Magnetic resonance imaging of the intratemporal facial nerve in idiopathic peripheral facial palsy

Contrast-Enhanced MRI Is Useful for Prognostic Prediction on Idiopathic Bilateral Simultaneous Facial Nerve Palsy: A Case Report and Literature Review

Idiopathic bilateral facial nerve palsy is a rare condition and presents a diagnostic and prognostic challenge. Specifically, when bilateral nerves are damaged, it is difficult to predict the prognosis. We showcase the usefulness of contrast-enhanced magnetic resonance imaging (MRI) by providing information about localization and severity of degeneration of facial nerve. A 70-year-old Japanese man presented with bilateral simultaneous facial nerve palsy of House-Brackmann Grade VI on both sides. Contrast-enhanced MRI revealed bilateral intensity enhancement of intratemporal facial nerves. The signal intensity was higher on the left side than on the right side. Facial nerve decompression was performed on the left side. The left facial nerve palsy was finally improved eight months after the onset, while the right side was improved just under two months after the onset. Contrast-enhanced MRI for facial nerve palsy can provide valuable information for the evaluation of damaged facial nerves. In our patient's case, it was useful as a prognostic predictor of bilateral facial nerve palsy.

The clinical availability of facial nerve enhancement in temporal bone MRI for the patients of idiopathic acute peripheral facial palsy

PURPOSE

This study is to evaluate the duration of facial nerve enhancement in gadolinium-enhanced temporal bone MRI after the onset of acute facial palsy.

METHODS

Gd-enhanced MRI imagines were examined in 13 patients with idiopathic acute facial palsy within 14 days after the onset. The degree of facial nerve function was measured according to the House-Brackmann (H-B) grading system at their first visit at outpatient clinic. The follow-up MRI was taken about 16.5 months (7-24 months) after onset of disease. The degree of facial nerve enhancement was measured with signal intensity (SI) which was quantitatively analyzed using the region-of-interest (ROI) measurements for each segment of the facial nerve. SI was statistically analyzed by comparing SI values of contralateral site and ipsilateral site using the paired t test with SPSS program.

RESULTS

The gadolinium enhancement was statistically increased at labyrinthine segment and geniculate ganglion area of facial nerve at initial temporal bone MRI. The gadolinium enhancement was statistically decreased at all the segments of facial nerve except tympanic segment (p < 0.05) at follow-up MRI.

CONCLUSIONS

The facial nerve enhancement in Gd-enhanced MRI images prolonged more than 21 months of the onset. The newly developed pathologic lesions of acute facial palsy especially occur at the site of labyrinthine and geniculate ganglion.

A Case with Anti-ganglioside Antibodies Showing Multiple Cranial Nerve Palsies Detected on Gadolinium-enhanced Magnetic Resonance Imaging

The anti-GQ1b IgG antibody is often accompanied by other anti-ganglioside antibodies, which induces various neurological symptoms. We herein report a patient with anti-ganglioside antibodies, including anti-GQ1b IgG and anti-GT1a IgG antibodies, showing bilateral ophthalmoplegia, facial nerve palsies, dysarthria, dysphagia, dysesthesia in both hands, and enhancement of the bilateral oculomotor, abducens, and facial nerves on gadolinium (Gd)-enhanced T1-weighted brain magnetic resonance imaging (MRI). He was first treated with intravenous immunoglobulin, which improved ophthalmoplegia, bulbar palsies, and dysesthesia of hands, but the facial nerve palsies worsened, and Gd enhancement of the brain nerves persisted. High-dose methylprednisolone therapy subsequently improved the facial nerve palsies and Gd enhancement of the cranial nerves. This is the first case with anti-ganglioside antibodies presenting with multiple cranial nerve palsies that was followed to track the changes in the Gd enhancement of cranial nerves on MRI.

