Comparison of facial nerve paralysis in adults and children

The Effectiveness of Facial Neuromuscular Retraining on Patients with Facial Nerve Dysfunction: A Mental Health and Quality of Life Analysis

Background: Facial muscle dysfunction can have drastic psychosocial effects. Objectives: To evaluate the impacts of customized neuromuscular retraining on mental health, quality of life (QoL), facial muscle function, and synkinesis. Methods: Thirty patients with facial nerve dysfunction completed a course of neuromuscular retraining. Patients' mental health, QoL, facial muscle function, and synkinesis were evaluated using Patient Health Questionnaire (PHQ-9), Facial Clinimetric Evaluation (FaCE) scale, electronic, clinician-graded facial function scale (eFACE), and Synkinesis Assessment Questionnaire (SAQ) at the initial and final visits. Scores were compared before and after treatment. Results: Patients (n = 30) included had a mean age of 59.4 ± 13.4 years (range 32.3-82.8) and were mostly female (22/30, 73.3%). The most common etiology was Iatrogenic facial nerve paralysis (11/20, 36.7%). Most patients had postfacial paralysis synkinesis (15/30, 50%), while 10 had complete flaccid paralysis. The median house-Brackmann score was 2 (range 1-6). The mean duration of facial palsy was 39.5 ± 106.9 (range 1-576 months). The duration of follow-up after the initial treatment session was 5.5 months, including 10 sessions. After neuromuscular retraining median PHQ-9 scores improved from 5 (range 0-25) to 3 (range 0-20) (p = 0.002). Mean FaCE PROM scores increased from 47.7 ± 11.5 to 56.5 ± 8.8 (p = 0.001). The mean eFACE score increased from 55.8 ± 15.1 to 71.7 ± 13.6 (p < 0.001). Median SAQ score was lower at the final visit (34.6 ± 13.4) compared to the initial visit (47.7 ± 17.8; p < 0.001). Conclusion: Customized neuromuscular retraining may improve patient-reported mental health, QoL, and facial muscle function and reduce synkinesis in facial nerve dysfunction.

Facial Nerve Pathology in Children

Facial nerve pathology in children has devastating functional and psychosocial consequences. Facial palsy occurs less commonly in children than adults with a greater proportion caused by congenital causes. Most pediatric patients have normal life expectancy and few comorbidities and dynamic restoration of facial expression is prioritized. This article will focus on the unique aspects of care for facial palsy in the pediatric population.

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.

Predictors of Recovery in Facial Nerve Palsy: Insights From an Observational Study in Odisha, India

Background Facial nerve paralysis, leading to the loss of facial expression, poses significant discomfort to patients. While most individuals exhibit a favorable response to treatment, a subset experiences enduring facial deformities without clearly defined etiology. This study aimed to identify prognostic factors influencing outcomes and quality of life in facial nerve palsy patients, contributing to enhanced clinical management. Methods A prospective observational study was conducted in the Otorhinolaryngology Department of Maharaja Krishna Chandra Gajapati Medical College and Hospital, a tertiary care hospital. We included patients presenting with any clinical variety of facial nerve palsy, irrespective of age and gender. Only moribund and noncompliant cases were excluded. Patients underwent clinical assessment using the House-Brackmann (HB) grading at presentation and were subsequently monitored at three weeks, three months, and six months post-onset to assess recovery. Results Out of 66 patients, 18 (27.27%) fully recovered at three weeks, 50 (75.76%) recovered at three months, and 54 (81.82%) at six-month follow-up. Incomplete recovery was observed in 13 (19.69%) patients. Factors associated with favorable outcomes included younger age of onset (p = 0.003), lower baseline HB grade (IV or less) (p = 0.001), Electroneurography Degeneration Index (ENoG DI) of <70% (p < 0.0001), early initiation of treatment (within five days of onset) (p = 0.0003), and absence of comorbid conditions (p = 0.03). Gender and affected side (left or right) did not influence the outcome. Conclusion In summary, age, associated comorbid conditions, baseline HB grade, and extent of facial nerve degeneration are crucial predictors of outcomes in facial nerve palsy. This knowledge can guide clinicians in optimizing treatment strategies for improved patient care.

Complications After Pediatric Temporal Bone Fractures by Classification System: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze the rates of complications after pediatric temporal bone fractures (TBF) and the utility of the longitudinal, transverse, and mixed versus the otic capsule sparing (OCS) and otic capsule violating (OCV) classification systems in predicting these complications.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per PRISMA guidelines, studies of children with TBFs were included. Meta-analyses of proportions were performed.

