Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies

The Incidence of Underlying Mental Health Disorders in a Facial Synkinesis Population

OBJECTIVE

Synkinesis is estimated to impact 10% to 50% of those with facial palsy. We aim to identify the incidence and factors associated with anxiety and depression in the facial synkinesis population.

STUDY DESIGN

Prospective cohort study.

SETTING

Patients aged 18 and older with a diagnosis of facial synkinesis at a tertiary medical center were eligible for inclusion.

METHODS

Demographic variables were collected, and the following surveys were distributed: Synkinesis Assessment Questionnaire, Facial Clinimetric Evaluation Scale, Facial Disability Index, Center for Epidemiological Studies Depression Scale, and Fear of Negative Appearance Evaluation Scale. Patient videos were graded for physician perceived severity using the Electronic Facial Paralysis Assessment and Sunnybrook scale. Analysis of the overall incidence of anxiety and depression symptoms as well as the impact of demographic factors was performed using Pearson product moment correlation and regression modeling.

RESULTS

One-hundred patients met inclusion criteria. Over 25% of patients met criteria for possible or probable depression and the most common appearance-related anxiety score was 30, indicating severe anxiety. Female gender, younger age, and previous history of anxiety and depression were associated with increased depression and anxiety scores at baseline with shorter duration of synkinesis also trending toward higher scores. Worse patient reported severity was also associated with increased depression and appearance-related anxiety scores.

CONCLUSION

The overall prevalence of depression and appearance-related anxiety is relatively high in patients with facial synkinesis.

Early Prognostic Markers for Idiopathic Facial Palsy

OBJECTIVES

To analyze the prognostic value of markers available at the onset of idiopathic facial palsy. To define the evolution of the episode by tracing changes in facial function over time.

METHODS

This is an observational prospective study on patients with facial palsy consulting in the first 24 hs. The evolution was recorded with photographs and monthly visits. Multivariate analysis was conducted between clinical and analytical parameters determined in the first visit and prognostic outcomes: progression, resolution, and "facial palsy evolution index," which integrates severity of the palsy and duration.

RESULTS

Sixty-five patients were included. The mean initial HB grade was III, but 31% of the cases progressed in the following days. Complete recovery was observed in 89.5% of the cases (mean duration of the episode of 48 days), and exposure keratitis in 21.5%, with a mean of 42 days after the onset. Multivariate analysis showed that retroauricular pain and white blood cell count were significantly related to progression (odds ratio [OR] 19.08; 1.49, p < 0.05), incomplete resolution (OR 1/0.04; 1/0.59, p < 0.05), and higher evolution index (12.8; 2.9, p < 0.05). Age was also significantly associated with evolution index (0.27, p < 0.05), and platelet-to-lymphocyte ratio with progression (OR 1.02, p < 0.05). The rest of the parameters did not show an association with prognosis.

CONCLUSIONS

Retroauricular pain and white blood cell count are early indicators of prognosis in idiopathic facial palsy. Initial examinations may not reflect the maximum grade of weakness reached by the patient. Ocular complications can occur several weeks after the onset, even with mild grades of paralysis.

LEVEL OF EVIDENCE

3 Laryngoscope, 2025.

The Epidemiology and Treatment Outcomes of Facial Nerve Palsy Using a Population-Based Method

PURPOSE

To update the epidemiological patterns of facial nerve palsy (FNP) in Olmsted County, MN.

METHODS

A retrospective chart review using the Rochester Epidemiology Project database was conducted. Patients aged ≥18 years receiving a diagnosis of FNP within the Rochester Epidemiology Project database from the years 2000 to 2010 were included in the study. Data collected included age, gender, cause of FNP, degree of paralysis, medical and/or surgical management, and outcomes. Overall incidence rates were determined using gender-specific population figures for Olmsted County. Incidence trends were compared with previous Rochester Epidemiology Project studies.

RESULTS

The most common cause for FNP was Bell palsy (70.3% of cases). The overall incidence rate for Bell palsy in Olmsted County from 2000 to 2010 was 39.9 (95% CI, 36.1-43.7) per 100,000 person-years. This is an absolute increase of 14.9 per 100,000 person-years and a 60% relative increase in Bell palsy compared with a previous study performed at Mayo Clinic using the Rochester Epidemiology Project database population data from 1968 to 1982. Patients were infrequently evaluated by an ophthalmologist (8.4% of cases), and surgical intervention to address ophthalmic sequelae was rare (1.7% of cases).

CONCLUSIONS

The incidence of Bell palsy has increased dramatically over previous studies, which has occurred in the setting of declining herpes simplex virus type 1 seropositivity trends and increasing herpes zoster incidence in the United States. Few patients with FNP are referred to ophthalmologists, which may represent a gap in care for both acute and long-term ophthalmic sequelae.

Bell's Palsy-Unclear Terminology and Definitions Impede Progress

Importance: Bell's palsy (BP) is reported as the most common cause of facial paralysis, yet literature lacks a standardized definition of BP. Objective: To identify and categorize how the term "Bell's palsy" is defined and applied in published medical literature. Evidence Review: Randomized controlled trials, clinical trials, systematic reviews, meta-analyses, and reviews containing "Bell's palsy" were identified in MEDLINE, Embase, and CENTRAL databases from inception until April 2, 2024. Articles were indexed by their definition of BP: (1) acute (≤72-h onset) idiopathic facial paralysis with no known etiologies, (2) acute "idiopathic" facial paralysis despite providing etiologies, (3) acute non-idiopathic facial paralysis, (4) non-acute but "idiopathic" facial paralysis with or without providing etiologies, (5) synonymous with facial paralysis, and (6) no definition. Ascribed etiologies were recorded. Original articles' exclusion criteria for patients with BP were also categorized. Findings: Of 4,395 articles obtained, 924 met the criteria. Based on the aforementioned categories, incongruent definitions of BP exist in the literature: (1) 12.88%, (2) 14.72%, (3) 4.00% (4) 15.26%, (5) 8.12%, and (6) 45.02%. Ascribed etiologies and exclusion criteria for BP also varied. Conclusions and Relevance: BP is a common condition seen by providers of many specialties, and as such patient diagnosis, management, and research rely on consistency and a shared language. This systematic review found inconsistent definitions and applications of the term "Bell's palsy" in the literature.

Analytical review of facial nerve palsy following SARS-CoV-2 vaccination: comprehensive assessment

PURPOSE

The SARS-CoV-2 vaccination has reduced COVID-19 infection, though facial nerve palsy (FNP) has emerged as a notable side effect of the vaccine. We evaluated the current literature on the clinical presentation and outcomes of FNP related to COVID-19 vaccination.

METHODS

A comprehensive search of seven databases was conducted for studies up to January 2023. We included individually reported patients on FNP following COVID-19 vaccination, while cases with co-existing neurological disorders or secondary causes of FNP were excluded. Pooled descriptive and inferential analyses were conducted, with prognostic factors evaluated through regression and Kaplan-Meier survival analysis.

RESULTS

A total of 33 studies were included, with data from 52 patients who developed post-COVID-19 vaccination FNP (PV-FNP). Most cases (71%) followed mRNA vaccines, primarily occurring after the first dose and within the first week post-vaccination. Nearly all cases (98%) were unilateral, with Grade III palsy being most common. Complete recovery was achieved in 55% of patients, significantly lower than pre-pandemic rate (83%). A longer latency period was associated with a reduced likelihood of full recovery, and females experienced faster recovery compared to males.

CONCLUSION

FNP following SARS-CoV-2 vaccination tends to present as mild and unilateral, with a lower full recovery rate compared to pre-pandemic cases. Symptoms often develop within the first week after vaccination, and earlier symptom onset is associated with a higher likelihood of full recovery. Recognizing these patterns provides valuable guidance for clinicians in counseling patients about prognosis and managing follow-up care effectively.

Comparative Analysis of Vestibular Dysfunction and Compensation in Ramsay-Hunt Syndrome and Vestibular Neuritis

OBJECTIVE

To investigate vestibular loss and compensation in Ramsay-Hunt syndrome with dizziness (RHS-D) and vestibular neuritis (VN).

STUDY DESIGN

Retrospective cohort study from 2019 to 2023.

SETTING

Tertiary care neurotology practice.