Contrast-enhanced MRI findings of patients with acute Bell palsy within 7 days of symptom onset: A retrospective study

The brain magnetic resonance imaging (MRI) findings seen in patients with Bell palsy are abnormal contrast enhancement of affected facial nerves. Previous studies were conducted on a few patients, mainly those who had experienced palsy for several weeks. This study investigated the diagnostic usefulness of MRI by examining MRI findings of acute Bell palsy (within 7 days of symptom onset) in a large cohort. Among the patients with Bell palsy (idiopathic unilateral facial palsy) who visited the hospital, 123 patients who underwent contrast-enhanced MRI of the internal auditory canal within 7 days of symptom onset were reviewed retrospectively. MRI examination results were investigated along with the patient's clinical symptoms and electrodiagnostic test results. Based on the MRI results, the frequency of abnormal contrast enhancement and contrast-enhanced areas were investigated. Of the 123 patients, 13 (11%) had normal brain MRI results, and 110 (89%) had abnormal findings. The frequency of abnormal contrast enhancement was not significantly associated with test timing (P = .56). Of the 110 patients with abnormal findings, 65 (59%) showed contrast enhancement in the labyrinthine segment and 36 (33%) in both the labyrinthine segment and geniculate ganglion. Most patients with Bell palsy who are in the acute phase showed abnormal contrast enhancement in their facial nerves, and similar findings were even observed in the examination conducted on the day of symptom onset. Brain MRI helps in the diagnosis of acute Bell palsy.

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.

Evaluation of prognostic factors in patients with Bell's palsy

BACKGROUND

Bell's palsy is a common neurological problem that leads to peripheral palsy of the facial nerve. Most patients have a favorable response with or without treatment while some are left with significant facial deformity. Identification of factors which influence the outcome in patients with Bell's palsy may help clinicians counsel better.

METHODS

A prospective cross-sectional study was carried out in the Department of Neurology Nobel Medical College, Biratnagar, between February 2020 and February 2021 after obtaining ethical clearance from the institutional review committee. Patients were assessed at the time of presentation to hospital and followed up at 1 week, 1 month, and 3 months after the onset of illness to evaluate for recovery.

RESULTS

Sixty-two (61.4%) of 101 patients had a favorable outcome at the follow up on the third month, achieving H-B grade 2 or lower, while 33 (32.7%) had moderate dysfunction and 6 (5.9%) had severe dysfunction. The following factors were associated with favorable outcome: younger age of onset (p < .001), lower initial H-B grade of III or IV (p = .001), lesser degree of amplitude reduction on affected side as compared to unaffected side (p = .001) and absence of hypertension and diabetes. The following factors did not influence outcome at three months: duration of Bell's palsy (p = 0.142), side of face affected, and gender (p = .09).

CONCLUSIONS

Most of the patients with Bell's palsy have favorable outcomes. Age, hypertension, initial H-B grade, and extent of facial nerve degeneration as recorded by nerve conduction studies are important predictors of outcome.

Quantitative assessment of Bell's palsy-related facial thermal asymmetry using infrared thermography: A preliminary study

The temperature distribution of normal human skin is symmetrical. Facial paralysis generally changes this thermal symmetry. The aim of this study is to analyze facial thermal asymmetry during the early onset of Bell's palsy, and to assess the feasibility of the diagnosis of early-onset Bell's palsy using infrared thermography (IRT). Fifteen subjects with Bell's palsy and 15 healthy volunteers were considered in this study. The infrared thermal images of the front, left, and right sides of all the subjects were collected and analyzed. Each group of facial thermograms was divided into 16 symmetrical regions of interest (ROIs) with respect to the left and right sides. Three different temperature difference calculation methods were used to express the degree of thermal symmetry between the left- and right-side ROIs, namely, the mean temperature difference (ΔT_roi), maximum temperature difference (ΔT_max), and minimum temperature difference (ΔT_min). Among the facial ROIs, there were significant differences in the thermal symmetries of the frontal region, medial canthus region, and infraorbital region between subjects with and without Bell's palsy (p < 0.05). Based on the results, ΔT_roi was more effective than the other two methods for the diagnosis of early-onset Bell's palsy. The area under the ROC curve (AUC) of ΔT_roi in the infraorbital region was 0.818; and the sensitivity and specificity were 0.867 and 0.800, respectively. Subjects with early-onset Bell's palsy exhibited thermal asymmetry on the left and right sides of their faces. The diagnosis of early-onset Bell's palsy using IRT is therefore necessary. Nevertheless, more effective thermal symmetry analysis methods will be investigated further in future research.

