic outcomes.

METHODS

A total of 88 patients with Bell palsy who received standard treatment (ST group; n = 40, mean ± standard deviation age: 39.2 ± 6.6 years, 60.0% were males) or standard treatment plus electro-acupuncture (ST-EA group; n = 48, mean ± standard deviation age: 39.5 ± 6.9 years, 58.3% were males) were included. Data on patient demographics, symptoms, comorbidities, and 3-month outcomes on treatment response assessed via House-Brackmann grading system and facial nerve recovery profile and electromyography were recorded.

RESULTS

Application of ST-EA versus ST was associated with a significantly higher rate of normal nerve function on 12th week electromyography (66.7% versus 25.0%, P = 0.020), higher frequency of patients with House-Brackmann grade ≤2 in the 3rd week (79.2% versus 45.0%, P = 0.029), 6th week (87.5% versus 45.0%, P = 0.004), and 12th week (95.8% versus 50.0%, P = 0.001), and those with facial nerve recovery profile scores ≥8 in the 6th week (83.3% versus 45.0%, P = 0.011) and 12th week (87.5% versus 50.0%, P = 0.009) of treatment.

CONCLUSION

In conclusion, our findings in patients with Bell palsy revealed superiority of electro-acupuncture added to standard therapy over standard therapy alone in terms of improvement of nerve dysfunction, decrease in paralysis severity, and better functional recovery. This seems to indicate the likelihood of electro-acupuncture to be a safe and promising adjunct in the achievement of more satisfactory clinical outcomes in the management of Bell palsy when used in combination with standard medical and physiotherapy.

Differences in functional brain alterations driven by right or left facial nerve efferent dysfunction: Evidence from early Bell's palsy

BACKGROUND

Bell's palsy is defined as idiopathic unilateral facial nerve palsy. Early Bell's palsy is characterized by emerging asymmetric motor conduction of the facial nerve and obvious imbalance of facial muscle movement, which can result in a substantial psychological impact on patients and trigger brain cortical functional reorganization. However, the differences between the brain functional alterations were driven by right or left facial nerve efferent dysfunction in patients with early Bell's palsy are not fully understood. The neuroimage study in patients with different-sided Bell's palsy in the early stage will help to understand the different mechanisms involved in functional integration driven by unilateral facial efferent nerve dysfunction and to provide the theoretical foundation for the choice of suitable treatment strategy.

METHODS

Sixty-seven patients and 37 age- and sex-matched healthy controls were recruited to undergo resting-state functional magnetic resonance imaging (R-fMRI). Regional brain activity was analyzed by comparing the fractional amplitude of low-frequency fluctuations (fALFF) between right palsy and healthy control, left palsy and healthy control, and right and left palsy groups. The altered brain regions were further selected as seeds in subsequent functional connectivity (FC) analysis, and the correlations between the Toronto Facial Grading System (TFGS) scores and the connectivity alterations were also analyzed.

RESULTS

The right and left Bell's palsy groups showed fALFF alterations compared with the healthy control group, and several brain regions with different fALFF values between the right and left palsy groups were identified. In the right palsy group, overall inter-regional FC increased in the right supramarginal gyrus (SMG), bilateral superior frontal gyrus (SFG), and left precentral gyrus (PreCG), compared with the left palsy group. Furthermore, the brain region pairs with higher FC in the right palsy group were left temporal pole of the superior temporal gyrus (TPOsup) and right SMG, left TPOsup and middle cingulate cortex (MCC), left TPOsup and left PreCG, right SMG and SFG, MCC and left PreCG, left and right SFG, and right SFG and left PreCG. In the right palsy group, the left TPOsup and PreCG showed a negative correlation with the TFGS score, while the right SFG and left PreCG showed a positive correlation with the TFGS scores. In the left palsy group, the left TPOsup and right SMG, and the right SMG and SFG region pairs showed a negative correlation with the TFGS score.

CONCLUSIONS

The fALFF and FC analyses revealed the remodeling of different brain functional networks driven by right or left facial nerve efferent dysfunction in patients with early Bell's palsy. The reintegration mechanisms differed between patients with right and left Bell's palsy. Additionally, the severity of the disease showed different associations with altered FC.

Altered Brain Fraction Amplitude of Low Frequency Fluctuation at Resting State in Patients With Early Left and Right Bell's Palsy: Do They Have Differences?

Purpose: Bell’s palsy refers to acute idiopathic unilateral facial nerve palsy. It is a common disorder of the main motor pathway to the facial muscles. This study aimed to investigate the abnormal fraction amplitude of low frequency fluctuation (fALFF) of the brain in patients with early left and right Bell’s palsy.

