Chronic Facial Palsy Research Articles

Facial nerve disorders committee: Controversies in facial paralysis

The management of facial nerve paralysis is a topic that stimulates considerable debate. Depending on the features of a given case, practitioners may advocate treatment options ranging from no intervention to urgent surgery. There is some validity to all treatment options; the key is understanding when features of a given case dictate a particular therapeutic approach. This miniseminar will address several topics related to management of facial paralysis including: (1) pitfalls in diagnosis of Bell’s palsy; (2) acute facial paralysis in pregnancy; (3) use of antiviral medications; (4) indications for and interpretation of electroneuronography (ENoG) and electromyography (EMG); (5) role of imaging studies; (6) indications, timing, and outcomes of decompression surgery; (7) techniques to aid recovery from acute facial paralysis; (8) botulinum toxin for rehabilitation; and (9) medical legal aspects of chronic facial paralysis. The format will include short presentations, panel discussion of interesting cases, and audience participation.

Ophthalmic Management of the Facial Palsy Patient

The management of the ocular sequelae of facial palsy should be individualized for each patient. The patient's age, ocular motility, tear production, and corneal sensation are considered when developing a treatment plan. Individuals with transient weakness often require only therapy with topical lubricants. Permanent or chronic facial paralysis is usually associated with lagophthalmos, ectropion, and exposure keratitis. Both "static" and "dynamic" procedures can be performed to improve these conditions. Combined eyelid surgery and suspension of the midface often provides the best result. However, patients with permanent facial palsy usually suffer chronic ocular symptoms, requiring long-term follow-up and continued topical therapy.

Recipient vessel analysis for microvascular reconstruction of the head and neck.

The selection of recipient vessels that are suitable for microvascular anastomosis in the head and neck region is one of many components that is essential for successful free tissue transfer. The purpose of this study was to evaluate a set of factors that are related to the recipient artery and vein and to determine how these factors influence flap survival. A retrospective review of 102 patients over a 5-year consecutive period was completed. Indications for microvascular reconstruction included tumor ablation (n = 76), trauma (n = 13), and chronic wounds or facial paralysis (n = 13). The most frequently used recipient artery and vein included the facial, superficial temporal, superior thyroid, carotid, and jugular. Various factors that were related to the recipient vessels were analyzed and included patient age, recipient artery and vein, diabetes mellitus, tobacco use, the timing of reconstruction, the method of anastomosis, previous radiation therapy, creation of an arteriovenous loop, and use of an interposition vein graft. Successful free tissue transfer was obtained in 97 of 102 flaps (95%). Flap failure was the result of venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with an arteriovenous loop (2 of 5, P = 0.03) and tobacco use (3 of 5, P = 0.03). Flap failure was not related to patient age, choice of recipient vessel, diabetes mellitus, previous irradiation, the method of arterial or venous anastomosis, use of an interposition vein graft, or the timing of reconstruction.

Paediatric rhabdomyosarcoma of the ear and temporal bone.

The objective of the present study was to review the presentation, management, outcome and morbidity of paediatric patients presenting to a single centre with rhabdomyosarcoma of the ear and temporal region. All patients diagnosed with rhabdomyosarcoma of the ear and temporal region between 1980 and 2000 were entered into this retrospective study. Fourteen patients were identified. The median age at presentation was 4.5 years with a mean time of onset of symptoms to diagnosis of 21 weeks. In many patients, the presentation mimicked that of chronic otitis media, delaying diagnosis. Histological subtype was embryonal in 13 patients and alveolar in 1. All patients underwent multimodality treatment. The 5-year disease-free survival rate was 81%. Regional post-treatment morbidity included chronic aural discharge (6/14), facial palsy (8/14), growth disturbance (4/14) and maxillo-facial deformity occurring in four children. From the results, we conclude that these patients should usually present to an ENT surgeon who should keep the diagnosis in mind when dealing with children with chronic otitis media as early diagnosis with referral to a specialist multidisciplinary team will optimize the chance of survival. Discharge, hearing loss and aural polyp, although commonly because of chronic otitis media, should prompt urgent investigation and biopsy, particularly if associated with facial palsy, lymphadenopathy or an obvious mass.

