Botulinum toxin to improve lower facial symmetry in facial nerve palsy

Evaluation of the Patient with Facial Palsy: A Multidisciplinary Approach

This article aims to provide an overview of the management of facial palsy within a multidisciplinary team setting and discusses considerations used to develop patient-specific management plans. The national landscape of facial function services is also discussed including suggestions on what may enable a more equitable and sustainable service for the future.

Objective Assessment of the Repeated Botox Treatment to the Synkinesis of Facial Paralysis by the Integrated Electromyography

BACKGROUND

The widely used botox type A (BTX-A) is effective against synkinesis in facial palsy sequelae. Repeated injections are necessary and permanent improvements have been reported. We objectively evaluated the changes in synkinesis at >6 months after BTX-A injection, including changes over time with the number of administrations.

METHODS

In 48 patients who received multiple BTX-A injections, evaluation by the Sunnybrook Facial Grading System (FGS) and integrated electromyography (iEMG) was performed before treatment and at least 6 months after the first, second, and third BTX-A injection. The iEMG ratio on the affected and healthy sides was calculated for each mimetic muscle and mimic motion.

RESULTS

There was no significant difference in the FGS synkinesis score before treatment and after the third injection, although an improvement was observed. The iEMG ratio was significantly improved in the orbicularis oculi with open-mouth smile and lip pucker after the third dose compared to before treatment. The orbicularis oris showed a significant improvement when the eyelids were closed, while the platysma showed a significant improvement when the eyelids were closed and when the lip was pursed. Multiple regression analysis revealed that the orbicularis oculi and platysma had a greater effect on the iEMG ratio for the number of treatments than other factors.

CONCLUSIONS

Repeated BTX-A injections showed improvements in synkinesis for the orbicularis oculi, orbicularis oris, and platysma, even after >6 months, compared to before treatment.

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.

The psychological and psychosocial effects of facial paralysis: A review

Facial nerve function is essential for a multitude of processes in the face, including facial movement; expression; and functions, such as eating, smiling, and blinking. When facial nerve function is disrupted, facial paralysis may occur and various complications for the patient may result. Much research has been conducted on the physical diagnosis, management, and treatment of facial paralysis. However, there is a lack of knowledge of the psychological and social effects of the condition. Patients may be at an increased risk for anxiety and depression, as well as negative self and social perceptions. This review analyzes the current literature on the various adverse psychological and psychosocial effects of facial paralysis, factors that may play a role, and treatment options that may help improve patients' quality of life.

Bell felcinin viral patojenitesi ve tedavi olarak botulinum toksin tip A kullanımı

Bell'in felci, kraniyal sinir VII'nin iltihaplanmasının ortak adıdır. Kendine özgü genikulat ganglion iltihabı idiyopatiktir ve hemifasiyal felce neden olur. Bu felçten muzdarip olan hastaların semptomları 3 hafta ile 3 ay arasında kaybolabilir. Yüz felci devam eden bazı hastalar için botulinum toksin tip A etkili bir tedavi olabilir. Kas felcinin şiddetine göre botoksun yanı sıra ameliyat, steroid ve antiviral tedavi gibi farklı tedaviler sunulabilir. Bu derleme makalesinin amacı, viral patojenlerin fasiyal sinir iltihabının aktivasyonu ile olası ilişkisine ve Bell felçli hastaların tedavi olarak botoks tip-A'dan nasıl yararlanabileceğine dalmaktır.

Lower lip depressor reanimation using anterior belly of digastric muscle transfer improves psychological wellbeing in facial palsy patients

The authors previously published positive peer-reviewed (21 raters using the Terzis scale) and photogrammetric (Emotrics) outcomes in patients who had undergone two-stage lower lip reanimations up to 2018. Other series have published surgeon and peer-rated results, but we know of only two (n=12) that have assessed patients' views using patient satisfaction surveys. This paper presents patient-rated outcomes (PROMS) in an 11-year series of both single and two-stage anterior belly of digastric muscle (ABDM) lower lip reanimations. Demographics, paralysis characteristics, operative details, and complications were recorded. Patients were telephoned and requested to complete the Glasgow Benefit Inventory (GBI) to assess patient-rated outcomes. Thirty-two patients were eligible (mean age 36.4 years). Twenty-one (63.6%) completed the GBI (mean score +33.3). More patients reported benefit than detriment (95.2% vs 4.8%). Complications were infrequent and included three cases of superficial infections and one of dermatitis. Four patients (12.5%) underwent minor revisions, mostly lipofilling of lip notches. The median (range) duration of follow up was 2.8 (0.3 - 8.5) years. ABDM transfer for lower lip reanimation is a safe, low morbidity procedure that enhances the psychological wellbeing of patients with facial palsy.