RESULTS

A total of 22 studies with 1376 TBFs were included. Children with TBF had higher rates of conductive hearing loss (CHL) than sensorineural hearing loss (SNHL) (31.3% [95% confidence interval [CI] 23.2-40.1] vs 12.9% [95% CI 8.9-17.5]). No differences in both CHL and SNHL were seen between longitudinal and transverse TBFs; however, OCV TBFs had higher rates of SNHL than OCS TBFs (59.3% [95% CI 27.8-87.0] vs 4.9% [95% CI 1.5-10.1]). Of all patients, 9.9% [95% CI 7.2-13.1] experienced facial nerve (FN) paresis/paralysis, and 13.4% [95% CI 5.9-23.2] experienced cerebrospinal fluid otorrhea. Transverse TBFs had higher rates of FN paresis/paralysis than longitudinal (27.7% [95% CI 17.4-40.0] vs 8.6% [95% CI 5.2-12.8]), but rates were similar between OCS and OCV TBFs.

CONCLUSION

CHL was the most common complication after TBF in children; however, neither classification system was superior in identifying CHL. The traditional system was more effective at identifying FN injuries, and the new system was more robust at identifying SNHL. While these results suggest that both classification systems might have utility in evaluating pediatric TBFs, these analyses were limited by sample size. Future research on outcomes of pediatric TBFs stratified by type of fracture, mainly focusing on long-term outcomes, is needed.

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.

Cross-species Blink Characterisation Tool for the Analysis of Emerging Interventions for Overcoming Facial Paralysis

The loss of the ability to blink is considered the most severe consequence of facial nerve paralysis. Surgical techniques and implantable technologies continue to be developed to reanimate the eye; however, few analyse the full movement of blink when evaluating success. Here, we describe a method of taking high-quality, and high-speed video recordings of the eye, to non-invasively extract meaningful data about the dynamic movement of blinking. This can then be used to assess the effectiveness of a new technology in mimicking the natural movement. The tool was validated on humans (N=2, authors) before testing on an ovine recording (N=1), to confirm the cross-species utility of the tool, for use during preclinical development of technologies. It was found to be accurate and comprehensive, able to give insights on blinking in both human and ovine cases.

Characteristics of facial nerve palsy in 112 children and risk factors for ocular complications

PURPOSE

To report the ophthalmic findings and ocular complications in a large cohort of pediatric patients with facial nerve palsy (FNP).

METHODS

Ocular data of children (≤16 years of age) diagnosed with FNP presenting to an eye care network from 2012 to 2021 were analyzed. Study parameters were etiology of FNP, ocular and imaging findings, degree of lagophthalmos, and degree of vision loss. Clinical characteristics were compared between those with and without moderate-to-severe vision impairment (best-corrected visual acuity <20/50) and those with and without exposure keratopathy at presentation.

RESULTS

A total of 112 patients were included. Mean age at presentation was 8.3 ± 5.0 years. The most common etiology was idiopathic (57%) followed by congenital (22.3%) and traumatic (13.4%). There was bilateral involvement in 8% of children, multiple cranial nerve involvement in 15.2%, and exposure keratopathy at presentation in 38.4%. One-fifth (20.5%) of children (29.6% of affected eyes with known visual acuity) had moderate-to-severe visual impairment. Multiple cranial nerve involvement was present in 31% of eyes with visual impairment compared with 14% of those without. Corneal scarring and strabismic amblyopia were both frequent causes of visual impairment. Most children with exposure keratopathy had lagophthalmos (76.6%), whereas it was less common in those without keratopathy (49.2%).

CONCLUSIONS

Pediatric FNP was most commonly idiopathic, secondarily congenital. Strabismic amblyopia and corneal scarring were the most common causes of visual impairment in our cohort.

Late Recovery of Parathyroid Function after Total Thyroidectomy in Children and Adults: Is There a Difference?

BACKGROUND

Parathyroid failure after total thyroidectomy is the commonest adverse event amongst both children and adults. The phenomenon of late recovery of parathyroid function, especially in young patients with persistent hypoparathyroidism, is not well understood. This study investigated differences in rates of parathyroid recovery in children and adults and factors influencing this.

METHODS

A joint dual-centre database of patients who underwent a total thyroidectomy between 1998 and 2018 was searched for patients with persistent hypoparathyroidism, defined as dependence on oral calcium and vitamin D supplementation at 6 months. Demographic, surgical, pathological, and biochemical data were collected and analysed. <F00_Regular>Parathyroid Glands Remaining</F00_Regular> in Situ (PGRIS) score was calculated.

RESULTS

Out of 960 patients who had total thyroidectomy, 94 (9.8%) had persistent hypoparathyroidism at 6 months, 23 (24.5%) children with a median [range] age 10 [0-17], and 71 (75.5%) adults aged 55 [25-82] years, respectively. Both groups were comparable regarding sex, indication, extent of surgery, and PGRIS score. After a median follow-up of 20 months, the parathyroid recovery rate was identical for children and adults (11 [47.8%] vs. 34 [47.9%]; p = 0.92). Sex, extent, and indication for surgery had no effect on recovery (all p > 0.05). PGRIS score = 4 (HR = 0.48) and serum calcium >2.25 mmol/L (HR = 0.24) at 1 month were associated with a decreased risk of persistent hypoparathyroidism on multivariate analysis (p < 0.05).

