Bilateral facial palsy

Creation and Validation of the Facial Diplegia Scale for Assessment of Bilateral Facial Palsy

Objectives: House-Brackmann (HB) classification and the Sunnybrook Facial Grading System (SFGS), both reference tools for the assessment of facial palsy, are not suitable for bilateral facial palsy. The aim of this study was to develop, standardize, and validate the Facial Diplegia Scale (FDS). Methods: The FDS was standardized in a healthy population (n = 111) and validated in 40 patients with diplegia. Correlations with the SFGS were sought to prove its criterion validity. The comparison between healthy subjects and patients with diplegia was used to test the construct validity. The diagnostic performance of the FDS was verified using an ROC curve based on the HB classification. Internal and external consistency were investigated. Results: The FDS and the SFGS were significantly correlated for the right hemiface [F(39) = 51.51, p < 0.0001, R2 = 0.575] as well as for the left one [F(39) = 95.10, p < 0.0001, R2 = 0.714]. A significant difference between control subjects and patients with diplegia was found [t(149) = -9.95, p < 0.0001]. Good specificity and sensitivity were confirmed. Finally, internal consistency, inter-rater reliability, and test-retest reliability were largely proven. Conclusions: The FDS has been standardized and validated for the subjective assessment of facial diplegia in adults to improve comprehensive assessment.

Bilateral facial nerve palsy complicating Kawasaki disease: A case report and literature review

RATIONALE

Kawasaki disease (KD) manifests as an acute, self-limited vasculitis disease that constitutes the primary cause of acquired heart disease in children under 5 years of age. Facial nerve palsy (FNP) is a rare complication associated with coronary artery lesions (CALs) in patients with KD. Patients with KD and FNP usually present atypically, leading to a delayed diagnosis and treatment of KD.

PATIENT CONCERNS

A 4-month-old boy with fever, left FNP and bilateral conjunctival injection with spontaneous resolution, was admitted to the hospital, received a short course of intravenous dexamethasone, and experienced rapid FNP recovery on the first admission. The patient experienced a resurgence of fever, bilateral conjunctival injection, and right FNP, which led to readmission. Physical examination revealed redness at the site of Bacillus Calmette-Guérin inoculation, reddening of lips, and desquamation of the distal extremities. Echocardiography revealed right-sided CALs.

DIAGNOSES

The patient initially missed KD on the first admission, and was later diagnosed with complete KD with FNP on the second admission.

INTERVENTIONS AND OUTCOMES

After a short course of intravenous dexamethasone, the left FNP resolved quickly. However, right FNP recurred after corticosteroids withdrawal. Meanwhile, more typical symptoms were observed, and KD was diagnosed. Treatment ensued with intravenous immunoglobulin (IVIG), aspirin, and dexamethasone. The patient achieved rapid remission, without recurrence. Echocardiography continued to show normal findings during 1-year follow-up after discharge.

LESSONS

The clinical symptoms of FNP complicating KD in children are atypical and can easily lead to delayed diagnosis and treatment. FNP in patients with KD may serve as a risk factor for CALs, which are more challenging to resolve than the FNP itself. Adding corticosteroids to IVIG may be recommended to reduce IVIG resistance, decrease the risk of developing CALs, and alleviate CALs.

The Monocle Sign on 18 F-FDG PET Indicates Contralateral Peripheral Facial Nerve Palsy

BACKGROUND

The aim of our study was to retrospectively analyze FDG PET/CT data in patients with facial nerve palsy (FNP) for the presence of the monocle sign.

PATIENTS AND METHODS

A total of 85 patients with unilateral FNP were included into our study, thereof 73 with peripheral FNP and 12 with central FNP. FDG uptake (SUV max , SUV mean , total lesion glycolysis) was measured in both orbicularis oculi muscles (OOMs). FDG uptake of paretic and nonparetic muscles was compared in patients with FNP (Wilcoxon test and Mann-Whitney U test) and was also compared with FDG uptake in 33 patients without FNP (Mann-Whitney U test). SUV max ratios of OOM were compared. A receiver operating characteristic curve and Youden Index were used to determine the optimal cutoff SUV max ratio for the prevalence of contralateral peripheral FNP.