Bell palsy: quantitative analysis of MR imaging data as a method of predicting outcome.

To assess the prognostic value of quantitative analyses of region-of-interest (ROI) magnetic resonance (MR) imaging data in patients with acute facial nerve palsy. In a single-blinded study, MR images were obtained in 39 patients (32 men and seven women; age range, 18-75 years; average age, 37.9 years) with acute facial nerve palsy. MR images were obtained before the 6th day of illness, on the first day of standard inpatient treatment with high-dose steroids. Signal intensity (SI) was measured at ROIs in each of five segments (internal auditory canal [IAC]; geniculate ganglion; and labyrinth, tympanic, and mastoid segments) of the intratemporal portion of the facial nerve and quantitatively analyzed. The SI measurements in the five segments were summed and divided by 100 to provide a basis for establishing an MR imaging index. SI increases and MR imaging indexes were compared with available clinical findings and electrophysiologic data. Data for all 39 patients could be analyzed. The MR imaging index was significantly higher in patients with poor outcomes than in patients with favorable outcomes (specificity, 97%; sensitivity, 75%; P <.01). The SI increases in the IAC were significantly different between patients who progressed to full recovery (mean increase, 45.7%) and patients who developed chronic facial paralysis (mean increase, 156.5%) (sensitivity, 100%; specificity, 97%; P <.001). The results of differentiating between patients with good and those with poor outcomes on the basis of SI measurements in the IAC were found to be in complete agreement with electrophysiologic data. Quantitative analysis of ROI MR imaging data is a valid method of predicting the outcome of acute facial nerve palsy during the first days after onset of symptoms and thus at a time when it is not yet possible to obtain valuable prognostic information by using electrophysiologic methods.

Comprehensive midfacial elevation for ocular complications of facial nerve palsy.

A chief morbidity of facial nerve palsy is ocular exposure, which is largely due to lower lid retraction and ectropion. To assess the role of midfacial elevation in the comprehensive surgical treatment of paralytic lower lid malposition and ocular exposure. Eleven patients with chronic facial nerve palsy causing symptomatic ocular exposure were treated with subperiosteal midface elevation as a component of comprehensive lower lid elevation. Other procedures were performed concomitantly to treat lower lid ligament laxity and reduced lower lid rigidity, as required. Preoperative and postoperative ocular exposure symptoms, visual acuity, lower lid position, lagophthalmos, and keratopathy were compared. At an average of 17 months of follow-up, all patients reported improvement in symptoms. Visual acuity was maintained or improved in all patients. Lower eyelid position (P =.003), lagophthalmos (P =.07), and keratopathy (P<.001) were also improved. Midfacial elevation is a safe and effective surgical adjunct in the treatment of lower eyelid retraction in chronic facial palsy. Its use reduces the need for tarsorrhaphy, which limits the binocular visual field and negatively impacts cosmesis.

One-Stage Reversed and Rotated Gracilis Muscle Free Flap for Chronic Facial Palsy: A New Technique

Tehran, Iran From Iran University of Medical Sciences. Received for publication February 28, 2001; revised September 17, 2001. Presented at the 9th European Congress of Plastic and Esthetic Surgery, Rome, Italy, September 17 through 20, 2001. Hamid Karimi, M.D. Faculty of Medicine Iran University of Medical Sciences P. O. Box 19395-4949 Tehran, Iran[email protected]

One-stage reversed and rotated gracilis muscle free flap for chronic facial palsy: a new technique.

One-stage reversed and rotated gracilis muscle free flap for chronic facial palsy: a new technique.

High-intensity facial nerve lesions on T2-weighted images in chronic persistent facial nerve palsy.

Our aim was to estimate the value of MRI in detecting irreversibly paralysed facial nerves. We examined 95 consecutive patients with a facial nerve palsy (14 with a persistent palsy, and 81 with good recovery), using a 1.0 T unit, with T2-weighted and contrast-enhanced T1-weighted images. The geniculate ganglion and tympanic segment had gave high signal on T2-weighted images in the chronic stage of persistent palsy, but not in acute palsy. The enhancement pattern of the facial nerve in the chronic persistent facial nerve palsy is similar to that in the acute palsy with good recovery. These findings suggest that T2-weighted MRI can be used to show severely damaged facial nerves.

Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy

AIMSTo determine the adjuvant role of unilateral suborbicularis oculi fat (SOOF) lift in the periorbital rehabilitation of patients with chronic facial palsy.METHODSIn a non-comparative prospective case series nine adult patients...

Experience with extraoral masseter muscle transposition in chronic facial paralysis

In the case of aged patients with chronic facial palsy with severe muscular atrophy, muscle transposition is a good alternative in order to supply some form of movement. The masseter muscle may be transposed through either an intra- or extraoral approach. In the extraoral technique, most of the surgical details have been well documented, except the relationships between the masseter muscle and the parotid duct. Considering the anatomic direction of the parotid duct, a perfect axis of traction is available in order to lift both lips and the buccal commissure. Ten cases of extraoral masseter muscle transposition above the parotid duct were analyzed. Complete facial paralysis resulted from tumor extirpation (seven cases), arteriovenous malformation (two cases) or trauma (one case). The patients’ ages ranged from 47 to 76 years with a median age of 60 years; seven patients were female and three male. The duration of the palsy prior to the muscle transposition, ranged from 8 months to 18 years. The overall results were satisfactory in nine cases. Extraoral masseter muscle transposition is particularly attractive as a primary procedure, because of its efficiency in elderly patients with long-standing facial palsy. As a secondary procedure, masseter transposition may be considered as good an alternative for rehabilitation, when other reconstructive techniques have failed.

The SOOF lift as an adjunct in rehabilitation of facial paralysis: help or hype?

Rehabilitation of the midface in chronic facial paralysis is one of the last frontiers in global facial reanimation. The suborbicularis oculi fat pad lift, or SOOF lift, also known as the midface lift, has been popularized in aesthetic surgery literature as a way to restore midface fullness with a youthful appearance while eliminating midface sag associated with aging. These techniques of midface aesthetic rejuvenation have recently been applied in cases of chronic facial paralysis. This article analyzes the role of the midface lift or SOOF lift in cases of facial reanimation and determines whether or not it is of benefit to patients affected by chronic facial paralysis.

Facial reanimation with microneurovascular free flaps.

Numerous options are available for rehabilitation of chronic facial nerve paralysis, ranging from simple slings to complex procedures such as microneurovascular tissue transfer. Microneurovascular muscle transfer is generally indicated: 1) if the patient desires dynamic facial reanimation, particularly restoration of involuntary emotional facial expressions; 2) in the absence of distal facial nerve fibers or motor endplate function; 3) with an associated large soft tissue defect in the cheek; and 4) when other dynamic reanimation procedures have not been successful. The most commonly used free flaps for facial reanimation are gracilis, latissimus dorsi and inferior rectus abdominus muscle. When successfully performed free flaps yield excellent functional and aesthetic results in facial reanimation.

MR Findings of Facial Nerve on Oblique Sagittal MRI Using TMJ Surface Coil: Normal vs Peripheral Facial Nerve Palsy

Purpose: To evaluate the findings of normal facial nerve, as seen on oblique sagittal MRI using a TMJ (temporomandibular joint) surface coil, and then to evaluate abnormal findings of peripheral facial nerve palsy. Materials and Methods: We retrospectively reviewed the MR findings of 20 patients with peripheral facial palsy and 50 normal facial nerves of 36 patients without facial palsy. All underwent oblique sagittal MRI using a TMJ surface coil. We analyzed the course, signal intensity, thickness, location, and degree of enhancement of the facial nerve. According to the angle made by the proximal parotid segment on the axis of the mastoid segment, course was classified as anterior angulation (obtuse and acute, or buckling), straight and posterior angulation. Results: Among 50 normal facial nerves, 24 (48%) were straight, and 23 (46%) demonstrated anterior angulation; 34 (68%) showed iso signal intensity on T1WI. In the group of patients, course on the affected side was either straight (40%) or showed anterior angulation (55%), and signal intensity in 80% of cases was isointense. These findings were similar to those in the normal group, but in patients with post-traumatic or post-operative facial palsy, buckling, of course, appeared. In 12 of 18 facial palsy cases (66.6%) in which contrast materials were administered, a normal facial nerve of the opposite facial canal showed mild enhancement on more than one segment, but on the affected side the facial nerve showed diffuse enhancement in all 14 patients with acute facial palsy. Eleven of these (79%) showed fair or marked enhancement on more than one segment, and in 12 (86%), mild enhancement of the proximal parotid segment was noted. Four of six chronic facial palsy cases (66.6%) showed atrophy of the facial nerve. Conclusion: When oblique sagittal MR images are obtained using a TMJ surface coil, enhancement of the proximal parotid segment of the facial nerve and fair or marked enhancement of at least one segment within the facial canal always suggests pathology of the facial nerve. The use of this modality, together with the coil, is, therefore, an effective complementary technique for the evaluation of a facial nerve.