CONCLUSION

Almost half of patients recovered from persistent hypoparathyroidism after 6 months; therefore, the term persistent instead of permanent hypoparathyroidism should be used. Recovery rates of parathyroid function in children and adults were similar. Regardless of age, predictive factors for recovery were PGRIS score = 4 and a serum calcium >2.25 mmol/L at 1 month.

An unusual case of facial nerve palsy due to minor face trauma: A rare case report

There can be various causes of facial palsy, and sometimes the cause remains unidentified (Bell’s palsy). Among the various causes of facial palsy, trauma is a major one. Depending on the severity of paralysis, traumatic facial palsy can be medically managed using corticosteroid and eye care or with surgical decompression. In selective cases with incomplete facial palsy, radio-imaging studies may not always be required. We present the case of a 13-year-old boy who presented to the primary-level hospital with a complaint of facial palsy following minor trauma to the face (slapped over the face by a friend). His Sunnybrook Score was 63/100. We managed him with prednisolone (1 mg/kg/day) for 2 weeks and then tapered, and with eye care with artificial tears for 6 weeks. There was a complete resolution of symptoms in 6 weeks. Incomplete facial paralysis due to trauma to the face can be managed medically with corticosteroids and proper eye care with artificial tears.

Evaluation of Clinical Outcome in Traumatic Facial Nerve Paralysis

Introduction  The facial nerve is the most commonly paralyzed nerve in the human body, resulting in far-reaching functional, aesthetic and emotional concerns to the patient.

Objective  Evaluation of the clinical outcome of 47 patients with traumatic facial nerve paralyses, with respect to clinical recovery and audiological sequelae.

Methods  A descriptive longitudinal study was conducted over 24 months between January 2017 and December 2018 at a tertiary center with detailed clinical, topodiagnostic, audiometric and radiological evaluation and regular follow-up after discharge.

Results  Road traffic accidents constituted 82.98% of the trauma cases, out of which 76.60% were found to be under the influence of alcohol.

Delayed facial paralysis was observed in 76.60% cases. Temporal bone fracture was reported in 89.36%, with otic capsule (OC) sparing fractures forming 91.49% of the cases. Topologically, the injury was mostly at the suprachordal region around the second genu. The majority of the patients (65%) attained full recovery of facial nerve function with conservative medical management. Audiometrically, 77.27% of the patients had hearing loss at the time of presentation, of which 64.71% were conductive in nature; 51.22% attained normal hearing at follow-up visits.

Conclusion  Early initiation of steroid therapy, concurrent eye care and physiotherapy are the cornerstones in the management of traumatic facial nerve paralysis.

Deletion of CD38 and supplementation of NAD+ attenuate axon degeneration in a mouse facial nerve axotomy model

Following facial nerve axotomy, nerve function is not fully restored even after reconstruction. This may be attributed to axon degeneration/neuronal death and sustained neuroinflammation. CD38 is an enzyme that catalyses the hydrolysis of nicotinamide adenine dinucleotide (NAD+) and is a candidate molecule for regulating neurodegeneration and neuroinflammation. In this study, we analyzed the effect of CD38 deletion and NAD+ supplementation on neuronal death and glial activation in the facial nucleus in the brain stem, and on axon degeneration and immune cell infiltration in the distal portion of the facial nerve after axotomy in mice. Compared with wild-type mice, CD38 knockout (KO) mice showed reduced microglial activation in the facial nucleus, whereas the levels of neuronal death were not significantly different. In contrast, the axon degeneration and demyelination were delayed, and macrophage accumulation was reduced in the facial nerve of CD38 KO mice after axotomy. Supplementation of NAD+ with nicotinamide riboside slowed the axon degeneration and demyelination, although it did not alter the level of macrophage infiltration after axotomy. These results suggest that CD38 deletion and supplementation of NAD+ may protect transected axon cell-autonomously after facial nerve axotomy.