RESULTS

The SUV max ratio of OOM was significantly higher in patients with peripheral FNP compared with patients with central FNP and those without FNP (1.70 ± 0.94 vs 1.16 ± 0.09 vs 1.18 ± 0.21, respectively; P < 0.001). The SUV max ratio of OOM yielded an area under the curve (AUC) of 0.719 (95% confidence interval, 0.630-0.809), with an optimal cutoff of 1.41, yielding a specificity of 94.4% and a sensitivity of 44.1% for identifying contralateral peripheral FNP. One hundred percent specificity is achieved using a cutoff of 1.91 (sensitivity, 29.4%).

CONCLUSIONS

Asymmetrically increased FDG uptake of the OOM (the "monocle sign") indicates contralateral peripheral FNP. A nearly 2-fold higher SUV max represents a practically useful cutoff.

Uncommon Bilateral Idiopathic Facial Nerve Palsy (Bell's Palsy) in an Infant: An Atypical Age and Clinical Challenges Explored: A Case Report

Our case study explores Bell's palsy, a rare lower motor neuron facial nerve paralysis, particularly rare in newborns. While often idiopathic, it can stem from congenital or developmental factors. Unilateral facial paralysis is more prevalent, with Bell's palsy accounting for more than 50%, while bilateral facial paralysis is exceptionally rare. We present a distinctive case of idiopathic Bell palsy in a 3.5-month-old infant, initially affecting the right side and spontaneously resolved within 30 days, followed by involvement on the left side a month later. Despite comprehensive evaluations and treatment, persistent facial weakness was observed on the left side. The patient initially responded well but faced ongoing challenges during the second attack. Our findings underscore the need for further research to improve the understanding and management of these cases.

A Scoping Review of Otologic Manifestations of Hematologic Malignancies

OBJECTIVE

To examine the otologic and neurotologic symptoms, physical examination findings, and imaging features secondary to hematologic malignancies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases, including PubMed, Scopus, and CINAHL, were searched for articles including patients with otologic manifestations of leukemia, lymphoma and multiple myeloma. Data collected included patient and study demographics, specific hematologic malignancy, timing and classification of otologic symptoms, physical examination findings, imaging features and methods of diagnosis. Pooled descriptive analysis was performed.

RESULTS

Two hundred seventy-two articles, of which 255 (93.8%) were case reports and 17 (6.2%) were case series, reporting on 553 patients were identified. Otologic manifestations were reported on 307 patients with leukemia, 204 patients with lymphoma and 42 patients with multiple myeloma. Hearing loss and unilateral facial palsy were the most common presenting symptoms for 111 reported subjects with leukemia (n = 46, 41.4%; n = 43, 38.7%) and 90 with lymphoma (n = 38, 42.2%; n = 39, 43.3%). Hearing loss and otalgia were the most common presenting symptoms for 21 subjects with multiple myeloma (n = 10, 47.6%; n = 6, 28.6%). Hearing loss and unilateral facial palsy were the most common otologic symptoms indicative of relapse in subjects with leukemia (n = 14, 43.8%) and lymphoma (n = 5, 50%).

CONCLUSION

Hearing loss, facial palsy, and otalgia might be the first indication of a new diagnosis or relapse of leukemia, lymphoma, or multiple myeloma. Clinicians should have a heightened level of suspicion of malignant etiologies of otologic symptoms in patients with current or medical histories of these malignancies.