Botulinum Toxin Type A to Improve Facial Symmetry in Facial Palsy: A Practical Guideline and Clinical Experience

Unilateral peripheral facial nerve palsy jeopardizes quality of life, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and depression. Among therapeutical approaches, use of Botulinum toxin type A (BoNT-A) on the nonparalyzed side has shown promising results and improvement of quality of life. Nevertheless, the correct technique is paramount, since over-injection of the muscles can result in lack of function, leading to a "paralyzed" appearance, and even worse, functional incompetence, which may cause greater distress to patients. Therefore, the objective of this article is to provide a practical guideline for botulinum toxin use in facial palsy. To this aim, adequate patient assessment, BoNT-A choice, injection plan and dosage, and injection techniques are covered.

Does Botulinum Toxin Therapy Improve Quality of Life in Patients with Facial Palsy?

OBJECTIVES

To review the current literature for the efficacy of botulinum toxin therapy to improve quality of life in patients with facial palsy.

METHODS

A comprehensive systematic literature search was performed of the Medline, EMBase, PubMed and Cochrane Library databases. The population of interest was patients with facial palsy and the intervention of interest was botulinum toxin injection. The primary outcome of this review was quality of life outcomes before and after treatment.

RESULTS

Six studies were included for review. Outcome data were not amenable to meta-analysis due to the heterogeneity of outcome measures. There was an overall trend towards improvement in quality of life after botulinum toxin therapy with the majority of studies demonstrating a statistically significant benefit. The aspects of life in which patients saw benefit varied amongst studies. No patient factors were identified to predict which sub-cohort would likely have the greatest benefit from therapy. Two studies reported adverse effects to be common however minor in nature.

CONCLUSION

This review presents contemporary evidence that botulinum toxin is of benefit to the quality of life of patients with facial palsy. Additional larger randomised control trials would aid clinicians in quantifying the benefit of such therapies for patients with facial palsy.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trends in the Treatment of Bell's Palsy

The aim of the study is to: (1) evaluate national trends in care of facial paralysis, namely Bell's palsy, patients to identify the types of treatments patients are receiving and treatment gaps and (2) identify if newer, more complex surgical therapies published in the literature are being employed. Data were collected from the MarketScan Commercial Claims and Encounters Database by Truven Health. From the database, all inpatient and outpatient claims with International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes for facial paralysis/dysfunction between 2005 and 2013 were extracted. Trends in medical and surgical management were evaluated specifically cataloging the use of steroids, antivirals, botulinum toxin, surgical and rehabilitation service current procedural terminology codes. A total of 42,866 of patients with a formal diagnosis of Bell's palsy were identified with 39,292 (92%) adults and 3,754 (8%) children (< 18 years old), respectively. Steroids were provided to 50.1% of children and 59.8% of adults and antivirals were prescribed to 26.2 and 39.4% of the children and adults, respectively. Within the first 2 years after diagnosis, 0.5% of children and 0.9% of adults received surgery, 0.1% of children and 0.8% of adults received botulinum toxin treatments, and 10.9% of children and 21.5% of adults received rehabilitation services. Despite the limitations of a claims database study, results showing trends in care of facial paralysis are still nonsurgical with many patients receiving no treatment at all. Although limited literature has shown an increase in the use of pharmacotherapy as well as techniques including physiotherapy, chemodenervation, and various surgical therapies, these interventions may be underutilized.

Components of the alternative complement pathway in patients with psoriasis

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease. Adipose tissue plays important roles in the events that regulate body metabolism. This study determined the levels of complement 3 ( C3), acylation-stimulating protein (ASP), and adipsin, which take part in the alternate complement pathway, and are synthesized in and secreted by adipose tissue.

METHODS

Thirty-two patients with psoriasis were matched with 22 controls in terms of age, sex, body mass index, and lipid profiles. Serum C3, ASP, and adipsin levels were measured in both groups.

RESULTS

The serum C3 level was higher and ASP and adipsin levels were lower in the patient group, but these differences were not significant (p = 0.708, p = 0.628, and p = 0.218, respectively). ASP and adipsin levels were correlated positively in patients with psoriasis (p = 0.029).

CONCLUSION

To our knowledge, this study is the first to evaluate ASP and adipsin levels in patients with psoriasis. The roles of ASP and adipsin in the etiopathogenesis of psoriasis are unclear. Although not statistically significant, the lower ASP and adipsin levels in the patient group suggest a potential anti-inflammatory role of these proteins in psoriasis. Further studies should examine the relationships between ASP/adipsin and psoriasis.

Dermatobia hominis misdiagnosed as abscesses in a traveler returning from Brazil to Denmark

We present the case of a 62-year-old woman that consulted us for two boil-like lesions on her thighs after returning from a trip to São Paulo, Brazil, where she had swum in a freshwater lake. After consulting three specialist doctors and undergoing two antibiotic treatments, she was diagnosed with furuncular myiasis caused by Dermatobia hominis. The parasites were excised with no complications.