Deletion of CD38 and supplementation of NAD+ attenuate axon degeneration in a mouse facial nerve axotomy model

Following facial nerve axotomy, nerve function is not fully restored even after reconstruction. This may be attributed to axon degeneration/neuronal death and sustained neuroinflammation. CD38 is an enzyme that catalyses the hydrolysis of nicotinamide adenine dinucleotide (NAD⁺) and is a candidate molecule for regulating neurodegeneration and neuroinflammation. In this study, we analyzed the effect of CD38 deletion and NAD⁺ supplementation on neuronal death and glial activation in the facial nucleus in the brain stem, and on axon degeneration and immune cell infiltration in the distal portion of the facial nerve after axotomy in mice. Compared with wild-type mice, CD38 knockout (KO) mice showed reduced microglial activation in the facial nucleus, whereas the levels of neuronal death were not significantly different. In contrast, the axon degeneration and demyelination were delayed, and macrophage accumulation was reduced in the facial nerve of CD38 KO mice after axotomy. Supplementation of NAD⁺ with nicotinamide riboside slowed the axon degeneration and demyelination, although it did not alter the level of macrophage infiltration after axotomy. These results suggest that CD38 deletion and supplementation of NAD⁺ may protect transected axon cell-autonomously after facial nerve axotomy.

Unusual Mechanism of Facial Nerve Palsy Caused by Penetrating Neck Trauma

We present a case of a low energy penetrating neck injury with only facial nerve (FN) palsy in the clinical finding. A 32-year-old male patient was admitted to the emergency department with a penetrating injury on the right side of the neck just behind the right ear, accompanied by evident right (FN) palsy, evaluated as House Brackmann grade IV. Computed tomography demonstrated an isolated soft tissue injury in the right retroauricular region without bone fracture, parotid gland lesion, or vascular structure involvement. The FN palsy was treated with corticosteroids (CS), and the patient had an uneventful and complete recovery. This case report presents an unusual mechanism of isolated, extratemporal, blunt injury of the FN after a penetrating neck injury followed by complete recovery.

Factors Associated With Fast Recovery of Bell Palsy in Children

The purpose of this study was to identify the clinical characteristics and factors affecting the prognosis of children with Bell palsy. We retrospectively reviewed the medical records of 53 pediatric patients diagnosed with Bell palsy. After a mean follow-up period of 30 days, 30 patients (56%) were completely recovered, 21 patients (40%) were partially recovered, and 2 patients (4%) had not recovered. The patients in the complete recovery group were significantly younger than those in the partial and nonrecovery groups (8.8 ± 4.2 years vs 12.2 ± 3.0 years, P = .003). Patients <8 years old had a higher complete recovery rate than was found in patients >8 years old (80% vs 47%, P = .031). Sex, affected side, and early or late treatment did not influence the recovery rate. These results suggest that younger age may be a good prognostic factor affecting the fast recovery of children with Bell palsy.

Facial nerve palsy in children: A retrospective study of 124 cases

AIM

To report the causes and clinical evaluation of children with facial nerve palsy (FNP) admitted to an affiliated university hospital during a 5-year period (2011-2015).

METHODS

A total of 124 children were retrospectively categorised into two groups: idiopathic Bell's palsy (109 patients) and the second group into other FNP aetiologies (15 patients). All children received a standardised work-up and follow-up. Therapy consisted of steroid administration associated with antiviral treatment when a viral infection was suspected.

RESULTS

All children of the first group had a full recovery under oral steroids within 2 months of treatment. From the second group, seven children (46%) had a viral infection based on serological findings, two of them were positive for neurotropic herpes viruses, and one had Ramsay Hunt syndrome; six children with infectious FNP had recurrent FNP on the ipsilateral or contralateral side. Five patients had FNP as a complication of acute otitis media; three of them (60%) had partial or full recovery postoperatively. One child developed FNP following temporal bone trauma that had an uneventful recovery with conservative treatment. One child suffered from Melkersson-Rosenthal syndrome, and another child presented with FNP associated with unilateral hemiparesis following an ischaemic cerebral infarct.

CONCLUSIONS

Facial palsy in children is a manifestation of a heterogeneous group of causes. The most common aetiology of FNP in children in our study was idiopathic (Bell's palsy), followed by infective causes, such as acute otitis media and neurotropic herpes viruses. Therefore, treatment should be adapted to each patient depending on the underlying disease and severity of FNP.

Medical Management of Acute Facial Paralysis

Acute facial paralysis (FP) describes acute onset of partial or complete weakness of the facial muscles innervated by the facial nerve. Acute FP occurs within a few hours to days. The differential diagnosis is broad; however, the most common cause is viral-associated Bell Palsy. A comprehensive history and physical examination are essential in arriving at a diagnosis. Medical treatment for acute FP depends on the specific diagnosis; however, corticosteroids and antiviral medications are the cornerstone of therapy. Lack of recovery after 4 months should prompt further diagnostic workup.

Profile of facial palsy in Arar, northern Saudi Arabia

Background

The term facial palsy generally refers to weakness of the facial muscles, mainly resulting from temporary or permanent damage to the facial nerve. Common causes of facial paralysis include infection or inflammation of the facial nerve, head trauma, head or neck tumor, stroke.

Objective

To outline the incidence of several etiologies and the profile of patients with peripheral facial paralysis attending the outpatient clinic of the neurology department in Hospitals of Arar City, Saudi Arabia.