Materials and Methods: Sixty-seven patients (left 33, right 34) and 37 age- and sex-matched healthy controls underwent resting-state functional magnetic resonance imaging (R-fMRI) examination. The fALFF values were measured from all subjects and were compared among the left palsy, right palsy, and control groups. Then, correlations between the Toronto Facial Grading System (TFGS) scores of the patients and the fALFF values of abnormal brain regions were analyzed.

Results: Significant group differences in fALFF values among the three groups were observed mainly in the cerebral cortical, subcortical, and deep gray matter regions. Compared with the right Bell’s palsy group, the left Bell’s palsy group showed significantly decreased fALFF values in the left temporal pole of the superior temporal gyrus (TPOsup), right supramarginal, left and right middle cingulate cortex (MCC), left superior frontal gyrus (SFG), and left precentral gyrus (PreCG), and increased fALFF values were observed in the right SFG and PreCG. Furthermore, altered fALFF values correlated positively with the TFGS scores in the left superior TPO, bilateral MCC, and right PreCG, and correlated negatively with the TFGS scores in the right SFG of the left Bell’s palsy group. Altered fALFF values correlated positively with the TFGS scores in the bilateral MCC and right PreCG and correlated negatively with the TFGS scores in the left superior TPO and SFG of the right Bell’s palsy group.

Conclusion: Regulatory mechanisms seem to differ between patients with left and right early Bell’s palsy. The severity of the disease is associated with these functional alterations.

The role of external eyelid weights in acute facial palsy: functional and aesthetic considerations

Purpose

Patients with acute paralytic lagophthalmos are at high risk for ocular surface breakdown due to exposure. External eyelid weights are a temporary solution for paralytic lagophthalmos that aim to reduce exposure and optimize blink excursion. Despite easy application and high efficacy, this product is under-utilized in clinical practice with few physicians employing this treatment adjunct.

Results

Ocular surface health was maintained in all patients, and overall aesthetic satisfaction was high.

Conclusion

External eyelid weights are a valuable adjunct in the treatment of facial palsy but are under-utilized in clinical practice. This article highlights the benefits of external eyelid weights as an accessible adjunct to restore eyelid function and maintain cosmesis. The device can be implemented without specialist involvement and adds a dimension of independence for general practitioners to manage ocular complications of facial palsy.

Relative Location of Fundus Meatus Acustici Interni Via Porus Acusticus Internus in Facial Nerve Decompression

Facial neural edema is the pathophysiological base of Bell's palsy. The middle cranial fossa approach is used to relieve the oppression of facial nerve at its most narrow course in the facial canal. In this research, the authors mainly discussed the internal auditory canal segment of facial nerve, completely in the shadow of the bony structure, which is inconvenient for transmastoid decompression. Therefore, the objective was to explore the definite position of the fundus meatus acustici interni from internal acoustic pore. Two hundred persons (age 22-60, 100 men and 100 women), presenting with healthy facial nerve, ear, and internal auditory canal, were investigated by computed tomography 3-dimensional reconstruction. Using statistical method to analyze, the authors obtained the definite position of the fundus meatus acustici interni, regarding the internal acoustic pore as the origin of coordinates. Our data provided more significant information for medical workers to improve the efficiency of operation and to prevent complications of surgery.

Causes and management of facial nerve palsy

Facial nerve palsy causes disfigurement with cosmetic, functional and psychological repercussions. The facial nerve can be affected anywhere along its course. A comprehensive assessment considering all differential diagnoses is critical to optimal management, as prompt, appropriate therapy leads to better outcomes.

Microcystic adnexal carcinoma (MAC)-like squamous cell carcinoma as a differential diagnosis to Bell´s palsy: review of guidelines for refractory facial nerve palsy

Background

Bell´s palsy is the most common cause of facial paralysis worldwide and the most common disorder of the cranial nerves. It is a diagnosis of exclusion, accounting for 60–75% of all acquired peripheral facial nerve palsies. Our case shows the first case of a microcystic adnexal carcinoma-like squamous cell carcinoma as a cause of facial nerve palsy.

Case presentation

The patient, a 70-year-old Caucasian male, experienced subsequent functional impairment of the trigeminal and the glossopharyngeal nerve about 1½ years after refractory facial nerve palsy.

An extensive clinical work-up and tissue biopsy of the surrounding parotid gland tissue was not able to determine the cause of the paralysis. Primary infiltration of the facial nerve with subsequent spreading to the trigeminal and glossopharyngeal nerve via neuroanastomoses was suspected. After discussing options with the patient, the main stem of the facial nerve was resected to ascertain the diagnosis of MAC-like squamous cell carcinoma, and radiochemotherapy was subsequently started.

Conclusion

This case report shows that even rare neoplastic etiologies should be considered as a cause of refractory facial nerve palsy and that it is necessary to perform an extended diagnostic work-up to ascertain the diagnosis. This includes high-resolution MRI imaging and, as perilesional parotid biopsies might be inadequate for rare cases like ours, consideration of a direct nerve biopsy to establish the right diagnosis.