METHODS

Patients with RHS-D or VN who underwent videonystagmography, including cervical vestibular evoked myogenic potential (cVEMP), caloric stimulation, rotary chair, and oculomotor testing, were reviewed and stratified by vertigo etiology. The main outcome measures were rates and severity of vestibular loss, as measured by cVEMP and caloric stimulation, and of vestibular compensation, as measured by rotary chair and oculomotor testing.

RESULTS

Ten patients were found to have RHS-D and 22 with VN. Caloric and cVEMP abnormalities were noted in 100 and 70% of RHS-D patients compared to 60 and 20% with VN (P = .029 and P = .034, respectively). RHS-D patients were significantly more likely to present with concurrent caloric and cVEMP abnormalities compared to VN (70 and 13%, respectively; P = .009). Vestibular loss appeared more severe in RHS-D compared to VN suggested by significantly lower mean bithermal slow phase velocity sum (3.8 and 21 degrees per second, respectively), greater canal paresis (78.7 and 40.2%, respectively), and greater cVEMP amplitude asymmetry (64 and 31%, respectively) (P = .014, P < .001, and P = .053, respectively). Regarding vestibular compensation, abnormal gain asymmetry was present in 88% of RHS-D patients with a mean asymmetry of 31.2 compared to 11% in VN with a mean of 14.0 (P = .019 and P = .003, respectively).

CONCLUSION

Compared to VN, RHS-D patients appear to suffer from a more profound vestibular loss and a worsened ability to compensate for such deficits.

A case of congenital cholesteatoma in adult patient with intermittent episodes of facial palsy

INTRODUCTION AND IMPORTANCE

Congenital cholesteatoma is a rare entity that arises from epithelial cell rests in the middle ear, parts of temporal bone or even intracranially. However, it can go unrecognized for several years making the consideration of such diagnosis a bit tricky among otologists.

CASE PRESENTATION

We are reporting a case of a young female adult who presented with unilateral hearing loss for one year and intermittent episodes of facial twitching in addition to periods of recurrent unilateral facial palsy that happened about three times in the past two years.

CLINICAL DISCUSSION

Otoscopic examination revealed a slight whitish mass behind the superior half of an intact tympanic membrane. High-resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) proposed a differential diagnosis of congenital cholesteatoma and facial schwannoma. Canal wall up (CWU) mastoidectomy with exploration of anterior epitympanum and partial facial nerve decompression was made with complete removal of cholesteatoma mass and ossicular reconstruction.

CONCLUSION

A recurrent or non-resolving facial asymmetry in an otherwise healthy adult should raise the suspicion among otolaryngologists to investigate the possibility of congenital cholesteatoma.

Lower Motor Neuron Facial Nerve Paralysis Following Recombinant Hepatitis B Vaccine Administration: A Case Report and Literature Review

The Hepatitis B vaccine's safety profile is considered safe, but sometimes neurological complications, like Bell's palsy (acute peripheral facial neuropathy), can occur after its administration. A 35-year-old female doctor experienced left-sided facial weakness and paralysis six days after getting the Hepatitis B vaccine. On examination, she had lower motor neuron facial nerve palsy. After excluding other causes, a diagnosis of Bell's palsy was made following Hepatitis B vaccine. She was treated with corticosteroids, antiviral medication, and physiotherapy, which led to a complete resolution over four weeks. Bell's palsy is still an uncommon potential side effect even though the advantages of the Hepatitis B vaccination exceed the risks. Further investigation is necessary to prove a conclusive link between the vaccine and its neurological side effects.

Effects of phototherapy in patients with idiopathic facial palsy: Scoping review

Phototherapy has emerged as a promising treatment for Bell's palsy, offering potential improvements in facial nerve function and overall well-being. In this study, we selected seven relevant studies involving 306 patients with subacute or acute Bell's palsy from PubMed, EMBASE, Web of Science, and Scopus before June 5, 2024. Low-level laser therapy (LLLT) efficacy for facial nerve paralysis was assessed in seven studies. Two studies lacked standard deviation data, precluding meta-analysis. Sunnybrook scores favored LLLT (mean difference [MD] = 17.42, 95 % confidence interval [CI]: 4.00-30.84, p = 0.011). However, Facial Disability Index results showed no significant difference (MD = 12.16, 95 % CI: -0.60 to 24.92, p = 0.061) between LLLT and control. LLLT, particularly with wavelengths of 830 or 850 nm administered over 6 weeks, may lead to beneficial outcomes. Combining LLLT with exercise therapy appears to be effective．LLLT demonstrates promise as a management option for Bell's palsy, potentially offering advantages over other treatments, particularly in patients with comorbidities, such as diabetes. Phototherapy devices currently used in Japan offer non-invasive treatment with minimal patient burden. The safety and therapeutic efficacy of these devices have been confirmed as a potential treatment for facial nerve paralysis.

Recurrent Bell's Palsy: A Comprehensive Analysis of Associated Factors and Outcomes

Background: Bell's palsy is a common peripheral facial nerve disorder that manifests as sudden unilateral facial paralysis. The condition, believed to be caused by viral infections and ischemic processes, affects a significant portion of the population and is associated with various systemic comorbidities. This study aimed to analyze the clinical characteristics, risk factors, and prognosis in primary and recurrent Bell's palsy to identify factors associated with recurrence and outcomes. Methods: A retrospective study was conducted on patients diagnosed with Bell's palsy at tertiary hospital between 2018 and 2024. Data collected included demographic information, comorbid conditions, clinical features, and recovery outcomes. Statistical analyses were performed to determine the significance of various factors in the recurrence of Bell's palsy. Results: The study included 254 patients. Recurrence was observed in 20.9% of cases. Significant risk factors for recurrence included diabetes (33.3%), hypertension (41.0%), hypothyroidism (56.1%), autoimmune disorders (54.2%), and a family history of Bell's palsy (48.6%). The severity of initial paralysis also influenced recurrence rates. Complete recovery from the initial episode was achieved by 66.9% of patients, whereas prolonged recovery times were noted in recurrent cases. Conclusion: The study highlights the significant role of systemic comorbidities and the severity of initial presentation in the recurrence of Bell's palsy.

A Retrospective Study on the Gender Differences in Clinical Manifestations of Bell's Palsy

OBJECTIVES

Although many studies have assessed the clinical features and the factors affecting treatment outcomes of Bell's palsy, few have analysed differences between men and women. This study therefore evaluated whether the clinical features and treatment results, and the factors affecting them, differ between men and women with Bell's palsy.

METHODS

This retrospective study included 1708 patients (791 men and 917 women) who presented with facial palsy to the otolaryngology department between January 1986 and December 2022. Clinical features and treatment outcomes were compared in men and women diagnosed with Bell's palsy.

RESULTS

Age distribution, side affected by facial palsy, House-Brackmann (HB) Grade, underlying disease such as diabetes and hypertension, electroneuronography (ENoG) results, electromyography (EMG) results, and treatment methods did not differ significantly between men and women with Bell's palsy (p > 0.05 each). Factors significantly associated with better prognosis in men included milder initial facial palsy and better electromyography (EMG) results (p < 0.05). Factors significantly associated with better prognosis in women included younger age, milder initial facial palsy, and better EMG results (p < 0.05). Women had significantly better prognosis than men when treated with steroids within 3 days of the onset of paralysis (p < 0.05).

CONCLUSION

Milder initial facial palsy and better EMG results were associated with better prognosis in both men and women with Bell's palsy. Younger age at onset and early stage treatment with steroids were associated with a higher recovery rate in women, but not in men.

Laser therapy for Bell's palsy: a systematic review and meta-analysis of randomized trials

This meta-analysis investigated therapeautic effects of laser therapies in patients with Bell's palsy (BP). The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases using the following search terms: (facial paralysis OR Bell's palsy OR facial palsy OR idiopathic facial paralysis) AND (laser OR low-level laser OR photobiomodulation OR phototherapy). Relevant studies published before October 29th 2024 were identified. Randomized trials comparing the outcomes of laser therapies with other interventions, including electrical stimulation and control or usual care in patients with BP were included. The mean difference (MD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs). Twelve studies were included, with a total of 597 patients. Nine studies were further included in the quantitative analysis. Our meta-analysis revealed that laser therapy significantly improved disease severity (House-Brackmann facial paralysis scale) (MD = -1.51, 95% CI = -2.43 to -0.59), facial asymmetry (Sunnybrook facial grading system) (MD = 20.63, 95% CI = 10.33 to 30.94), and facial function and disability (Facial disability index) (MD = 17.91, 95% CI = 5.60 to 30.22) when compared with control care in adult patients. Moreover, laser therapy significantly improved facial severity (MD = 21.05, 95% CI = 16.77 to 25.33) when compared with electrical stimulation. In addition, no adverse effects of laser therapy were reported. Laser therapy has favorable effects on disease severity, facial asymmetry, and facial function and disability for patients with BP.