Methods

This cross-sectional study was carried out in Arar city from October 2016 to May 2017. The study was conducted in the outpatient clinic of the neurology department in hospitals of Arar City. Any ages of both sexes of all newly diagnosed unilateral facial palsy were included in the study. Data were analyzed by SPSS version 15, using descriptive statistics and Chi-square test. P-value was considered significant if <0.05

Results

The mean age of the facial palsy cases was 33.65 (±11.71) years. Among the studied participants, the total prevalence of facial palsy was 26.3% (61% females and 39% males). The right side of the face was affected in 51.2% and the etiology was exposure to cold air current in 92.7% of cases. The treatment was physiotherapy in 80.5% of the cases, medical in 17.1% and surgical in 2.4%. There was significant relationship between smoking and the occurrence of facial palsy (p<0.05).

Conclusion

The study revealed that facial palsy was common in Arar city. The rate is higher among males than females. We also concluded that exposure to cold air current was the main etiology. We recommend health education sittings to bring awareness to the public about the nature, causes, risk factors, prevention and treatment of the disease.

An Anatomical study for localisation of Zygomatic branch of Facial nerve and Masseteric nerve - An aid to nerve coaptation for facial reanimation surgery: A cadaver based study in Eastern India

CONTEXT

In cases of chronic facial palsy, where direct neurotisation is possible, ipsilateral masseteric nerve is a very suitable motor donor. We have tried to specifically locate the masseteric nerve for this purpose.

AIMS

Describing an approach of localisation and exposure of both the zygomatic branch of Facial nerve and the nerve to masseter, with respect to a soft tissue reference point over face.

SETTINGS AND DESIGN

Observational cross sectional study, conducted on 12 fresh cadavers.

SUBJECTS AND METHODS

A curved incision was given, passing about 0.5cms in front of the tragal cartilage. A reference point "R" was pointed out. The zygomatic branch of facial nerve and masseteric nerve were dissected out and their specific locations were recorded from fixed reference points with help of copper wire and slide callipers.

STATISTICAL ANALYSIS USED

Central Tendency measurements and Unpaired "t" test.

RESULTS

Zygomatic branch of the Facial nerve was located within a small circular area of radius 1 cm, the centre of which lies at a distance of 1.1 cms (±0.4cm) in males and 0.2cm (±0.1cm) in females from the point, 'R', in a vertical (coronal) plane. The nerve to masseter was noted to lie within a circular area of 1 cm radius, the centre of which was at a distance of 2.5cms (±0.4cm) and 1.7cms (±0.2cm) from R, in male and female cadavers, respectively. Finally, Masseteric nerve's depth, from the masseteric surface was found to be 1cm (±0.1cm; male) and 0.8cm (±0.1cm; female).

CONCLUSIONS

This novel approach can reduce the post operative cosmetic morbidity and per-operative complications of facial reanimation surgery.

Cranial Nerve Disorders in Children: MR Imaging Findings

Cranial nerve disorders are uncommon disease conditions encountered in pediatric patients, and can be categorized as congenital, inflammatory, traumatic, or tumorous conditions that involve the cranial nerve itself or propagation of the disorder from adjacent organs. However, determination of the normal course, as well as abnormalities, of cranial nerves in pediatric patients is challenging because of the small caliber of the cranial nerve, as well as the small intracranial and skull base structures. With the help of recently developed magnetic resonance (MR) imaging techniques that provide higher spatial resolution and fast imaging techniques including three-dimensional MR images with or without the use of gadolinium contrast agent, radiologists can more easily diagnose disease conditions that involve the small cranial nerves, such as the oculomotor, abducens, facial, and hypoglossal nerves, as well as normal radiologic anatomy, even in very young children. If cranial nerve involvement is suspected, careful evaluation of the cranial nerves should include specific MR imaging protocols. Localization is an important consideration in cranial nerve imaging, and should cover entire pathways and target organs as much as possible. Therefore, radiologists should be familiar not only with the various diseases that cause cranial nerve dysfunction, and the entire course of each cranial nerve including the intra-axial nuclei and fibers, but also the technical considerations for optimal imaging of pediatric cranial nerves. In this article, we briefly review normal cranial nerve anatomy and imaging findings of various pediatric cranial nerve dysfunctions, as well as the technical considerations of pediatric cranial nerve imaging. Online supplemental material is available for this article. (©)RSNA, 2016.

Prevalence and associated factors of facial palsy and lifestyle characteristics: data from the Korean National Health and Nutrition Examination Survey 2010-2012

OBJECTIVES

To report the nationwide prevalence of facial palsy (FP) of grade III or worse in the House-Brackmann (H-B) grading system in South Korea and assess the associated factors.

DESIGN

Cross-sectional analysis of a nationwide health survey.

SETTINGS

South Korea.