Facial reanimation for chronic facial paralysis

Chronic facial paralysis is a devastating functional and cosmetic deformity that can physically, socially, and emotionally isolate the affected person from the rest of society. Current efforts in the restoration of facial nerve function focus on nerve regeneration, new ways to grade and evaluate pre- and postoperative facial nerve status, adjunct methods for finetuning postoperative results, and refinements of long-established surgical procedures.

Psychological distress: Linking impairment with disability in facial neuromotor disorders

The relationship between facial neuromotor system impairment, disability, and psychological adjustment is not well understood. This study was designed to explore the relation between impairment and disability and the impact of psychological adjustment on the relation for individuals with disorders of the facial neuromotor system. We studied outpatients ( n = 48; mean age, 49.0; SD = 16.3; range, 18 to 84 years) with a facial neuromotor disorder and acute or chronic facial paralysis. Measures of impairment (Facial Motion Assay, House-Brackmann scale, and Facial Grading System), disability (Facial Disability Index, physical and social well-being subscales), and psychological adjustment (Beck Anxiety Inventory, Beck Depression Inventory) were administered. Bivariate correlations between impairment and disability measures indicated impairment was positively correlated with physical and social disability (r = 0.44, p < 0.01; r = 0.39, p < 0.05, respectively). Stepwise regression analysis to predict disability indicated physical disability was predicted by impairment and the interaction of impairment and psychological distress (R 2 = 0.425; F = 12.57; df = 2, 34; p = 0.002). Psychological distress, and not impairment and the interaction of impairment and distress, was the single predictor of social disability (R 2 = 0.274; F = 13.23; df = 1, 35; p = 0.001). Psychological distress was a moderator of the relation between impairment and physical disability and a mediator of the relation between impairment and social disability for individuals with facial neuromotor disorders. Assessment and interventions targeted for psychological distress in addition to interventions targeted for impairments appear warranted to effectively reduce the disability associated with facial neuromotor disorders. (Otolaryngol Head Neck Surg 1998;118:790-6.)

Quantitative facial motion analysis after functional free muscle reanimation procedures.