Bell's palsy characteristics, clinical manifestations, complications, and prognosis in a primary care setting, a single center study: A retrospective cohort study

Background

Bell's palsy (BP) is a cranial nerve disorder in which unilateral or bilateral paralysis of the facial nerve occurs. The study aims to study BP's characteristics, including its clinical manifestations, prognosis, and complications among adult patients aged 18 years and above.

Methods

A retrospective study of adult patients diagnosed with BP in a primary care setting] [January 2015 to December 2022].

Results

The study included a total number of 92 patients with an incidence rate of 23 cases per 100,000 people. The mean age was 43.52 years. The most common symptoms reported were dropping of the mouth at 38.9%, loss of forehead muscle movement at 24.4%, loss of nasolabial fold at 22.2%, loss of facial expressions at 20%, and headache at 18.9%. Immunodeficiency affected 2.3% of the patients. The management of patients involved the use of steroids in 76.1% and the use of antiretroviral medications in 48.9%. Physiotherapy was used in 29.5%. The complete recovery rate during the first year was 90.8%. The rate of complete recovery within two years was 96.9%.

Conclusion

The incidence of BP in the region seems to be similar to the incidence rate reported elsewhere in the world. The use of antiviral therapy seems to be high despite the controversy around the use of antivirals in the management of BP. The majority of patients with BP recover within the first year.

Fixel-Based Analysis of White Matter Alterations in Facial Palsy

Predicting individual prognosis is difficult despite various risk factor studies, due to the complex recovery involving peripheral nerve restoration and cerebral plasticity. This study uses fixel-based analysis (FBA) to better understand neural pathway alterations, hypothesizing that FBA can effectively link functional outcomes with diffusion metrics in the process of rehabilitation. The authors recruited 50 participants including 30 patients and 20 healthy controls into the study. All of them underwent assessment 3 months and 6 months after injury. Both whole-brain fixel-based analysis and tract of interest analysis were performed. The authors observed multiple regions including the superior corona radiata, posterior limb of the internal capsule, and cerebral peduncle displaying significant changes of FD (fiber density), FC (fiber-bundle cross-section), and FDC (fiber density and cross-section). Patients with unfavorable outcomes showed increased FD in the ipsilesional side and decreased FD in the contralesional side compared with patients with favorable outcomes. In addition, FD values of the contralesional side exhibited positive correlations with differences in FGS at 3 months and 6 months. Conversely, FD values in the ipsilesional side showed a negative correlation. Our findings suggest that FD metrics within the corticobulbar tract could serve as predictive biomarkers for symmetry outcomes. Thus, FBA holds promise for early estimation of behavioral outcomes in facial palsy, guiding more targeted interventions.

Knowledge and Attitude Towards Bell's Palsy Rehabilitation Among Physical Therapists in Saudi Arabia: A Cross-Sectional Study

Background

Bell's Palsy (BP) is an acute lower motor nerve impairment of the facial nerve, causing sudden paralysis on one side of the face and significantly affecting the patient's quality of life. Physiotherapy is critical for rehabilitation after BP, aiding functional recovery. Various physical therapy interventions, such as dry needling, taping, and nerve mobilization, have proven effective in treating BP. However, different rehabilitation approaches and knowledge levels among therapists can result in varying treatment outcomes. Therefore, understanding rehabilitation specialists' knowledge and attitudes towards BP is essential for ensuring effective treatment. To date, no studies have examined the knowledge and attitudes of rehabilitation professionals in Saudi Arabia regarding BP.

Objective

This study aims to evaluate the knowledge and attitudes of physical therapists in Saudi Arabia regarding the rehabilitation of BP.

Methods

A cross-sectional observational study was conducted with 150 licensed physical therapists in Saudi Arabia, selected via convenience sampling. Participants completed an anonymous online survey covering demographics, knowledge of, and attitudes toward BP rehabilitation techniques. Descriptive and inferential statistics were used to analyze the data.

Results

The participants had a mean age of 33.13 ± 6.85 years, with 68.7% being female. Most held Bachelor's degrees (65.3%) and worked in general hospitals (72.7%). The average knowledge score was 8.99 ± 1.95, indicating moderate knowledge levels. Attitudes towards BP rehabilitation were positive, particularly regarding early intervention, emotional support, and coordination exercises. Significant differences in knowledge and attitudes were observed based on gender, experience, and practice location.

Conclusion

Physical therapists in Saudi Arabia demonstrate moderate knowledge and positive attitudes toward BP rehabilitation. Continued professional education and collaboration are recommended to improve clinical standards in treating BP.

Unraveling Facial Nerve Palsy: A Case Series Highlighting Diagnostic and Therapeutic Challenges

Facial nerve palsy (FNP) may arise from multiple etiological reasons, including anatomical anomalies, circulatory complications, and infectious agents. This case series underscores the importance of a comprehensive diagnostic approach to identify the precise etiology, including structural abnormalities, vascular anomalies, or infectious illnesses. Here, we present three distinct occurrences of FNP, emphasizing the varied diagnostic difficulties and therapeutic strategies. It includes an arachnoid cyst, which when occurring at the cerebellopontine angle can affect multiple cranial nerves, specifically the seventh and eighth cranial nerve, a neurovascular compression syndrome, where the anterior inferior cerebellar artery loops around the facial nerve. Most often, this scenario causes hemifacial spasms, which in our scenario manifests as FNP. Lyme disease is a tick-borne disease that affects multiple cranial nerves, specifically the facial nerve. Effective management necessitates a focused treatment strategy that tackles the symptoms and the underlying disease. Advanced imaging techniques, serological tests, and a tailored treatment approach are essential for effective diagnosis, can have significant implications for patient well-being, and necessitate a thorough evaluation to identify underlying causes. This case series illustrates the diverse etiologies of FNP, emphasizing the need for comprehensive diagnostic strategies and targeted treatments. As clinicians encounter FNPs more often, this case series can help physicians understand facial palsy better. Continuous research and clinical awareness are vital for improving patient outcomes in cases of FNP.

Etiology and Management of 800 Patients With Facial Palsy at a Private Practice Setting Over a 5-Year Period

INTRODUCTION

Very few papers investigated the etiologic breakdown and demographic characteristics of patients with facial nerve (FN) palsy. Our paper aims to present the etiologic breakdown and demographic characteristics of patients with FN palsy, presenting at a private care center between 2014 and 2019, along with the treatment modalities that were offered to them.

METHODS

Charts of 800 patients with facial palsy (FP) were reviewed. Data included the etiology of their diagnosis, family history, recurrent FP, demographic information, and treatment provided before and after presentation.

RESULTS

Seventy-five percent of our study population were females. The average period between diagnosis with FP and presentation at our center was 10.8 years. The most commonly identified etiology was Bell's palsy, followed by acoustic neuroma. Eighty-one percent of the study subjects were prescribed steroids and/or antivirals. Facial neuromuscular retraining, electrical stimulation, chemodenervation, and surgical intervention were also part of some treatment plans for our population.

DISCUSSION

Recommendations for the treatment of idiopathic FP include steroids with adjuvant antiviral medications. Data remains uncertain whether the combination therapy of steroids and antivirals has better results compared to steroids alone. Electrical stimulation is still a controversial therapeutic tool for facial paralysis with a potential role in exacerbating synkinesis. The difference in referral patterns between tertiary and private care centers can explain the disparity in the ranking of the etiologies between our study and what has been published.

CONCLUSION

Management of FP is a complex process. The FN community must develop a common database to improve its understanding of the different presentations.

Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research

OBJECTIVE

The "Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research" aims to review the latest evidence regarding the treatment of Bell's palsy and to provide appropriate recommendations.

METHOD

Regarding the treatment of Bell's palsy, a guideline panel identified key clinical questions using an analytic PICO framework. The panel produced recommendations following the standards for trustworthy guidelines and the GRADE approach. The panel considered the balance of benefits, harm, and preferences when making recommendations.

RESULTS

The panel identified nine key clinical questions: systemic (high/standard dose) corticosteroids, intratympanic corticosteroids, systemic antivirals, decompression surgery, acupuncture, physical therapy, botulinum toxin, and reanimation surgery.