METHODS

We obtained data from the 2010 to 2012 Korea National Health and Nutrition Examination Surveys, which were cross-sectional surveys of the South Korean civilian population living in households and aged ≥1 year (N=23 533). A field survey team performed interviews, physical examinations and laboratory tests. Facial expression was evaluated based on the H-B grading system.

RESULTS

Among the population aged ≥1 year, the prevalence of FP of grade III or worse in the H-B grading system was 0.12% (95% CI 0.07% to 0.17%). FP was more prevalent in women (p=0.01) and the prevalence rate increased with age (p<0.001). In participants aged ≥19 years, age, female gender, history of cardiovascular disease and the serum total cholesterol level were associated with FP in a multivariable analysis. In the evaluation of lifestyle, the individuals with FP had a higher rate of depressive mood and were more restricted in their daily activities.

CONCLUSIONS

Considering the significance of facial expression in psychosocial activities, public acknowledgement and further intervention are required to support patients with this distressing condition.

Prognostic factors for facial nerve palsy in a pediatric population: A retrospective study and review

OBJECTIVES/HYPOTHESIS

To identify and analyze factors influencing the outcome of facial nerve palsy (FNP) in a pediatric population.

STUDY DESIGN

Retrospective study.

METHODS

Sixty-seven pediatric patients (72 consecutive cases) diagnosed with and treated for FNP were divided into two severity subgroups. Associations between recovery in these groups and categorical variables were assessed using the Fisher exact test and for age using the t test.

RESULTS

Mean age on admission was 12.0 ± 4.5 years. Neither FNP outcome (graded by severity) nor improvement rates (expressed as the percentage of patients achieving a higher FNP grade over time) were influenced by gender, affected side, presence of polyneuropathy, etiology, or recurrent or familial FNP. In cases with comparable final outcome, improvement rates of those diagnosed with severe FNP on presentation (38.9% of cases) were significantly higher than mild-to-moderate FNP. Of the 47 patients who attended a follow-up examination 2 months after discharge, 70.2% have already recovered (by at least one House-Brackmann [H-B] grade) by the time they were discharged, whereas 90.9% achieved H-B grade ≤2, and 72.3% fully recovered (H-B grade 1) 2 months postdischarge. Adding antiviral medication did not affect FNP improvement rates or outcomes.

CONCLUSIONS

Rates of infectious and traumatic etiology in our patients were higher than reported for adults, but the most common etiology-as in those adults-was idiopathic. Routine extended diagnostic workup was not helpful, and antiviral medications were ineffective. The prognosis of FNP in pediatric patients is excellent, with 90% recovery by 2 months after initial presentation.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:1175-1180, 2017.

Macroscopic in vivo imaging of facial nerve regeneration in Thy1-GFP rats

IMPORTANCE

Facial nerve injury leads to severe functional and aesthetic deficits. The transgenic Thy1-GFP rat is a new model for facial nerve injury and reconstruction research that will help improve clinical outcomes through translational facial nerve injury research.

OBJECTIVE

To determine whether serial in vivo imaging of nerve regeneration in the transgenic rat model is possible, facial nerve regeneration was imaged under the main paradigms of facial nerve injury and reconstruction.

DESIGN, SETTING, AND PARTICIPANTS

Fifteen male Thy1-GFP rats, which express green fluorescent protein (GFP) in their neural structures, were divided into 3 groups in the laboratory: crush-injury, direct repair, and cross-face nerve grafting (30-mm graft length). The distal nerve stump or nerve graft was predegenerated for 2 weeks. The facial nerve of the transgenic rats was serially imaged at the time of operation and after 2, 4, and 8 weeks of regeneration. The imaging was performed under a GFP-MDS-96/BN excitation stand (BLS Ltd).

INTERVENTION OR EXPOSURE

Facial nerve injury.

MAIN OUTCOME AND MEASURE

Optical fluorescence of regenerating facial nerve axons.

RESULTS

Serial in vivo imaging of the regeneration of GFP-positive axons in the Thy1-GFP rat model is possible. All animals survived the short imaging procedures well, and nerve regeneration was followed over clinically relevant distances. The predegeneration of the distal nerve stump or the cross-face nerve graft was, however, necessary to image the regeneration front at early time points. Crush injury was not suitable to sufficiently predegenerate the nerve (and to allow for degradation of the GFP through Wallerian degeneration). After direct repair, axons regenerated over the coaptation site in between 2 and 4 weeks. The GFP-positive nerve fibers reached the distal end of the 30-mm-long cross-face nervegrafts after 4 to 8 weeks of regeneration.

CONCLUSIONS AND RELEVANCE

The time course of facial nerve regeneration was studied by serial in vivo imaging in the transgenic rat model. Nerve regeneration was followed over clinically relevant distances in a small number of experimental animals, as they were subsequently imaged at multiple time points. The Thy1-GFP rat model will help improve clinical outcomes of facial reanimation surgery through improving the knowledge of facial nerve regeneration after surgical procedures.