The purpose of this study was to evaluate the success of functional free muscle transfer in patients with chronic facial paralysis using a recently developed quantitative method known as the maximum static response assay of facial motion. A retrospective review of a single surgeon series of six patients with longstanding facial paralysis was performed. The maximum static response assay was performed on all patients preoperatively and serially during the postoperative period. Twenty-seven patients (54 sides) with normal facial function were also evaluated and served as controls. The contralateral normal side in those patients with unilateral facial paralysis (n = 4) also served as a control. Movement of the modiolus during smile was recorded in the x axis and y axis. To determine net smile movement, the vector of movement was calculated by means of the Pythagorean theorem. Vectors were then defined mathematically by calculating direction and magnitude. The average direction of the vector during smile for the normal control population was 58.3 degrees (range 32.5 to 83.1 degrees) from the horizontal through the modioli, and the average magnitude was 10.6 mm (range 4.2 to 20.1 mm). The average preoperative direction for the reanimated sides was 176.8 degrees with a range of 83.3 to 225 degrees. Patients with bilateral paralysis (n = 2) were excluded for calculation of the vectors on the normal contralateral side. The average preoperative direction for the normal contralateral side in patients with facial paralysis was 58.3 degrees with a range of 48.2 to 68.4 degrees. Postoperatively, the average direction of the vector during smile for the reanimated sides improved to a value of 77.6 degrees with a range of 45.7 to 113.8 degrees. The average change in direction of the preoperative reanimated side compared with the postoperative reanimated side was significant (p = 0.01). Postoperatively, the average direction of the vector for the contralateral normal sides was 43 degrees with a range of 11 to 57.2 degrees. The change in direction for the contralateral normal side was not significant (p = 0.18). The average magnitude of the reanimated side improved from a non-anatomic 2.8 mm preoperatively (range 0.8 to 6.8 mm) to an anatomic 4.9 mm postoperatively (p = 0.02). The contralateral normal side magnitude decreased from 9.4 mm (range 7.3 to 11.6 mm) preoperatively to 5.7 mm (range 3.8 to 7.7 mm) postoperatively (p = 0.006). More specifically, the absolute change in movement on the reanimated side during smile for the x axis and y axis was 2.3 mm (p = 0.05) and 4.0 mm (p = 0.002), respectively. This corresponded to an absolute change in the magnitude of the vector of 4.6 mm in an anatomic direction. On the contralateral side the absolute change in magnitude during smile from preoperative to postoperative for the x axis and y axis decreased by 1.5 mm (p = 0.13) and 5.3 mm (p = 0.05), respectively. This reflected an absolute change in the magnitude of the vector of 5.5 mm. Functional free muscle transfer in patients with chronic facial paralysis resulted in anatomic recovery of motion in the majority of patients in this series. The maximum static response assay can be used to objectively assess the results of facial reanimation.

Treatment of Chronic Facial Palsy by Transplantation of the Neurovascularized Free Rectus Abdominis Muscle

We performed neurovascularized free rectus abdominis muscle transplantations in two patients with chronic facial palsy. In one patient, the postoperative course was uneventful, but the patient died from rupture of esophageal varices. In the other patient, both morphologic and functional results were satisfactory. Therefore, the rectus abdominis muscle is considered to be a suitable donor for muscle transplantation for the treatment of chronic facial palsy. The rectus abdominis muscle is advantageous in that (1) simultaneous operations by two teams are possible with the patient in the supine position, (2) it is supplied by long nerves and long and large vessels, (3) it is flat and consists of segments with appropriate lengths, (4) the force and distance of contraction are appropriate, and (5) the tendinous intersections are suitable for anchoring sutures.

Treatment of Chronic Facial Palsy by Transplantation of the Neurovascularized Free Rectus Abdominis Muscle

Hata, Yuiro M.D.; Yano, Kenji M.D.; Matsuka, Kazunori M.D.; Ito, Osamu M.D.; Matsuda, Hidenori M.D.; Hosokawa, Ko M.D.; Manktelow, R. T. M.D.; Manktelow, Ralph T. M.D., F.R.C.S.(C) Author Information

Contrast-enhanced MR imaging of the facial nerve in 11 patients with Bell's palsy.

Contrast-enhanced MR images (at 1.5 T) were obtained in 11 patients with facial palsy. The group included five people with acute idiopathic facial (Bell's) palsy, three with chronic idiopathic facial palsy, and one each with acute facial palsy after local radiation therapy, acute facial palsy resulting from herpes zoster virus infection, and facial palsy caused by facial neuroma. Eight of the 11 patients demonstrated marked enhancement of the affected facial nerve from the labyrinthine portion through the descending canal. Three patients also demonstrated mild enhancement of the distal canalicular portion of the facial nerve, simulating small distal acoustic neuromas. No difference in the pattern of enhancement between the acute or chronic Bell's palsy patients was seen. Radiographic resolution appeared to lag behind clinical resolution. The facial neuroma appeared distinct from the other lesions as a focally enhancing mass. The enhancement pattern in the Bell's group correlated with the histopathologic features of Bell's palsy and is consistent with the viral hypothesis of the syndrome. Thin-section contrast-enhanced MR scans are recommended for individuals with atypical presentation of facial paralysis. In the proper clinical setting, contrast-enhanced MR imaging may permit a positive radiographic diagnosis of Bell's palsy, which has previously been a diagnosis of exclusion.