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

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

Chimeric Antigen Receptor-T Cell Mediated Bilateral Facial Nerve Palsy: A Case Report

Chimeric antigen receptor (CAR-T) cell therapy is highly effective against hematological cancers but is associated with immune mediated side effects, including neurotoxicity. The most commonly described presentations of immune cell mediated neurotoxicity syndrome (ICANS) include cortical symptoms and generally localize to the central nervous system. In this report, we present a patient with acute onset of bilateral facial nerve palsy following CAR-T cell therapy, followed by a complete clinical recovery. Aside from a temporary anisocoria, he had no other neurologic symptoms and no encephalopathy or seizures. MRI Brain was non-contributory and cerebrospinal fluid revealed a modest increase in lymphocytes without systemic leukocytosis and viral studies were all negative. He was diagnosed with bilateral facial nerve palsy secondary to CAR-T cell therapy and subsequently treated with a course of steroids. Several weeks after presentation he returned to his neurological baseline. The presentation of CAR-T cell mediated facial nerve palsy is both clinically and scientifically relevant for physicians, patients, and researchers.

Bilateral peripheric facial nerve palsy following SARS-CoV-2 infection: A case report and review of literature

Neurologic complications of SARS-CoV-2 infection have been reported commonly. Peripheric facial nerve palsy is one of the most reported neurologic problems. However, idiopathic bilateral facial palsy is a very rare complication of SARS-CoV-2 infection. Herein, we present a case of a COVID-19 35-year-old man, which developed bilateral facial palsy.

Spontaneous Bilateral Facial Paralysis Secondary to Metastatic Breast Cancer

Sudden onset, bilateral facial paralysis is a rare clinical entity, representing less than 2% of all diagnoses of facial nerve paralysis. The differential for these patients is necessarily broad and includes numerous etiologies. Metastatic breast carcinoma to the bilateral parotid glands is also exceedingly rare with only 2 reported case reports noted in the literature, neither of which demonstrated facial nerve paralysis. Here, we report the only known occurrence of a patient presenting with synchronous bilateral facial nerve paralysis secondary to metastatic breast carcinoma to the bilateral parotid glands. This exceedingly rare clinical presentation was further confounded by the presence of autoimmune antibodies, highlighting the importance of the diagnostic process and maintaining broad clinical suspicion.

Bilateral peripheral facial palsy: A rare case report

Peripheral facial palsy (PFP) is an inflammation of the facial nerve, which paralyses the face unilaterally or bilaterally, causing pain and discomfort to the patient. PFP affects the lives of compromised individuals not only due to the loss of essential facial functions (smiling, blinking, talking) but also their emotional state. When the face is paralysed, the lost ability to animate the face can be devastating and is often associated with depression, social isolation, and reduced quality of life. Bilateral involvement is extremely rare and as it occurs in unilateral cases, a thorough clinical and laboratory evaluation must be carried out to determine the etiology of the disease, which can be idiopathic, infectious, neoplastic, traumatic, or iatrogenic. In addition to these, in times of the pandemic, coronavirus disease 2019 (COVID-19) and the vaccine against it should be considered as possible causal factors. Drug therapy and physiotherapy are indicated to recover facial movements. The aim of the present study was to report a case of bilateral peripheral facial palsy due to herpes simplex virus reactivation in a 20-year-old female patient.

Newly Prepared 129Xe Nanoprobe-Based Functional Magnetic Resonance Imaging to Evaluate the Efficacy of Acupuncture on Intractable Peripheral Facial Paralysis