Imaging of facial neuritis using T2-weighted gradient-echo fast imaging employing steady-state acquisition after gadolinium injection

BACKGROUND

MRI is the modality of choice for the imaging of facial neuritis. Previously, gadolinium-enhanced T1-weighted imaging of the petrous bone, then FLAIR sequences were thought to be most informative for acute facial neuritis imaging. The aim of this study is to evaluate the value of contrast-enhanced T2-weighted sequence for the diagnosis of acute facial neuritis and compare it to contrast-enhanced T1-weighted and FLAIR sequences.

METHODS

We included 50 patients with an acute unilateral idiopathic peripheral facial neuritis. An MRI (3 T) with three sequences was performed (T1-weighted, T2-weighted and FLAIR), all acquired after intravenous contrast-media injection.

RESULTS

The contrast-enhanced T2-weighted sequence appeared to be the most accurate one for the diagnosis of acute facial neuritis (Se 94%, Sp 100%, accuracy 98.2%, p < 0.001), with a pathological facial nerve strongly (grade 2-3) enhancing and a homogenous enhancement along the course of the entire facial nerve. Contrast-enhanced T1-weighted (Se 80%, Sp 100%, accuracy 94.1%) and FLAIR sequences (92%, Sp 88%, accuracy 90%, p < 0.001) showed lower accuracy. On T1-weighted sequence, a strong enhancement (blurred margins) of the canalicular segment was observed in 80% of the cases when it was never observed in normal nerves.

CONCLUSION

A strong (= iso to hyperintense to the petrous fat signal) and diffuse (all segments) enhancement of the facial nerve on T2-weighted steady-state free precession sequence is a sensitive and specific sign for the diagnosis of acute idiopathic facial neuritis, and appears superior to T1WI and FLAIR sequences.

The ratio of facial nerve to facial canal as an indicator of entrapment in Bell's palsy: A study by CT and MRI

OBJECTIVES

To find out if the ratio of facial nerve to facial canal diameter plays any role in the etiopathogenesis and grade of Bell's palsy.

PATIENTS AND METHODS

Twenty-nine consecutive patients (16 females, 13 males) diagnosed with unilateral Bell's palsy were enrolled into the study. At admission, 5 patients were grade V, 11 were grade IV, 11 were grade III and 2 were grade II. The grade of Bell's palsy was documented by House-Brackmann facial nerve grading system at admission, 15th day, 1st month and 3th month. Temporal MRI and CT scans were obtained at the time of diagnosis. Diameter of facial nerve and facial canal at the middle of five different segments were measured equidistantly at the same workstation. Both sides of every patient (affected and unaffected) were measured by one radiologist who was not informed about the side of the paralysis. MRI and CT values of each segment were compared between affected and unaffected sides. In addition, FN/FC ratio of affected and non-affected sides was calculated and compared for each segment. We also analyzed if a relationship exists between above-mentioned measurements and the House-Brackmann grade.

RESULTS

Considering MRI values; statistically significant thickening of facial nerve between affected and unaffected sides was found at labyrinthine (p = 0.012), tympanic (p = 0.023) and geniculate parts (p = 0.04). Considering CT values; statistically significant difference between affected and unaffected sides was not found at any segment. Comparison of FN/FC ratio of both sides revealed statistically significant increment of the affected side at labyrinthine segment (p = 0.015) and geniculate ganglion (p = 0.032). We determined positive correlation between diameter of FN and HB grade at labyrinthine segment (p = 0.03, R = 0.531). On the other hand, we determined negative correlation between diameter of FC and HB grade at labyrinthine segment (p < 0.001, R = -318). A positive correlation between HB grade and FN/FC ratio was found only at the labyrinthine segment (p = 0.003, R = 0.673).

CONCLUSION

FN/FC ratio of labyrinthine segment and geniculate ganglion was found to be increased in patients with Bell's palsy. In addition, a positive correlation was determined between this ratio and grade of Bell's palsy particularly at labyrinthine segment. Basing the current study, if FN decompression is recommended in Bell's palsy patients with objective findings of bad prognosis, conservative surgery targeting the labyrinthine segment and geniculate ganglion alone might be safer.