Toxin yet not toxic: Botulinum toxin in dentistry

Paracelsus contrasted poisons from nonpoisons, stating that “All things are poisons, and there is nothing that is harmless; the dose alone decides that something is a poison”. Living organisms, such as plants, animals, and microorganisms, constitute a huge source of pharmaceutically useful medicines and toxins. Depending on their source, toxins can be categorized as phytotoxins, mycotoxins, or zootoxins, which include venoms and bacterial toxins. Any toxin can be harmful or beneficial. Within the last 100 years, the perception of botulinum neurotoxin (BTX) has evolved from that of a poison to a versatile clinical agent with various uses. BTX plays a key role in the management of many orofacial and dental disorders. Its indications are rapidly expanding, with ongoing trials for further applications. However, despite its clinical use, what BTX specifically does in each condition is still not clear. The main aim of this review is to describe some of the unclear aspects of this potentially useful agent, with a focus on the current research in dentistry.

Cutaneous cooling to manage botulinum toxin injection-associated pain in patients with facial palsy: A randomised controlled trial

INTRODUCTION

Botulinum toxin injections are an effective, well-established treatment to manage synkinesis secondary to chronic facial palsy, but they entail painful injections at multiple sites on the face up to four times per year. Cutaneous cooling has long been recognised to provide an analgesic effect for cutaneous procedures, but evidence to date has been anecdotal or weak. This randomised controlled trial aims to assess the analgesic efficacy of cutaneous cooling using a cold gel pack versus a room-temperature Control.

MATERIAL AND METHODS

The analgesic efficacy of a 1-min application of a Treatment cold (3-5 °C) gel pack versus a Control (room-temperature (20 °C)) gel pack prior to botulinum toxin injection into the platysma was assessed via visual analogue scale (VAS) ratings of pain before, during and after the procedure.

RESULTS

Thirty-five patients received both trial arms during two separate clinic appointments. Cold gel packs provided a statistically significant reduction in pain compared with a room-temperature Control (from 26.4- to 10.2-mm VAS improvement (p < 0.001)), with no variance noted secondary to age, the hemi-facial side injected or the order in which the Treatment or Control gel packs were applied.

CONCLUSION

Cryoanalgesia using a fridge-cooled gel pack provides an effective, safe and cheap method for reducing pain at the botulinum toxin injection site in patients with facial palsy.

Characteristics of the perception for unilateral facial nerve palsy

Patients with facial nerve palsy (FNP) are actually evaluated by other people rather than doctors or the patients themselves. This study was performed to investigate the characteristics of the perception of unilateral FNP in Korean people. A questionnaire using photographs of four patients with four different grades (House-Brackmann) of FNP was given to two hundred people with no FNP. Subjects of each gender, ranging from 20 to 69 years of age, participated. The questionnaire, showing facial expressions of resting, smiling, whistling, eye closing, and frowning, consisted of questions concerning the identification and the involved side of FNP, the unnatural areas of the face, and the unnaturalness of the facial expressions. The overall identification rate of FNP was 75.0%. The identification rate increased according to the increase in the grade of the patient's FNP (p < .001). The overall detection rate of the involved side was 54.5%, and that rate decreased with increasing subject age (p < .001). The area of the most unnatural facial expression was reported to be the mouth, followed by the eyes and cheeks. The most unnatural facial expression was also reported to be smiling, followed by eye closing and whistling. There was no difference in the identification rate of FNP according to education level. However, the overall detection rate of the involved side was higher in the high-education group (p < .001). The detection rate for the involved side of FNP was lower than the rate of identification of FNP and was significantly low in the middle-aged/elderly and low-education level groups.

Treatment with botulinum toxin: An update

Botulinum neurotoxin (BoNT) is a potent toxin produced by the anaerobic bacterium clostridium botulinum. It causes flaccid, long-lasting, local and reversible paralysis. In addition, BoNT inhibits the secretion of the exocrine glands and could have properties in the control of pain. Thus, BoNT is useful in the treatment of many neuromuscular conditions where an increase of muscle tone is associated with the pathogenic mechanism. Furthermore, BoNT is recommended in the treatment of some hypersecretion disorders of the exocrine gland and could play a role in the treatment of migraine and other chronic pain conditions. In the BoNT therapy adverse effects are usually mild and reversible. However, repeated injections of BoNT can lead to the development of neutralizing antibodies that can subsequently inhibit the biological activity of the toxin. In this sense, many factors can influence the immunogenicity of the BoNT, such as product-related factors, the dose of BoNT used, the frequency of injection and the previous exposure to the toxin. In this review, we are going to discuss the current clinical applications of BoNT with a special focus on evidence, doses, injection technique and adverse effects for those applications more frequently used in neurology, namely spasticity, blepharospasm, hemifacial spasm, cervical dystonia and other focal dystonias, as well as chronic migraine, tremor, sialorrhea, facial palsy, neurogenic bladder and many other neurological condition.