CONCLUSION

These guidelines strongly recommend systemic standard-dose corticosteroids for the clinical management of Bell's palsy. Other treatments are weakly recommended due to insufficient evidence. The absolute risk reduction of each treatment differed according to the disease severity. Therefore, physicians and patients should decide on treatment based on the disease severity.

Super-Selective Intra-arterial Thrombolytic Therapy for Peripheral Facial Paralysis After Postauricular Hyaluronic Acid Injection for the Esthetic Correction of Lying Ears

BACKGROUND

Hyaluronic acid (HA) injection in the auricular base is one of the most popular and non-surgical cosmetic procedures for correcting lying ears and optimizing the facial profile because of its minimal invasiveness, immediate effect and safety (Li et al. in Aesthet Surg J 44: 746-75, 2024). But we have recently discovered that this treatment may lead to a new and rare complication called peripheral facial paralysis that has never been reported before. Until now, the etiology, clinical traits, treatment strategies, outcomes and possible reversibility have not been characterized.

METHODS

In the present study, we enrolled 4 patients with peripheral facial paralysis after subcutaneous postauricular HA filler injection. Preoperative digital subtraction angiography revealed a vascular embolism. Then, the patients underwent super-selective facial arterial thrombolytic therapy via hyaluronidase and papaverine injections. Simultaneously, general symptomatic treatment and nutritional therapy were performed.

RESULTS

The patients were relieved of their clinical symptoms and the significant improvement was observed in terms of motor function in her left facial areas after treatment. The auricular skin necrosis of all patients was restored to near normal appearance.

CONCLUSION

Our results indicate that super-selective facial arterial thrombolytic therapy is feasible for patients with peripheral facial paralysis induced by HA embolism. It was also beneficial in the recovery from skin necrosis. The therapy was shown to be worthy of clinical application.

LEVEL OF EVIDENCE IV

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 .

Needles, Herbs, and Electricity: A Meta-Analysis of Traditional Eastern Medicine in the Management of Facial Paralysis

In Eastern nations, interventions like acupuncture and herbal medicine are often first-line for patients presenting with facial paralysis. Despite the rising popularity of Eastern medicine in Western nations, the literature assessing whether Eastern medicine interventions should be recommended for patients with facial paralysis is lacking. This meta-analysis aims to define what Eastern medicine interventions exist for the management of facial paralysis and assess whether current research supports these approaches as safe and effective. The PubMed and Cochrane databases were reviewed in accordance with PRISMA guidelines. Inclusion criteria consisted of peer-reviewed studies published between 2000 and 2023 that reported on Eastern medicine, also described as, "complementary" or "alternative" interventions for facial paralysis. Effective and cured rates were the primary outcomes extracted from the literature. Interventions within these studies were categorized into six groups: (1) standard acupuncture, (2) special needle therapies, (3) needle therapy + other alternative treatments, (4) herbal medicine, (5) alternative treatments + Western medicine, and (6) Western medicine alone. A multiple-treatment meta-analysis was performed to assess differences in effective and cured rates. Fifteen studies involving Eastern medicine for the treatment of facial paralysis met the inclusion criteria. No significant differences were found in effective and cured rates across groups. Multiple quality concerns were noted, such as the lack of control groups, blinding, and randomization noted in several studies. Many studies failed to report complications, preventing conclusions from being drawn on the safety of these Eastern medicine interventions. This meta-analysis was unable to support the recommendation of Eastern medicine approaches for patients with facial paralysis. No Eastern medicine treatments, combination of Eastern medicine treatments, or Eastern medicine treatments given with Western medicine were seen to be more effective than Western medicine alone.

Current Treatments and Future Directions for Facial Paralysis

Facial palsy is a condition that affects the facial nerve, the seventh of the 12 cranial nerves. Its main function is to control the muscles of facial expression. This involves the ability to express emotion through controlling the position of the mouth, the eyebrow, nostrils, and eye closure. The facial nerve also plays a key role in maintaining the posture of the mouth and as such, people with facial paralysis often have problems with drooling, speech, and dental hygiene.Due to the devastating effects on the quality of life of individuals with facial palsy, there are a multitude of various treatment options for the paralyzed face. This article reviews current management strategies and points towards promising future directions for research in the field of facial reanimation.

Rethinking Oncologic Facial Nerve Reconstruction in the Acute Phase Through Classification of the Level of Injury

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

Approaches to the Management of Synkinesis: A Scoping Review

Postparalysis facial synkinesis (PPFS) can develop in any facial palsy and is associated with significant functional and psychosocial consequences for affected patients. While the prevention of synkinesis especially after Bell's palsy has been well examined, much less evidence exists regarding the management of patients with already established synkinesis. Therefore, the purpose of this review is to summarize the available literature and to provide an overview of the current therapeutic options for facial palsy patients with established synkinesis. A systematic literature review was undertaken, following the Preferred Reporting Items of Systematic Reviews and Meta-analyses 2020 guidelines. MEDLINE via PubMed and Cochrane Library were searched using the following strategy: ([facial palsy] OR [facial paralysis] OR [facial paresis]) AND (synkinesis) AND ([management] OR [guidelines] OR [treatment]). The initial search yielded 201 articles of which 36 original papers and 2 meta-analyses met the criteria for inclusion. Overall, the included articles provided original outcome data on 1,408 patients. Articles were divided into the following treatment categories: chemodenervation (12 studies, 536 patients), facial therapy (5 studies, 206 patients), surgical (10 studies, 389 patients), and combination therapy (9 studies, 278 patients). Results are analyzed and discussed accordingly. Significant heterogeneity in study population and design, lack of control groups, differences in postoperative follow-up, as well as the use of a variety of subjective and objective assessment tools to quantify synkinesis prevent direct comparison between treatment modalities. To date, there is no consensus on how PPFS is best treated. The lack of comparative studies and standardized outcome reporting hinder our understanding of this complex condition. Until higher quality scientific evidence is available, it remains a challenge best approached in an interdisciplinary team. An individualized multimodal therapeutic concept consisting of facial therapy, chemodenervation, and surgery should be tailored to meet the specific needs of the patient.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Electrically Induced Blink for the Prevention of Ocular Symptoms and Blurred Vision in Patients With Acute Facial Nerve Palsy

Objectives: Facial nerve palsy causes blurred vision and ocular discomfort due to deficits in blinking and eye closure. The objective of this study was to determine whether eye-blinks could be elicited by electrical stimulation and whether electrically induced blink would have an effect on the visual acuity and ocular symptoms in patients with acute facial nerve palsy. Methods: The zygomatic branch of the facial nerve of fifteen participants with acute facial nerve palsy was electrically stimulated in order to elicit a blink. In successful cases, the participant proceeded with a two-hour TV watching session in which an electrically induced blink was delivered every 5 seconds. The control condition consisted of an otherwise similar TV watching session without electrically induced blinking. Subjective ocular symptoms were evaluated with a Dry Eye Questionnaire and visual acuity was assessed with a Logarithm of the Minimum Angle of Resolution (LogMAR) chart before and after both sessions. Results: The stimulation produced a blink in 8 participants (53%). The visual acuity in the affected eye decreased during the control session, whereas no significant change occurred during the stimulation session. The ocular symptoms were significantly reduced during the stimulation session. Conclusions: Electrically elicited blink is a promising method for reducing the eye symptoms in individuals with acute facial nerve palsy.

Monocyte to high-density lipoprotein ratio as a novel-potential biomarker for predicting prognosis of Bell's palsy

OBJECTIVES

In several disorders, the monocyte to high-density lipoprotein ratio (MHR) has been considered a biomarker of systemic inflammation and oxidative stress. However, its role in Bell's palsy (BP) remains unclear. This study investigates the relationship between elevated MHR and poor recovery in BP patients.

METHODS

The clinical data of 729 BP patients were analyzed retrospectively. The House-Brackmann Facial Nerve Grading System (H-B) was utilized to assess the severity of facial motor dysfunction during admission and the follow-up period after discharge. According to the 6 months follow-up data, H-B grades 1-2 were classified as recovered (n = 557), and H-B grades 3-6 as unrecovered (n = 172). The patients were split into MHR ≤ 0.26 (n = 361) and MHR > 0.26 (n = 368) groups based on the median MHR to further analyze the connection between different MHRs and prognosis.