Automatic Facial Paralysis Assessment via Computational Image Analysis

Facial paralysis (FP) is a loss of facial movement due to nerve damage. Most existing diagnosis systems of FP are subjective, e.g., the House-Brackmann (HB) grading system, which highly depends on the skilled clinicians and lacks an automatic quantitative assessment. In this paper, we propose an efficient yet objective facial paralysis assessment approach via automatic computational image analysis. First, the facial blood flow of FP patients is measured by the technique of laser speckle contrast imaging to generate both RGB color images and blood flow images. Second, with an improved segmentation approach, the patient's face is divided into concerned regions to extract facial blood flow distribution characteristics. Finally, three HB score classifiers are employed to quantify the severity of FP patients. The proposed method has been validated on 80 FP patients, and quantitative results demonstrate that our method, achieving an accuracy of 97.14%, outperforms the state-of-the-art systems. Experimental evaluations also show that the proposed approach could yield objective and quantitative FP diagnosis results, which agree with those obtained by an experienced clinician.

The role of EEG and EMG combined virtual reality gaming system in facial palsy rehabilitation - A case report

BACKGROUND

The recovery rates for facial palsy are usually excellent; however, regularly patients present with problems with their fine facial movements that affect their emotional expressions.

OBJECTIVE

To discover the viability and ease of using an Electroencephalogram (EEG) and Electromyography (EMG) combined Virtual Reality (VR) gaming system - the 'Oculus Rift' device in the evaluation and rehabilitation of facial palsy.

DESIGN

Single case study.

PATIENT INFORMATION

A young 23-year-old female with facial palsy.

CLINICAL FINDINGS

Most of the patient's facial features were re-established within the recovery time frame, except for her right forehead and eyebrow movements.

INTERVENTION

A 10 day exercise program (Day 2-11) with an immersive virtual reality device, which randomly shoots virtually animated white balls in an unpredictable and testing pattern.

OUTCOME MEASURES

EEG and EMG patterns corresponding to the facial upper quadrant were taken at baseline, post-intervention, and at follow up.

RESULTS

EMG and EEG investigation revealed a progressive improvement in the muscle activation in response to the impulsive and unpredictable activities in the virtual environment provided through the immersive VR device.

CONCLUSION

The case report found a positive relationship between VR, facial upper quadrant EMG activation and EEG pattern changes following the intervention.

Bell's Palsy

PURPOSE OF REVIEW

Bell's palsy is a common outpatient problem, and while the diagnosis is usually straightforward, a number of diagnostic pitfalls can occur, and a lengthy differential diagnosis exists. Recognition and management of Bell's palsy relies on knowledge of the anatomy and function of the various motor and nonmotor components of the facial nerve. Avoiding diagnostic pitfalls relies on recognizing red flags or features atypical for Bell's palsy, suggesting an alternative cause of peripheral facial palsy.

RECENT FINDINGS

The first American Academy of Neurology (AAN) evidence-based review on the treatment of Bell's palsy in 2001 concluded that corticosteroids were probably effective and that the antiviral acyclovir was possibly effective in increasing the likelihood of a complete recovery from Bell's palsy. Subsequent studies led to a revision of these recommendations in the 2012 evidence-based review, concluding that corticosteroids, when used shortly after the onset of Bell's palsy, were "highly likely" to increase the probability of recovery of facial weakness and should be offered; the addition of an antiviral to steroids may increase the likelihood of recovery but, if so, only by a very modest effect.

SUMMARY

Bell's palsy is characterized by the spontaneous acute onset of unilateral peripheral facial paresis or palsy in isolation, meaning that no features from the history, neurologic examination, or head and neck examination suggest a specific or alternative cause. In this setting, no further testing is necessary. Even without treatment, the outcome of Bell's palsy is favorable, but treatment with corticosteroids significantly increases the likelihood of improvement.