LEVEL OF EVIDENCE

NA.

Multiple recurrences of ipsilateral facial palsy in a patient with widening of the facial canal

The incidence of facial palsy (FP) is 6-12/100,000 in children, however only one in twenty experience recurrences. This report describes the clinical approach and diagnostic considerations in a child with multiple ipsilateral FP. The first occurrence of FP in conjunction with fever occurred at age 13 months, and was succeeded by more than 20 recurrences. Imaging revealed widening of the facial canal along with thickening of the facial nerve, allowing collateral inflammation and edema to induce pressure on the nerve. This is the first case describing the association between an abnormally widened facial canal and recurrent FP in childhood.

Peripheral facial palsy in children

The aim of this study is to evaluate the types and clinical characteristics of peripheral facial palsy in children. The hospital charts of children diagnosed with peripheral facial palsy were reviewed retrospectively. A total of 81 children (42 female and 39 male) with a mean age of 9.2 ± 4.3 years were included in the study. Causes of facial palsy were 65 (80.2%) idiopathic (Bell palsy) facial palsy, 9 (11.1%) otitis media/mastoiditis, and tumor, trauma, congenital facial palsy, chickenpox, Melkersson-Rosenthal syndrome, enlarged lymph nodes, and familial Mediterranean fever (each 1; 1.2%). Five (6.1%) patients had recurrent attacks. In patients with Bell palsy, female/male and right/left ratios were 36/29 and 35/30, respectively. Of them, 31 (47.7%) had a history of preceding infection. The overall rate of complete recovery was 98.4%. A wide variety of disorders can present with peripheral facial palsy in children. Therefore, careful investigation and differential diagnosis is essential.

Facial neuropathy with imaging enhancement of the facial nerve: a case report

A young women developed unilateral facial neuropathy 2 weeks after a motor vehicle collision involving fractures of the skull and mandible. MRI showed contrast enhancement of the facial nerve. We review the literature describing facial neuropathy after trauma and facial nerve enhancement patterns with different causes of facial neuropathy.

Comparison of sudden deafness in adults and children

Objectives

Although many studies have assessed sudden deafness in adults, sudden deafness has not been evaluated in children. We therefore evaluated the differences in sudden deafness between children and adults.

Methods

We compared clinical manifestations, including gender, audiogram pattern of initial hearing loss, and recovery rate after treatment in 87 children and 707 adults diagnosed with sudden deafness from September 2003 and August 2012.

Results

There were no differences in sex, side, or audiogram between children and adults (P>0.05 each). Hearing recovery rates in children and adults were 72.4% and 70.6%, respectively (P>0.05). Both children and adults with mild hearing loss showed significantly greater hearing recovery rates than individuals with profound hearing loss (P<0.05 each). The percentage with initially mild and moderate hearing loss was higher in children than in adults, as were the recovery rates of children compared to adults with initially mild, moderate-severe, and profound hearing loss (P<0.05 each). In regard to final hearing outcome after treatment, a low percentage of children showed no improvement whereas a high percentage showed complete recovery; a higher percentage of children than of adults showed complete recovery (P<0.05). Recovery rate from profound hearing loss was significantly higher in children than in adults (60.0% vs. 45.4%, P<0.05).

Conclusion

Degree of hearing loss, gender, side, and recovery rate were similar in children and adults, but the rate of complete recovery was higher in children.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between Bell's palsy and morphometric aspects of the facial nerve

Epidemiological data of Bell's palsy (BP) have been reported. For example, the annual incidence of BP is 15-30 per 100,000 persons, with equal numbers of men and women affected, and there is no predilection for either side of the face. However, details of the relationship between BP and morphometric aspects of the facial nerve have not been available in textbooks. We performed a morphometric analysis of human facial nerve fibers and estimated the total number of myelinated axons (TN) and average transverse area of myelinated axons (ATA). The facial nerve showed a significant decrease of TN with increasing age (r = -0.77; p < 0.01), but showed no significant changes of ATA with age (r = -0.01; p = 0.96). We supposed that the TN decrease with age was a factor in the delayed recovery from BP seen in the elderly. Moreover, the TN and ATA showed no significant differences between female and male specimens (p < 0.05), or between the right and left side specimens (p < 0.05). Our present results seem to explain the absence of significant sex and affected side differences in BP.

Effects of strength training on neuromuscular facial rehabilitation

OBJECTIVE

Physical trauma is the third leading cause of facial nerve damage, which can disrupt communication, social interaction and emotional expression. The objective of this report was to investigate the effects of facial muscle exercise as a stand-alone treatment in a young adult with unilateral facial nerve damage 13-years post-onset.