RESULTS

The level of MHR was substantially greater in the unrecovered group of BP patients than in the restored group (medians[interquartile range], 0.32[0.20, 0.49] vs 0.24[0.11, 0.39], P < 0.001). MHR was an independent risk factor for BP prognosis as indicated by the multivariate logistic regression analysis (OR = 4.467, 95% CI = 1.875-10.646, P = 0.001). The area under the curve (AUC) was 0.615 (95% CI = 0.566-0.664, P < 0.001). The initial H-B score did not differ significantly between MHR ≤ 0.26 (n = 361) and MHR > 0.26 (n = 368) groups. However, after 6 months of follow-up, the high-MHR group's H-B score was considerably greater than the low-MHR group's.

CONCLUSIONS

MHR is expected to be an accessible and effective biomarker of BP. In BP patients, elevated MHR is related to an increased chance of poor recovery.

The Impact of the COVID-19 Pandemic on Bell's Palsy and Ramsay-Hunt Syndrome: A Multicenter Retrospective Study

BACKGROUND

This article presents a comprehensive review of data on the impact of facial palsy during the coronavirus disease 2019 (COVID-19) pandemic. The possible causes and pathophysiological mechanisms of changes in the epidemiology of facial palsy during the COVID-19 pandemic are also discussed.

METHODS

This multicenter retrospective cohort study included 943 patients diagnosed with Bell's palsy or Ramsay Hunt syndrome. This study compared patient demographics, comorbidities, symptoms, and treatments before the COVID-19 pandemic (from 2017 to 2019) and during the COVID-19 pandemic, from 2020 to 2022).

RESULTS

Following the COVID-19 outbreak, there has been a significant increase in the number of cases of Bell's palsy, particularly among elderly individuals with diabetes. Bell's palsy increased after the COVID-19 outbreak, rising from 75.3% in the pre-COVID-19 era to 83.6% after the COVID-19 outbreak. The complete recovery rate decreased from 88.2% to 73.9%, and the rate of recurrence increased from 2.9% to 7.5% in patients with Bell's palsy. Ramsay Hunt syndrome showed fewer changes in clinical outcomes.

CONCLUSION

This study highlights the impact of the COVID-19 pandemic on the presentation and management of facial palsy, and suggests potential associations with COVID-19. Notably, the observed increase in Bell's palsy cases among elderly individuals with diabetes emphasizes the impact of the pandemic. Identifying the epidemiological changes in facial palsy during the COVID-19 pandemic has important implications for assessing its etiology and pathological mechanisms of facial palsy disease.

Acute peripheral facial paralysis caused by tegmental pontine infarction

Facial paralysis presents as unilateral mouth drooping and lagophthalmos. The main causes of peripheral facial paralysis are Bell's palsy and Ramsay-Hunt syndrome. However, rarely occurring pontine infarctions of the facial nucleus also manifest a lower motor neuron pattern of facial paralysis. We report a case of a man in his 50s who presented to the emergency department with unilateral peripheral facial paralysis. The initial diffusion-weighted images were unremarkable, and the patient was managed as per guidelines for hypertensive encephalopathy or Bell's palsy. On the 3rd day after admission, he was diagnosed with left pontine infarction and suspected infarction of the left anterior inferior cerebellar artery. We propose that in similar cases, re-examination of imaging results should be considered, as diffusion-weighted imaging is characteristically prone to generate false-negative results in patients with early onset or posterior circulation infarction.

Bionic blink improves real-time eye closure in unilateral facial paralysis

Facial paralysis is the inability to move facial muscles thereby impairing the ability to blink and make facial expressions. Depending on the localization of the nerve malfunction it is subcategorised into central or peripheral and is usually unilateral. This leads to health deficits stemming from corneal dryness and social ostracization.Objective: Electrical stimulation shows promise as a method through which to restore the blink function and as a result improve eye health. However, it is unknown whether a real-time, myoelectrically controlled, neurostimulating device can be used as assistance to this pathological condition.Approach: We developed NEURO-BLINK, a wearable robotic system, that can detect the volitional healthy contralateral blink through electromyography and electrically stimulate the impaired subcutaneous facial nerve and orbicularis oculi muscle to compensate for lost blink function. Alongside the system, we developed a method to evaluate optimal electrode placement through the relationship between blink amplitude and injected charge.Main results: Ten patients with unilateral facial palsy were enrolled in the NEURO-BLINK study, with eight completing testing under two conditions. (1) where the stimulation was cued with an auditory signal (i.e. paced controlled) and (2) synchronized with the natural blink (i.e. myoelectrically controlled). In both scenarios, overall eye closure (distance between eyelids) and cornea coverage measured with high FPS video were found to significantly improve when measured in real-time, while no significant clinical changes were found immediately after use.Significance: This work takes steps towards the development of a portable medical device for blink restoration and facial stimulation which has the potential to improve long-term ocular health.

How to Enhance the Success of Selective Neurectomy for Facial Synkinesis by Considering the Patient's Preferences: Lesson Learned from a Retrospective Analysis of 122 Cases

BACKGROUND

Facial synkinesis can result in facial tightness, smile dysfunction, and eyelid aperture narrowing due to overactive and uncoordinated muscle activity. We hypothesized that the outcome of a selective neurectomy could rely on the patient's chief complaints.

METHODS

We retrospectively reviewed 122 patients who underwent selective neurectomy at our hospital. Preoperatively, the patients were asked nine questionnaires to identify their two major chief complaints (treatment priorities). Postoperatively, facial tightness, limited mouth movement, and eyelid aperture narrowing were measured.

RESULTS

The most common chief complaints in our series were facial tightness (n=38), eyelid narrowing (n=32), and limited mouth movement (n=28); the second most common chief complaints (second priority) were limited mouth movement (n=47), facial tightness (n=21), and eyelid narrowing (n=20). The mean score for facial tightness significantly improved from 4.3 to 1.1 in the first priority group. Among the 28 patients whose corners of the mouth constituted the top priority of surgical correction, the vertical inclination on the affected side significantly improved from 74.1 ± 7.6° to 55.5 ± 6.0°, and the horizontal angles were changed from 4.2 ± 2.7° to 2.0 ± 1.3° after selective neurectomy without statistically significant. Among the 32 patients for whom eyelid narrowing constituted the top priority, the mean eyelid narrowing score improved from 4.5 ± 1.1 to 1.5 ± 1.2.

CONCLUSIONS

Selective neurectomy can provide a significantly satisfactory outcome regarding facial tightness and eyelid aperture narrowing. The vertical inclination of the mouth corner can be significantly improved, while the improvement of horizontal angles can be suboptimal.

LEVEL OF EVIDENCE IV

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 .

An Unusual Case of Unilateral Marginal Mandibular Nerve Palsy Associated with Odontogenic Space Infection

Odontogenic space infections are common in dental practice, characterized by localized abscess formation with potential to spread to adjacent anatomical spaces. Neurogenic involvement in odontogenic infections is primarily found to be associated with sensory nerve branches, however involvement of motor nerves in odontogenic space infection leading to facial asymmetry has not been widely reported. In this case report, the authors present an unusual finding of facial asymmetry due to isolated marginal mandibular nerve weakness in a patient with a submandibular space infection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-023-02019-x.

Facial Function in Bell Palsy in a Cohort of Children Randomized to Prednisolone or Placebo 12 Months After Diagnosis

BACKGROUND

Information on the medium-term recovery of children with Bell palsy or acute idiopathic lower motor neuron facial paralysis is limited.

METHODS

We followed up children aged 6 months to <18 years with Bell palsy for 12 months after completion of a randomized trial on the use of prednisolone. We assessed facial function using the clinician-administered House-Brackmann scale and the modified parent-administered House-Brackmann scale.

RESULTS

One hundred eighty-seven children were randomized to prednisolone (n = 93) or placebo (n = 94). At six months, the proportion of patients who had recovered facial function based on the clinician-administered House-Brackmann scale was 98% (n = 78 of 80) in the prednisolone group and 93% (n = 76 of 82) in the placebo group. The proportion of patients who had recovered facial function based on the modified parent-administered House-Brackmann scale was 94% (n = 75 of 80) vs 89% (n = 72 of 81) at six months (OR 1.88; 95% CI 0.60, 5.86) and 96% (n = 75 of 78) vs 92% (n = 73 of 79) at 12 months (OR 3.12; 95% CI 0.61, 15.98).

CONCLUSIONS

Although the vast majority had complete recovery of facial function at six months, there were some children without full recovery of facial function at 12 months, regardless of prednisolone use.