The asymmetric facial skin perfusion distribution of Bell's palsy discovered by laser speckle imaging technology

Bell's palsy is a kind of peripheral neural disease that cause abrupt onset of unilateral facial weakness. In the pathologic study, it was evidenced that ischemia of facial nerve at the affected side of face existed in Bell's palsy patients. Since the direction of facial nerve blood flow is primarily proximal to distal, facial skin microcirculation would also be affected after the onset of Bell's palsy. Therefore, monitoring the full area of facial skin microcirculation would help to identify the condition of Bell's palsy patients. In this study, a non-invasive, real time and full field imaging technology - laser speckle imaging (LSI) technology was applied for measuring facial skin blood perfusion distribution of Bell's palsy patients. 85 participants with different stage of Bell's palsy were included. Results showed that Bell's palsy patients' facial skin perfusion of affected side was lower than that of the normal side at the region of eyelid, and that the asymmetric distribution of the facial skin perfusion between two sides of eyelid is positively related to the stage of the disease (P <  0.001). During the recovery, the perfusion of affected side of eyelid was increasing to nearly the same with the normal side. This study was a novel application of LSI in evaluating the facial skin perfusion of Bell's palsy patients, and we discovered that the facial skin blood perfusion could reflect the stage of Bell's palsy, which suggested that microcirculation should be investigated in patients with this neurological deficit. It was also suggested LSI as potential diagnostic tool for Bell's palsy.

The role of facial canal diameter in the pathogenesis and grade of Bell's palsy: a study by high resolution computed tomography

Introduction

The exact etiology of Bell's palsy still remains obscure. The only authenticated finding is inflammation and edema of the facial nerve leading to entrapment inside the facial canal.

Objective

To identify if there is any relationship between the grade of Bell's palsy and diameter of the facial canal, and also to study any possible anatomic predisposition of facial canal for Bell's palsy including parts which have not been studied before.

Methods

Medical records and temporal computed tomography scans of 34 patients with Bell's palsy were utilized in this retrospective clinical study. Diameters of both facial canals (affected and unaffected) of each patient were measured at labyrinthine segment, geniculate ganglion, tympanic segment, second genu, mastoid segment and stylomastoid foramen. The House-Brackmann (HB) scale of each patient at presentation and 3 months after the treatment was evaluated from their medical records. The paired samples t-test and Wilcoxon signed-rank test were used for comparison of width between the affected side and unaffected side. The Wilcoxon signed-rank test was also used for evaluation of relationship between the diameter of facial canal and the grade of the Bell's palsy. Significant differences were established at a level of p = 0.05 (IBM SPSS Statistics for Windows, Version 21.0.; Armonk, NY, IBM Corp).

Results

Thirty-four patients – 16 females, 18 males; mean age ± Standard Deviation, 40.3 ± 21.3 - with Bell's palsy were included in the study. According to the HB facial nerve grading system; 8 patients were grade V, 6 were grade IV, 11 were grade III, 8 were grade II and 1 patient was grade I. The mean width at the labyrinthine segment of the facial canal in the affected temporal bone was significantly smaller than the equivalent in the unaffected temporal bone (p = 0.00). There was no significant difference between the affected and unaffected temporal bones at the geniculate ganglion (p = 0.87), tympanic segment (p = 0.66), second genu (p = 0.62), mastoid segment (p = 0.67) and stylomastoid foramen (p = 0.16). We did not find any relationship between the HB grade and the facial canal diameter at the level of labyrinthine segment (p = 0.41), tympanic segment (p = 0.12), mastoid segment (p = 0.14), geniculate ganglion (p = 0.13) and stylomastoid foramen (p = 0.44), while we found significant relationship at the level of second genu (p = 0.02).

Conclusion

We found the diameter of labyrinthine segment of facial canal as an anatomic risk factor for Bell's palsy. We also found significant relationship between the HB grade and FC diameter at the level of second genu. Future studies (MRI-CT combined or 3D modeling) are needed to promote this possible relevance especially at second genu. Thus, in the future it may be possible to selectively decompress particular segments in high grade BP patients.

Treatment of Bell's Palsy Using Monochromatic Infrared Energy: A Report of 2 Cases

OBJECTIVE

The purpose of the study is to describe the use of monochromatic infrared energy (MIRE) therapy in the management of 2 patients with Bell's palsy.

CLINICAL FEATURES

Two patients presented to a chiropractic clinic with Bell's palsy that was diagnosed by a medical physician. Both patients were treated using MIRE. The acute patient was a 32-year-old male. He presented with left facial palsy 1 day before the consultation. He was unable to puff the left cheek and close the left eyelid. He had difficulty raising the left eyebrow. The chronic case was a 46-year-old lady. Prior to the first consultation, she was treated with corticosteroid and electro-acupuncture for one and a half years, with incomplete recovery. When first seen, the left corner of mouth drooped and she had difficulty raising her left eyebrow.