METHOD

This single case study examines the long-term results of a 7-week intensive facial exercise programme followed by a 16-week moderate facial exercise programme.

RESULTS

Intensive exercise increased facial strength and upper lip elevation on the affected side and upper and lower lip strength on the affected and non-affected sides. With subsequent moderate exercise followed by 24 weeks of rest, strength was maintained but not increased.

CONCLUSION

With intensive facial exercise, muscle weakness resulting from facial nerve damage sustained during childhood can be improved years after injury.

Clinical management of microstomia due to the static treatment of facial paralysis and oral rehabilitation with dental implants

Facial-nerve paralysis is seldom seen and may occur because of a broad spectrum of causes. The most commonly seen cause of facial paralysis is the Bell palsy; iatrogenic causes and tumors are relatively rare. Facial asymmetry, drooling, garbled speech, and difficulty in feeding: all adversely affect the psychosocial conditions of the patients. Fascial and tendon sling procedures may be performed for the static treatment of the unilateral permanent facial paralysis. These techniques are used both for the correction of the asymmetry of the face, especially by providing static support for the corner of the mouth, and to prevent drooling. Microstomia after a sling procedure is not a previously observed complication in the literature. A patient is presented with the surgical management of the complication of microstomia that had risen because of a static treatment of his unilateral facial paralysis via a tendon that passes circularly through his orbicularis oris muscle. Oral rehabilitation thereafter was maintained with the support of dental implants and fixed prosthodontics. The most efficient treatment protocol was decided with an interdisciplinary consultation of the oral and maxillofacial surgeon, the plastic surgeon, and the prosthodontist.

Prednisolone in Bell's palsy related to treatment start and age

OBJECTIVE

To evaluate if treatment start and age are related to the outcome in Bell's palsy patients treated with prednisolone.

STUDY DESIGN

Prospective, randomized, double-blind, placebo-controlled, multicenter trial.

SETTING

Sixteen otorhinolaryngologic centers in Sweden and 1 in Finland.

PATIENTS

Data were collected from the Scandinavian Bell's palsy study. A total of 829 patients were treated within 72 hours of onset of palsy. Follow-up was 12 months.

INTERVENTION

Patients were randomly assigned to treatment with placebo plus placebo (n = 206), prednisolone plus placebo (n = 210), valacyclovir plus placebo (n = 207), or prednisolone plus valacyclovir (n = 206).

MAIN OUTCOME MEASURES

Facial function was assessed with the Sunnybrook grading system, and complete recovery was defined as Sunnybrook = 100. Time from onset of palsy to treatment start was registered.

RESULTS

Patients treated with prednisolone within 24 hours and 25 to 48 hours had significantly higher complete recovery rates, 66% (103/156) and 76% (128/168), than patients given no prednisolone, 51% (77/152) and 58% (102/177) (p = 0.008 and p = 0.0003, respectively). For patients treated within 49 to 72 hours of palsy onset, there were no significant differences. Patients aged 40 years or older had significantly higher complete recovery rates if treated with prednisolone, whereas patients aged younger than 40 years did not differ with respect to prednisolone treatment. However, synkinesis was significantly less in patients younger than 40 years given prednisolone (p = 0.002).

CONCLUSION

Treatment with prednisolone within 48 hours of onset of palsy resulted in significantly higher complete recovery rates and less synkinesis compared with no prednisolone.

Facial palsy in children: emergency department management and outcome

OBJECTIVE

To describe the characteristics of children who present to an emergency department (ED) with facial palsy and determine the association of outcome with etiology, degree of initial paralysis, and ED management.

METHODS

This was a retrospective cohort study of children who presented to an ED with facial nerve paralysis (FNP).

RESULTS

There were 85 patients with a mean age of 8.0 (SD, 6.1) years; 60% (n = 51) of the patients were male, and 65.9% (n = 56) were admitted to the hospital. Bell palsy (50.6%) was the most common etiology followed by infectious (22.4%), traumatic (16.5%), congenital (7.1%), and neoplastic etiologies (3.5%). Patients with Bell palsy had shorter recovery times (P = 0.049), and traumatic cases required a longer time for recovery (P = 0.016). Acute otitis media (AOM)-related pediatric FNP had shorter recovery times than non-AOM-related cases (P = 0.005) in infectious group. Patients given steroid therapy did not have a shorter recovery time (P = 0.237) or a better recovery (P = 0.269). There was no difference in recovery rate of pediatric patients with Bell palsy between hospitalization or not (P = 0.952).

CONCLUSION

Bell palsy, infection, and trauma were most common etiologies of pediatric FNP. Recovery times were shorter in pediatric patients with Bell palsy and AOM-related FNP, whereas recovery took longer in traumatic cases. Steroid therapy did not seem beneficial for pediatric FNP. Hospitalization is not indicated for pediatric patients with Bell palsy.