'Precursory symptoms, awareness or progression of facial palsy' are more useful than 'forehead wrinkling ability' in differentiating central facial palsy examined in the emergency department

BACKGROUND

Forehead wrinkling ability has been considered to be the sign of the central facial palsy (CFP).

AIMS/OBJECTIVES

To identify characteristics of peripheral FP (PFP) patients in the emergency room (ER), differentiate PFP from central FP (CFP), and assess the utility of forehead wrinkling for this purpose.

MATERIALS AND METHODS

ER patients with FP were clinically split into PFP (72 patients) and CFP (161 patients) groups. Factors like age, sex, medical history, time from onset to consultation, symptom awareness or progression, precursory symptoms, forehead wrinkling, and imaging history were compared. Multivariate analysis differentiated PFP from CFP, examining misdiagnosis risks based on forehead wrinkling.

RESULTS

Precursory symptoms and symptom awareness or progression had the highest odds ratios. Some PFP patients could wrinkle their foreheads, typically examined within 1 day of symptoms. PFP patients had more same-day imaging than those assessed a day later.

CONCLUSIONS AND SIGNIFICANCE

Forehead wrinkling, a traditional CFP sign, is also common in early-stage PFP, decreasing its diagnostic reliability. Patients with solely CFP unable to wrinkle the forehead are very rare at a single institution. Evaluating precursors symptoms, and FP awareness and progression is crucial for differentiation.

Ocular-oral synkinesis caused by partial injury of the zygomatic and buccal branches of the facial nerve after mid-face trauma

BACKGROUND

Facial nerve paralysis induced by acute traumatic facial nerve injuries limited to the zygomatic and buccal branches shows unique complications, such as strong co-contractions of the lower facial muscles around the lips during voluntary blinking (ocular-oral synkinesis). We investigated the characteristics of facial complications after facial nerve injury in the mid-face area and reported the treatment results.

METHODS

A total of 21 patients with facial nerve injuries to the zygomatic and/or buccal branches were evaluated for the degree of facial synkinesis and mouth asymmetry. Patients with mild-to-moderate symptoms were treated using physical rehabilitation therapy combined with botulinum toxin (Botox) injection, and patients with severe or uncontrolled symptoms were treated using surgical therapy.

RESULTS

Initial/final mean synkinesis scores and mouth asymmetry degrees were 2.17/1.75 and 0.85/0.66 in the physical therapy group and 3.11/0.78 and 2.41/-0.31 in the surgery group, respectively. Physical therapy with Botox injection alone did not show significant improvements in synkinetic symptoms of the patients with mild-to-moderate synkinesis (p > 0.05), whereas surgical therapy resulted in significant improvements in synkinesis and mouth asymmetry (p < 0.05).

CONCLUSIONS

Surgical treatment is an effective adjustment procedure for the management of facial complications in patients with severe or uncontrolled synkinesis after facial nerve injury to the mid-face area.

Comparison of oral versus intravenous steroid in the management of Bell's palsy: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Bell's palsy is a condition affecting cranial nerve VII that results in acute peripheral unilateral facial weakness or paralysis of unclear etiology. Corticosteroids are the primary therapy choice, because they improve outcomes. According to a recent study, prednisolone effectively treats Bell's palsy in the short and long term. This study aimed to assess the effectiveness and safety of Single-Dose Intravenous Methylprednisolone to Oral Prednisolone in treating Bell's palsy patients.

METHODS

PRISMA statement guidelines were used to design and conduct this systemic review. MEDLINE, Cochrane Library, and EMBASE databases were used in our search. We conducted the database search in November 2022.

RESULTS

Thirty-three publications were reviewed as a result of the literature review. Three studies were included in the meta-analysis after applying our criteria. 317 Bell's palsy patients were included in our study. Regarding complete recovery to grade 1 in 1 month, IV methylprednisolone was higher than oral prednisolone; (log OR = 0.52, 95% CI [0.08, 0.97], P = 0.022). However, at 3 months, the two groups had no significant difference. Patients with grade 4 Bell's palsy were more likely to fully recover to grade 1 in 1 month with IV methylprednisolone than with oral prednisolone (log OR = 0.73, 95% CI [0.19, 1.26], P = 0.008), but not for patients with grade 3 or grade 2 Bell's palsy.

CONCLUSION

This study shows evidence that patients with Bell's palsy can fully recover to grade 1 in 1 month when IV methylprednisolone is used instead of oral prednisolone. At 3 months, however, there was no discernible difference between the two treatments. Within 3 days of the onset of symptoms, IV methylprednisolone treatment can be started, which may help patients recover fully to grade 1 in 1 month. However, administering IV methylprednisolone may not always have long-term advantages compared to oral prednisolone.

Pain in children with Bell's palsy: secondary analysis of a randomised controlled trial

OBJECTIVE

To describe the prevalence and severity of pain experienced by children with Bell's palsy over the first 6 months of illness and its association with the severity of facial paralysis.

METHODS

This was a secondary analysis of data obtained in a phase III, triple-blinded, randomised, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children aged 6 months to <18 years conducted between 13 October 2015 and 23 August 2020 in Australia and New Zealand. Children were recruited within 72 hours of symptom onset and pain was assessed using a child-rated visual analogue scale (VAS), a child-rated Faces Pain Score-Revised (FPS-R) and/or a parent-rated VAS at baseline, and at 1, 3 and 6 months until recovered, and are reported combined across treatment groups.

RESULTS

Data were available for 169 of the 187 children randomised from at least one study time point. Overall, 37% (62/169) of children reported any pain at least at one time point. The frequency of any pain reported using the child-rated VAS, child-rated FPS-R and parent-rated VAS was higher at the baseline assessment (30%, 23% and 27%, respectively) compared with 1-month (4%, 0% and 4%, respectively) and subsequent follow-up assessments. At all time points, the median pain score on all three scales was 0 (no pain).

CONCLUSIONS

Pain in children with Bell's palsy was infrequent and primarily occurred early in the disease course and in more severe disease. The intensity of pain, if it occurs, is very low throughout the clinical course of disease.

TRIAL REGISTRATION NUMBER

ACTRN12615000563561.

Association between Bell's Palsy and Cardiometabolic Risks: An Age- and Sex-Matched Case-Control Study

BACKGROUND

Bell's palsy is possibly an ischemic cranial neuropathy, although reactivation of herpes virus infection has been proposed.

METHODS

This was an age-and sex-matched and 1:2 case-control study enrolling Bell's palsy patients during 2011-2021 in a university hospital to investigate the significant associations of cardiometabolic risks (CMRs) with Bell's palsy. We analyzed the differences in waist circumference (WC), body mass index (BMI), systolic and diastolic blood pressures (SBP and DBP), fasting blood sugar (FBS), and lipid levels at 12 weeks post-Bell's palsy with those of the controls by descriptive statistics (p < 0.05). The differences in means or medians of individual CMR values across the consecutive 10-year age intervals were analyzed by ANOVA F-tests and Kruskal-Wallis tests (p < 0.05).

RESULTS

A total of 140 cases and 280 controls were enrolled. Bell's palsy patients had significantly higher WC, BMI, SBP, DBP, FBS, and triglyceride but lower high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Moreover, high WC, elevated FBS (≥100 mg/dL), SBP (≥130 mmHg), and total cholesterol were significantly associated with Bell's palsy cases by multivariable analysis. Only FBS in Bell's palsy patients significantly elevated across consecutive 10-year age intervals.

CONCLUSION

Screening and monitoring for CMRs, especially hyperglycemia, in every patient presenting with Bell's palsy is essential despite initial normoglycemia, particularly in older-onset cases.

Unraveling Bell's Palsy: Exploring HSV's Role and Facial Therapy's Impact on Aberrant Reinnervation and Synkinesis

Introduction

Bell's Palsy, a disorder characterized by the abrupt onset of facial paralysis, has a significant impact on individuals globally. The precise contribution of the Herpes Simplex Virus (HSV) to its aetiology remains uncertain. The present study investigates the correlation between Herpes Simplex Virus (HSV) and Bell's Palsy, as well as evaluates the effectiveness of specialized facial therapy in its treatment.