INTERVENTION AND OUTCOME

Monochromatic infrared energy therapy, emitting 890 nm infrared light, was placed on the post-auricular area, pre-auricular area, the temple and mandibular area of the affected side. Each treatment lasted 30 minutes. Photographs were taken every week to document changes. The acute case received 19 treatments in 6 weeks. He reported an improvement of 95%. The chronic case received a total of 45 treatments in 9 months. She rated an improvement of 50%. At the conclusion of treatment, she was able to close her left eyelid and puff her left cheek but still could not raise her left eyebrow.

CONCLUSION

These 2 patients seemed to respond to a different degree to the MIRE therapy. As 71% of patients with Bell's palsy recover uneventfully without any treatment, the present study describes the course of care but cannot confirm the effectiveness of MIRE therapy in the management of Bell's palsy.

Usefulness of contrast-enhanced 3-dimensional T1-VISTA in the diagnosis of facial neuritis: comparison with contrast-enhanced T1-TSE

BACKGROUND AND PURPOSE

Compared with 2-dimensional imaging, 3D-reformatted imaging is a valuable technique that offers improved anatomic accuracy with minimal flow artifact and thinner sections without gaps between slices. Our aim was to evaluate the usefulness of CE 3D T1-VISTA with fat suppression sequences compared with CE T1-TSE with fat suppression sequences in patients with facial neuritis.

MATERIAL AND METHODS

The study enrolled 32 consecutive patients who underwent IAC MR imaging for Bell's palsy. IAC MR scanning, including CE T1-VISTA and CE T1-TSE, was performed in all patients using a 3T scanner. The order of the scans was random. Signal intensity was measured at three segments (canalicular, labyrinthine, and anterior genu) of the facial nerve by drawing a ROI along the affected side and the normal side in each segment. We compared the quantitative CR of the two MR sequences with paired t-tests.

RESULTS

In all three segments, the lesion-to-normal contrast ratios on CE 3D T1-VISTA (canalicular: 2.32; labyrinthine: 2.22; anterior genu: 1.97) were greater than those on CE T1-TSE (canalicular: 2.17; labyrinthine: 1.72; anterior genu: 1.68). The labyrinthine and anterior genu segments had significantly higher lesion-to-normal contrast ratios on CE 3D T1-VISTA in patients with facial neuritis (labyrinthine: P<0.001; anterior genu: P=0.002).

CONCLUSION

CE 3D T1-VISTA was superior to CE T1-TSE in terms of image contrast between lesions and the normal facial nerve.

Management of Bell's palsy in children: an audit of current practice, review of the literature and a proposed management algorithm

OBJECTIVE

We carried out a complete audit cycle, reviewing our management of paediatric patients with Bell's palsy within 72 h of symptom onset. Our protocol was published after the initial audit in 2009, and a re-audit was carried out in 2011. We aimed to improve our current practice in accordance with up-to-date evidence-based research on the use of steroids and antivirals.

PATIENTS AND METHODS

A total of 17 patients were included in the first cycle, but only eight patients met our inclusion and exclusion criteria for the re-audit. We assessed documentation of House-Brackmann (HB) grade on presentation, initial treatment, follow-up and recovery.

RESULTS

The first cycle revealed inconsistent management with steroids (41%), antivirals (6%), steroids and antivirals (6%) or nothing at all (47%). In addition, only 65% of patients were followed-up in the ear, nose and throat (ENT) clinic. Our management protocol was published in 2010, and a re-audit was completed. Our results showed 100% compliance with steroid treatment and 100% follow-up with the ENT team. A thorough literature review revealed some additional benefit from the use of antivirals.

CONCLUSIONS

At present there is insufficient evidence to discount the use of steroids and antivirals. Therefore, with our new management protocol, we recommend the use of steroids in patients presenting within 72 h of symptom onset, and antivirals for patients with a HB grade of IV or higher.