This study focused on the application value of the newly prepared 129Xe nanoprobe-based functional magnetic resonance imaging (fMRI) in exploring the mechanism of the acupuncture treatment for intractable facial paralysis, expected to provide a theoretical reference for the mechanism of acupuncture for the treatment of facial paralysis. In this study, 30 patients with intractable peripheral facial paralysis (experimental group) and 30 healthy volunteers (control group) were selected. All patients were scanned by the newly prepared 129Xe nanoprobe-based fMRI technology, and then brain functional status data and rating data were collected. fMRI scanning results showed that multiple brain regions were activated in the experimental group before treatment, among which the central posterior brain, insula, and thalamus were positively activated, while the precuneus, superior frontal gyrus, and other parts showed signal reduction. After treatment, several brain regions also showed signal enhancement. Comparisons within the healthy control group also showed activation in multiple brain regions, including the lenticular nucleus, inferior frontal gyrus, and superior temporal gyrus, while in the experimental group, no signal changes were detected in these brain regions. At the same time, comparison of fMRI images of patients with intractable peripheral facial paralysis before and after treatment showed that the cerebellar amygdala, superior frontal gyrus, cerebellar mountaintop, and other brain areas were activated, and all showed positive activation. After treatment, the average House–Brackmann (H-B) and Sunnybrook scores of the experimental group were 3.82 and 51, respectively, and the change was significant compared with that before treatment (P < 0.05). In conclusion, the newly prepared 129Xe nanoprobe-based fMRI scan can reflect the functional changes of cerebral cortex after acupuncture. The acupuncture treatment may achieve its therapeutic effect by promoting the functional reorganization of the cerebral cortex in the treatment of intractable facial paralysis.

Bilateral Facial Nerve Palsy and COVID-19 Vaccination: Causation or Coincidence?

Bell's palsy is a mononeuropathy of the facial nerve that typically causes unilateral facial paralysis. The incidence of unilateral Bell's palsy is not uncommon, but sequential or simultaneous bilateral Bell's palsy is exceedingly rare. While unilateral Bell's palsy is oftentimes idiopathic, bilateral Bell's palsy is almost exclusively explained by an identifiable trigger. In pre-clinical trials, Bell's palsy cases were recorded at higher rates in the vaccine cohort than the placebo cohort. Herein, we present a case of isolated sequential bilateral Bell's palsy that after an extensive workup, proved to be idiopathic. Notably, in the setting of a recent coronavirus disease 2019 (COVID-19) vaccine and absence of identifiable etiology, our case highlights a potential correlation of the COVID-19 vaccine and bilateral Bell's palsy.

Miller-Fisher Syndrome Presenting as Facial Diplegia With COVID-19 Co-Infection

Coronavirus disease 2019 (COVID-19) has reportedly been associated with various neurological manifestations, including unilateral facial palsy and, very rarely, facial diplegia. We present a unique case of Miller-Fisher Syndrome (MFS), a variant of Guillain-Barré Syndrome (GBS) that was noted in conjunction with a COVID-19 infection. In this case, a patient presented with bilateral facial palsy, dysarthria, right-sided hemiparesis, ataxia, and the confirmation of SARS-CoV-2 infection. His computed tomography (CT) scan of the brain and serology test results did not support alternate etiologies for facial palsy. His cerebrospinal fluid (CSF) studies demonstrated albuminocytologic dissociation, which was consistent with the diagnosis of MFS and further supported by his ataxia and ophthalmoplegia. A five-day course of intravenous immunoglobulin (IVIG) therapy combined with physical, occupational, and speech therapy improved his recovery.

Bilateral Facial Palsy: A Clinical Approach

Bilateral facial palsy (BFP) is exceedingly rare, representing only 0.3%-2.0% of facial palsy cases. Unlike unilateral facial palsy, it is often caused by a serious underlying systemic disease and therefore warrants urgent medical intervention. The differential diagnosis is broad, and detailed history, physical examination, and investigations are essential for identifying the etiology. Common acquired causes in existing case series include Lyme disease, Guillain-Barré syndrome, sarcoidosis, trauma, and Bell’s palsy. Palsy that develops rapidly is often caused by trauma, infections, or autoimmune disorders, whereas slow progressive palsy suggests neoplastic diseases. While management varies by etiology, the physician can consider early empiric corticosteroids given their efficacy in numerous differential diagnoses. Antivirals can be considered in those with a strong history of viral prodrome. In this paper, we present the case of a puerperal patient with BFP and discuss its differential diagnosis, diagnostic approach, and management.