Methodology

A five-year longitudinal study was conducted at a tertiary care centre, with a sample of 100 patients diagnosed with Bell's Palsy, ranging in age from 18 to 65 years. The participants were divided into two groups: one receiving normal treatment and the other receiving specialized facial therapy. The assessments included HSV testing, the House-Brackmann scale for evaluating facial nerve function, the Facial Clinimetric Evaluation (FaCE) scale for assessing quality of life, and measures of patient satisfaction.

Findings

The findings of the study revealed evidence supporting a robust association between HSV and the severity of Bell's Palsy. Significantly, individuals who underwent specialized facial therapy exhibited significant enhancements in facial nerve function, a decrease in synkinesis episodes, and better scores suggesting improved quality of life compared to those who received standard care. Additionally, this particular cohort also confirmed a noteworthy rise in patient satisfaction.

Conclusion

This study indicates the potential association between HSV and Bell's Palsy while emphasizing the advantages of facial therapy. The above findings are of great significance; however, additional research is required in order to develop more precise ways of managing Bell's Palsy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04275-2.

Physical therapy for peripheral facial palsy: A systematic review and meta-analysis

OBJECTIVE

This study aimed to reveal the efficacy of physical therapy for patients with peripheral facial palsy.

METHODS

A literature search was conducted using PubMed, Ichushi-Web, and Cochrane Central Register of Controlled Trials. Published randomized controlled trials comparing the physical therapy versus placebo/non-treatment for peripheral facial palsy such as Bell's palsy, Ramsay Hunt syndrome, and traumatic facial palsy were included for meta-analysis. The primary outcome was non-recovery at the end of the follow-up. Non-recovery was defined according to the authors' definition. The secondary outcomes were the composite score of the Sunnybrook facial grading system and sequelae (presence of synkinesis or hemifacial spasm) at the end of the follow-up. Data was analyzed using Review Manager software and pooled risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) were calculated.

RESULTS

Seven randomized controlled trials met the eligible criteria. The data on non-recovery from four studies was obtained and included 418 participants in the meta-analysis. Physical therapy might reduce non-recovery (RR = 0.51 [95% CI = 0.31-0.83], low quality). Pooling the data of composite score of the Sunnybrook facial grading system from three studies (166 participants) revealed that physical therapy might increase the composite scores (MD = 12.1 [95% CI = 3.11-21.0], low quality). Moreover, we obtained data on sequelae from two articles (179 participants). The evidence was very uncertain about the effect of physical therapy on reduction of sequelae (RR = 0.64 [95% CI = 0.07-5.95], very low quality).

CONCLUSION

The evidence suggested that physical therapy reduces non-recovery in patients with peripheral facial palsy and improves the composite score of the Sunnybrook facial grading system, whereas the efficacy of physical therapy in reducing sequelae remained uncertain. The included studies had high risk of bias, imprecision, or inconsistency; therefore, the certainty of evidence was low or very low. Further well-designed randomized controlled trials are needed to confirm its efficacy.

Bell Palsy: Facts and Current Research Perspectives

Bell palsy is a non-progressive neurological condition characterized by the acute onset of ipsilateral seventh cranial nerve paralysis. People who suffer from this type of facial paralysis develop a droop on one side of their face, or sometimes both. This condition is distinguished by a sudden onset of facial paralysis accompanied by clinical features such as mild fever, postauricular pain, dysgeusia, hyperacusis, facial changes, and drooling or dry eyes. Epidemiological evidence suggests that 15 to 23 people per 100,000 are affected each year, with a recurrence rate of 12%. It could be caused by ischaemic compression of the seventh cranial nerve, which could be caused by viral inflammation. Pregnant women, people with diabetes, and people with respiratory infections are more likely to have facial paralysis than the general population. Immune, viral, and ischemic pathways are all thought to play a role in the development of Bell paralysis, but the exact cause is unknown. However, there is evidence that Bell's hereditary proclivity to cause paralysis is a public health issue that has a greater impact on patients and their families. Delay or untreated Bell paralysis may contribute to an increased risk of facial impairment, as well as a negative impact on the patient's quality of life. For management, antiviral agents such as acyclovir and valacyclovir, and steroid treatment are recommended. Thus, early diagnosis accompanied by treatment of the uncertain etiology of the disorder is crucial. This paper reviews mechanistic approaches, and emerging medical perspectives on recent developments that encounter Bell palsy disorder.

An ACS-NSQIP Data Analysis of 30-Day Outcomes Following Surgery for Bell's Palsy

BACKGROUND

There exists a paucity of large-scale, multi-institutional studies that investigate the outcomes of surgery for Bell's palsy (BP). Here, we utilize a large, multi-institutional database to study the risk factors and early-stage outcomes following surgical procedures in BP.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2019) to identify patients who underwent surgery for the diagnosis of BP. We extracted data on comorbidities and preoperative blood values, and 30-day postoperative outcomes.

RESULTS

Two hundred fifty-seven patients who underwent surgery for BP symptoms over the 12-year review period were identified. Muscle grafts (n=50; 19%) and fascial grafts (n=48; 19%) accounted for the majority of procedures. The most common comorbidities were hypertension (n=89; 35%) and obesity (n=79; 31%). Complications occurred in 26 (10.1%) cases. Additionally, length of hospital stay was significantly associated with both surgical and medical complications (3.9±4.7 versus 1.5±2.0; P <0.01) and (3.2±3.8 versus 1.4±2.0; P <0.01), respectively. Preoperative creatinine, blood urea nitrogen, and alkaline phosphatase were identified as potential predictors of poor postoperative outcomes.

CONCLUSION

Based on multi-institutional analysis, complication rates following surgery for BP were found to be overall low and seen to correlate with length of hospital stay. Reoperations and readmissions were the most frequent complications after surgery for BP. The preoperative evaluation of routine laboratory values may help refine patient eligibility and risk stratification. In addition, our findings call for future large-scale prospective studies in the field of facial palsy surgery to further improve the quality of care and optimize perioperative protocols.

Variations in the treatment of acute peripheral facial paralysis. A nationwide survey

BACKGROUND

Acute peripheral facial paralysis may be diagnosed and treated by different specialists.

OBJECTIVE

The aim of this study was to explore the variability in the treatment of Bell's palsy (BP) and Ramsay Hunt Syndrome (RHS) among different medical specialties.

METHODS

An anonymous nationwide online survey was distributed among the Spanish Societies of Otorhinolaryngology (ORL), Neurology (NRL) and Family and Community Medicine (GP).

RESULTS

1039 responses were obtained. 98% agreed on using corticosteroids, ORL using higher doses than NRL and GP. Among all, only 13% prescribed antivirals in BP routinely, while 31% prescribed them occasionally. The percentage of specialists not using antivirals for RHS was 5% of ORL, 11% of NRL, and 23% of GP (GP vs. NRL p = 0.001; GP vs. ORL p < 0.0001; NRL vs. ORL p = 0,002). 99% recommended eye care. Exercises as chewing gum or blowing balloons were prescribed by 45% of the participants with statistically significant differences among the three specialties (GP vs. NRL p = 0.021; GP vs. ORL p < 0.0001; NRL vs. ORL p = 0.002).

CONCLUSION

There is general agreement in the use of corticosteroids and recommending eye care as part of the treatment of acute peripheral facial paralysis. Yet, there are discrepancies in corticosteroids dosage, use of antivirals and recommendation of facial exercises among specialties.

Post-parotidectomy facial nerve rehabilitation outcomes: Comparison between benign and malignant neoplasms

BACKGROUND

Facial nerve dysfunction can be a devastating trouble for post-parotidectomy patients.

OBJECTIVE

To assess rehabilitation outcomes concerning patients with post-parotidectomy facial nerve dysfunction, comparing benign versus malignant neoplasms.

METHODS

Prospective study enrolling adults who underwent parotidectomy with facial nerve sparing between 2016 and 2020. The Modified Sunnybrook System (mS-FGS) was used for facial assessments. Physiotherapy began on the first post-operative day with a tailored program of facial exercises based on Neuromuscular Retraining, to be performed at home 3 times/day. From the first outpatient consultation, Proprioceptive Neuromuscular Facilitation was added to the treatment of cases with moderate or severe facial dysfunctions.

RESULTS

Benign and malignant groups had a statistically significant improvement in mS-FGS (p < 0.001 and p = 0.005, respectively). There was no significant difference between groups regarding treatment duration or number of physiotherapy sessions performed. The history of previous parotidectomy resulted in more severe initial dysfunctions and worse outcome. Age over 60 years and initially more severe dysfunctions impacted the outcome.