Gabriel Falloppius (1523-1562) and the facial canal

Gabriel Falloppius is known for his contributions to anatomy. Indeed, many anatomic structures bear his name, such as the Fallopian tubes, and his descriptions often contradicted those of other notable anatomists, such as Galen and Andreas Vesalius. In his textbook "Observationes Anatomicae," he described for the first time the structures of the ear, eye, and female reproductive organs, and elucidated the development of the teeth. Furthermore, Falloppius described the facial canal. The objectives of this paper are to provide an overview of Falloppius's life and to discuss the clinical relevance of the facial canal as understood from his description of this anatomic structure.

MR diagnosis of facial neuritis: diagnostic performance of contrast-enhanced 3D-FLAIR technique compared with contrast-enhanced 3D-T1-fast-field echo with fat suppression

BACKGROUND AND PURPOSE

Current MRI with the CE T1-weighted sequence plays a limited role in the evaluation of facial neuritis due to prominent normal facial nerve enhancement. Our purpose was to retrospectively investigate the usefulness of the CE 3D-FLAIR sequence compared with the CE 3D-T1-FFE sequence in facial neuritis patients.

MATERIALS AND METHODS

We assessed 36 consecutive patients who underwent temporal bone MR imaging at 3T for idiopathic facial palsy. Two readers independently reviewed CE 3D-T1-FFE and CE 3D-FLAIR images to determine the degree of enhancement in each of 5 segments of the facial nerve. We compared AUCs using the Z-test, compared diagnostic performance of 2 MR techniques with the McNemar test, and evaluated interobserver agreement. The Pearson χ(2) test was used for each segment of the facial nerve.

RESULTS

The AUC of CE 3D-FLAIR (reader 1, 0.754; reader 2, 0.746) was greater than that of CE 3D-T1-FFE (reader 1, 0.624; reader 2, 0.640; P < .001). The diagnostic sensitivities, specificities, and accuracies were 97.2%, 86.1%, and 91.7%, respectively, for CE 3D-FLAIR, and 100%, 56.9%, and 78.5%, respectively, for CE 3D-T1-FFE. The specificity and accuracy of CE 3D-FLAIR were greater than those of CE 3D-T1-FFE (specificity, P = .029; accuracy, P = .008). The interobserver agreements for CE 3D-FLAIR (κ-value, 0.831) and CE 3D-T1-FFE (κ-value, 0.694) were excellent. Enhancement of the canalicular and anterior genu segments on CE 3D-FLAIR were significantly correlated with the occurrence of facial neuritis (P < .001 for canalicular; P = .032 and 0.020 for anterior genu by reader 1 and reader 2, respectively).

CONCLUSIONS

CE 3D-FLAIR can improve the specificity and overall accuracy of MR imaging in patients with idiopathic facial palsy.

Increased seroprevalence of Toxoplasma gondii in a population of patients with Bell's palsy: a sceptical interpretation of the results regarding the pathogenesis of facial nerve palsy

Facial nerve oedema and anatomical predisposition to compression within the fallopian tube seem to be the only generally accepted facts in the pathophysiology of Bell's palsy. Several infectious causes have been suggested as possible triggers of this oedema. Most of the suggested pathogens have been associated with facial nerve lesions during latent infections, reinfections or endogenous reactivations. The aim of this study was to investigate the seroprevalence of three such pathogens Toxoplasma gondii, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) in a population of patients with facial nerve palsy. Fifty-six patients with Bell's palsy were included in the study. A group of 25 individuals with similar age and gender distribution was used as control. Seropositivity for T. gondii, EBV viral capsid antigen (VCA) and CMV-specific IgM and IgG antibodies was investigated 2-5 days after the onset of the palsy. Comparisons for both IgM and IgG antibodies against T. gondii attributed significantly higher seroprevalence in the patients' group than in the control group (p = 0.024 and 0.013, respectively). The respective examinations for EBV and CMV attributed no significant results. The roles of EBV and CMV in the pathogenesis of Bell's palsy were not confirmed by this study. However, a significantly higher seroprevalence of IgM- and IgG-specific T. gondii antibodies was detected in patients with Bell's palsy when compared to healthy controls. The possibility that facial nerve palsy might be a late complication of acquired toxoplasmosis may need to be addressed in further studies.