CONCLUSION

Patients with benign and malignant parotid neoplasms had significant and equivalent improvement in postoperative facial dysfunction following an early tailored physiotherapy program, with no significant difference in the final facial score, treatment duration, or number of sessions required.

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.

Optimal Bell's Palsy Treatment: Steroids, Antivirals, and a Timely and Personalized Approach

IMPORTANCE

The optimal treatment approach for patients with Bell's palsy, a condition characterized by acute facial nerve palsy, remains unclear. The present study was designed to provide insights into the most effective treatment strategies, whether steroids alone or steroids plus antiviral agents, as well as the optimal timing of treatment initiation.

OBJECTIVE

To investigate the impact of treatment modalities and timing on the recovery rates of Bell's palsy patients and to assess the roles of individual factors.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective analysis included 1504 patients with Bell's palsy who visited Kyung Hee University Hospital. Patients were divided based on the treatment modality (steroid monotherapy vs. combined steroid and antiviral therapy) and the timing of treatment initiation (≤72 vs. >72 h).

MAIN OUTCOMES AND MEASURES

The primary outcome was the recovery rate, as assessed by the House-Brackmann (HB) grade. Secondary outcomes included factors such as age, electroneurography (ENoG) and electromyography (EMG) results, and comorbid conditions.

RESULTS

A combined comparison of patients treated with steroids plus antivirals and steroids alone, stratified by treatment start time, showed that recovery rates were highest in patients who received steroid monotherapy initiated within 72 h (OR 2.36; p < 0.05). Patients with severe Bell's palsy tended to benefit more from combined therapy when treatment was initiated within 72 h. The recovery rate was higher in patients who received steroid monotherapy than combined therapy (86.32% vs. 79.25%, p < 0.05). Initiating treatment beyond 72 h was associated with a higher recovery rate than starting treatment within 72 h (85.69% vs. 76.92%, p < 0.05). An evaluation of the factors affecting recovery showed that patients aged 20 to 39 years had a higher recovery rate than other age groups (OR 1.47; p < 0.05). Fairly predictive EMG results were associated with significantly higher recovery rates (OR 3.52; p < 0.05).

CONCLUSIONS

These findings underscore the importance of individualized treatment approaches in Bell's palsy management. Steroid monotherapy remains effective, although combined treatment may have potential advantages, especially in patients with more severe disease. The best treatment results were achieved when steroid treatment was administered within 72 h. Our results suggest that there may be more flexibility in the application of the 72 h treatment period if we consider the time of treatment initiation alone, but this should take into account patient behavior patterns and the limitations of retrospective analysis. Further research is warranted to validate these findings and refine treatment recommendations for patients with Bell's palsy.

The Impact of Early Acupuncture on Bell's Palsy Recurrence: Real-World Evidence from Korea

Evidence-based treatment for Bell's palsy includes the administration of steroids within 3 days of symptom onset. Additionally, a few studies have suggested the importance of combining early acupuncture treatment in the acute phase of Bell's palsy with steroids. This study aimed to observe the impact of early acupuncture for Bell's palsy using real-world health insurance data in Korea. This retrospective study extracted data from 45,986 adult patients with Bell's palsy who received steroids between 2015 and 2017 with a follow-up period of at least 3 years until 2020 from the Korea National Health Insurance database. They were divided into the early acupuncture group (n = 28,267) and the comparison group (n = 17,719) based on the presence of an acupuncture treatment code within 7 days of diagnosis. The impact of early acupuncture on the likelihood of Bell's palsy recurrence was evaluated using multivariate logistic regression. The patients in the early acupuncture group had a lower likelihood of recurrence (odds ratio: 0.81, 95% confidence interval: 0.69-0.95). This study observed a beneficial impact of early acupuncture on Bell's palsy using real-world health insurance data in Korea. Further research is required to confirm these findings.

Electroneurography Values Based on Degree of Facial Muscle Contraction Response to Electroacupuncture in Patients with Peripheral Facial Nerve Palsy: A Retrospective Study

Objective

Japanese acupuncture practice cannot easily predict the prognosis of patients with peripheral facial palsy. Electroneurography (ENoG) predicts prognosis in patients with peripheral facial palsy; however, the difference between ENoG values and degree of facial muscle contraction response (FMCR) to electroacupuncture stimulation (ES) targeting the affected facial nerve is unexplored. Therefore, an exploratory evaluation of the differences in ENoG values was conducted across the degrees of FMCR induced by ES targeting the affected facial nerve in patients with peripheral facial nerve palsy.

Methods

In total, 90 patients with peripheral facial nerve palsy were selected who underwent acupuncture treatment at the Department of Oriental Medicine, Saitama Medical University Hospital, between January 2005 and December 2014. The FMCR degree and ENoG values were assessed through patients' medical records. The patients were divided into excellent, moderate, and noresponse groups (65, 16, and 9 patients, respectively) according to the FMCR degree. The differences in ENoG values were analyzed among the groups.

Results

The ENoG values were 26.6% (10.4%-55.9%), 2.45% (0.35%-8.80%), and 2.00% (0.00%-5.10%) for the excellent, moderate, and no-response groups, respectively. These values significantly differed between the excellent group and the no-response (P < 0.01) and moderate (P < 0.01) groups.

Conclusion

The ENoG values varied according to degree of FMCR induced by ES targeting the facial nerve in patients with peripheral facial nerve palsy. This might allow to predict the prognosis based on the ES-induced FMCR.

The Significance of Bell's Palsy That Presents as Monocranial Versus Polycranial Neuropathy: A Case Series and Systematic Literature Review

PURPOSE

To investigate the effect of Bell's palsy (BP) presenting as polycranial neuropathy (PCN) compared with BP caused by isolated facial nerve (CNVII).

METHODS

We carried out a retrospective cohort study of the medical records of all consecutive patients who were diagnosed with BP at a single tertiary referral center between 2010 and 2017. Included were patients 18 years or older who were clinically diagnosed with BP and completed 7 days of systemic steroidal treatment and at least 6 months of follow-up. The patients were divided into two groups according to whether the BP derived from a monocranial neuropathy or a PCN. Demographics and BP severity and outcome were compared between these groups. A systematic literature review using Medline via "PubMed," "Embase," and "Web of Science" was conducted.

RESULTS

In total, 321 patients with BP were enrolled. The median (interquartile range) age at presentation was 44 (33-60) years. Sex distribution showed male predominance of 57.6% (n = 185) versus 42.4% (n = 136), and 21.2% (n = 68) had PCN. The most concomitantly affected cranial nerve (CN) was the trigeminal (CNV; n = 32, 47%), followed by the glossopharyngeal nerve (CNIX; n = 14, 21%) and the audiovestibular nerve (CNVIII; n = 10, 15%). Age, House-Brackmann score on presentation, and diabetes mellitus (DM) were independent predictors for PCN etiology ( p = 0.001, p = 0.034, and p < 0.001, respectively). Each increase in 1 year of age was associated with additional odds ratio (95% confidence interval) of 0.97 (0.95-0.99) for PCN. The odds ratio (95% confidence interval) associated with DM was 8.19 (4.02-16.70). Our systematic literature review identified 1,440 patients with the PCN type of BP. The most commonly affected CN was the trigeminus (25-48%), followed by the glossopharyngeal and audiovestibular nerves (2-19% and 0-43%, respectively).

CONCLUSION

The severity of facial weakness on initial presentation among PCN patients was significantly higher compared with the monocranial neuropathy-type BP patients. The authors believe that the significant association and prevalence rate ratio between DM and PCN warrant that a patient presenting with PCN undergo screening for DM.

Boosting brain-computer interfaces with functional electrical stimulation: potential applications in people with locked-in syndrome

Individuals with a locked-in state live with severe whole-body paralysis that limits their ability to communicate with family and loved ones. Recent advances in brain-computer interface (BCI) technology have presented a potential alternative for these people to communicate by detecting neural activity associated with attempted hand or speech movements and translating the decoded intended movements to a control signal for a computer. A technique that could potentially enrich the communication capacity of BCIs is functional electrical stimulation (FES) of paralyzed limbs and face to restore body and facial movements of paralyzed individuals, allowing to add body language and facial expression to communication BCI utterances. Here, we review the current state of the art of existing BCI and FES work in people with paralysis of body and face and propose that a combined BCI-FES approach, which has already proved successful in several applications in stroke and spinal cord injury, can provide a novel promising mode of communication for locked-in individuals.