Is the width of the labyrinthine portion of the fallopian tube implicated in the pathophysiology of Bell's palsy?: a prospective clinical study using computed tomography

OBJECTIVES/HYPOTHESIS

The pathogenetic mechanisms underlying Bell's palsy remain obscure, despite the extensive relevant research. Magnetic resonance imaging (MRI) studies have strongly indicated that facial nerve edema cannot be regarded as the sole etiologic factor, because it might persist long after full clinical recovery, or might be demonstrated in the clinically unaffected side or healthy controls. The aim of this study was to investigate the hypothesis that a narrow facial canal might be implicated in the pathophysiology of Bell's palsy.

STUDY DESIGN

Prospective clinical study.

METHODS

A high-resolution computerized tomography of the temporal bone with 1-mm thick contiguous axial sections was performed in 25 patients with unilateral Bell's palsy. The width of the fallopian tube was measured at the meatal foramen and the middle part of its labyrinthine segment.

RESULTS

When using paired Student t tests, the measured width of the affected ear was found significantly smaller than that of the unaffected side, both at the meatal foramen (P = .007) and at the middle part of the labyrinthine segment (P = .03).

CONCLUSIONS

Bell's palsy seems to usually coincide with the narrower fallopian tube of the patient. This anatomical detail, supported by previous MRI studies, seems to indicate that an asymmetry between the right and left fallopian tube might be a necessary pathogenetic mechanism for the development of a facial nerve edema into Bell's palsy in the narrower fallopian canal. More studies on large healthy populations are needed before a notable facial canal asymmetry is linked to a higher risk for developing Bell's palsy.

Clinical significance of quantitative analysis of facial nerve enhancement on MRI in Bell's palsy

CONCLUSIONS

Quantitative analysis of the facial nerve on the lesion side as well as the normal side, which allowed for more accurate measurement of facial nerve enhancement in patients with facial palsy, showed statistically significant correlation with the initial severity of facial nerve inflammation, although little prognostic significance was shown.

OBJECTIVES

This study investigated the clinical significance of quantitative measurement of facial nerve enhancement in patients with Bell's palsy by analyzing the enhancement pattern and correlating MRI findings with initial severity of facial palsy and clinical outcome.

SUBJECTS AND METHODS

Facial nerve enhancement was measured quantitatively by using the region of interest on pre- and postcontrast T1-weighted images in 44 patients diagnosed with Bell's palsy. The signal intensity increase on the lesion side was first compared with that of the contralateral side and then correlated with the initial degree of facial palsy and prognosis.

RESULTS

The lesion side showed significantly higher signal intensity increase compared with the normal side in all of the segments except for the mastoid segment. Signal intensity increase at the internal auditory canal and labyrinthine segments showed correlation with the initial degree of facial palsy but no significant difference was found between different prognostic groups.

MAGNETIC RESONANCE IMAGING OF THE INTRATEMPORAL FACIAL NERVE IN IDIOPATHIC FACIAL PARALYSIS IN THE DOG

The most common cause of peripheral facial nerve paralysis in dogs, in the absence of otitis media, is thought to be idiopathic. Gadolinium-enhanced (Gd) magnetic resonance (MR) imaging has been used to study peripheral facial weakness in humans with a wide variety of disorders, including Bell's palsy, the clinical equivalent of idiopathic facial nerve paralysis in dogs. Gd-MR imaging may be useful to demonstrate abnormal enhancement of the intratemporal facial nerve. The aim of this study was to define the role of the Gd-MR imaging in dogs with idiopathic facial nerve paralysis, with regard to pattern of enhancement, and to search for prognostic information. Six dogs with peripheral facial nerve paralysis, followed between 2003 and 2005, were studied. Physical and neurologic examinations, as well as clinical tests, were performed, including routine hematology, serum biochemistry, thyroid screening, cerebrospinal fluid analysis, and MR imaging. The time interval between the onset of the clinical signs, the progress of the disease, and the final recovery was noted in each dog. The following four intratemporal segments of the facial nerve were analyzed: internal acoustic meatus, labyrinthine segment/geniculate ganglion, tympanic segment, and mastoid segment. Along its length, contrast enhancement was found in four dogs. In this group, contrast enhancement of the facial nerve was found in all segments of two dogs, in three segments of one dog, and in one segment of the other dog. In the four dogs with enhancement, one recovered completely in 8 weeks and three have not recovered completely. The two dogs without evidence of enhancement recovered completely in an average time of 4 weeks.