Facial Disorders Research Articles

Neoplastic causes of nonacute facial paralysis: A review of 221 cases

We conducted a retrospective review to assess the clinical presentation of patients with tumor-related nonacute complete peripheral facial weakness or an incomplete partial facial paresis and to provide an algorithm for the evaluation and management of these patients. Our study population was made up of 221 patients-131 females and 90 males, aged 14 to 79 years (mean: 49.7)-who had been referred to the Facial Nerve Disorders Clinic at our tertiary care academic medical center over a 23-year period with a documented neoplastic cause of facial paralysis. In addition to demographic data, we compiled information on clinical signs and symptoms, radiologic and pathologic findings, and surgical approaches. All patients exhibited gradual-onset facial weakness or facial twitching. Imaging identified an extratemporal tumor in 128 patients (58%), an intratemporal lesion in 55 patients (25%), and an intradural mass in 38 (17%). Almost all of the extratemporal tumors (99%) were malignant, while 91% of the intratemporal and intradural tumors were benign. A transtemporal surgical approach was used in the 93 intratemporal and intradural tumor resections, while the 128 extratemporal lesions required a parotidectomy with partial temporal bone dissection. The vast majority of patients (97%) underwent facial reanimation. We conclude that gradual-onset facial paralysis or twitching may occur as a result of a neoplastic invasion of the facial nerve along its course from the cerebellopontine angle to the parotid gland. We caution readers to beware of a diagnosis of "atypical Bell's palsy."

Traumatic and Nontraumatic Facial Nerve Disorder

Background: The facial nerve has the longest intraosseous paths of the cranial nerves. There is controversy regarding the surgical approaches and time of surgery to obtain the best outcome after facial nerve surgery. Different surgical approaches depending on severity and location of injury, hearing status, and surgeon skills have been used in facial nerve disorders. Whenever the continuity of the facial nerve has been disrupted, we should restore its continuity. In some instances, an end-to-end reapproximation can be accomplished, but if any tension occurs at the anastomotic site, interposition nerve grafts confer a better chance of allowing facial movement. Patients: In this cross-sectional study, 16 patients with facial paralysis were evaluated and followed up for at least 12 month and at most 36 month. Patients according to cause of paralysis were divided into 4 groups: traumatic (10 cases), iatrogenic (2 cases), chronic middle ear infection (2 cases), and idiopathic (2 cases). All of them were suffering from complete facial paralysis (grade VI). Surgery was performed on those who demonstrated either >90% fiber degeneration in ENOG within 3 weeks of injury or passing >4 to 6 months since the start of paralysis in the absence of regeneration. Finally, 12 decompression only, 1 decompression and end-to-end anastomosis, and 3 decompression and facial nerve grafting were accomplished. Conclusions: Results were good to satisfactory (I-II/VI) in 12 cases, acceptable (III-IV/VI) in 2 cases, and no recovery was observed in 2 cases.

Facial skin findings are indicators of human immunodeficiency virus infection and acquired immune deficiency syndrome: a retrospective study

To explore HIV-related facial skin disorders among HIV-positive outpatients and the role in identifying HIV infection and/or AIDS. We retrospectively evaluated records from all HIV-positive patients who initially presented at our Dermatology and Venereology Department (Southwest Hospital, Chongqing, China) between January 2009 and March 2016. We also compared the prevalences of facial skin disorders among HIV-positive and HIV-negative outpatients. We identified 827 HIV-positive patients, who included 150 patients who initially presented with 1 of 14 different facial skin disorders. Noninfectious/inflammatory dermatosis was the most common diagnosis (109/150, 72.7 %), and infectious dermatosis was diagnosed in 41 cases (27.3 %). Most facial skin disorders exhibited a higher proportion of HIV-positive patients, compared to HIV-negative patients. Herpes zoster was the most common disorder, and psoriasis and eczema or neurodermatitis were secondary disorders. Some disorders, such as seborrheic dermatitis, exhibited a severe and refractory clinical manifestation. Photosensitive dermatoses were significantly more common among HIV-positive patients, compared to HIV-negative patients (1.9 % vs. 0.0 %). No malignancies were diagnosed. There is a wide spectrum of facial skin disorders among HIV-positive patients in southwest China, and some of these disorders may provide the first clinical indication of HIV infection and/or AIDS. However, these findings require confirmation using immunological data.

Weighting of Facial Grading Variables to Disfigurement in Facial Palsy.

A universal, health care professional-graded scale for facial assessment would be a useful tool for reporting, comparing, and assessing facial function among patients with facial paralysis. To correlate scores of an assessment tool, the eFACE scale, with expert-rated facial disfigurement and to determine the relative contributions of facial features to facial palsy-related disfigurement. The eFACE scale yields 15 individual variable scores, in addition to subscores for static, dynamic, and synkinesis elements, and a total score that is based on 100-point scales. Two hundred patients with varying degrees of unilateral facial palsy underwent independent eFACE assessment and assignment of a disfigurement score by 2 facial nerve surgeons. The mean scores were determined, and multivariate regression analysis was performed to fit eFACE subset scores (static, dynamic, and synkinesis) to disfigurement ratings. A hybrid regression model was then used to weight each of the 15 eFACE variables, using stepwise regression to control for the effect of the other variables. Scoring was performed during an 8-week period from March 16 to May 8, 2015. Use of the 100-point eFACE variables, together with a 100-point visual analog scale of disfigurement, with 0 representing the most extreme disfigurement possible from a facial nerve disorder and 100 representing no discernible facial disfigurement. In the 200 patients included in analysis (126 [63.0% female]; mean [SD] age, 46.5 [16.4] years]), predicted disfigurement scores based on eFACE subset scores demonstrated excellent agreement with surgeon-graded disfigurement severity (r2 = 0.79). Variable weighting demonstrated that the 6 key contributors to overall disfigurement were (in order of importance) nasolabial fold depth at rest (normalized coefficient [NC], 0.18; P < .001), oral commissure position at rest (NC, 0.15; P < .001), lower lip asymmetry while pronouncing the long /ē/ (NC, 0.09; P < .001), palpebral fissure width at rest (NC, 0.09; P < .001), nasolabial fold orientation with smiling (NC, 0.08; P = .001), and palpebral fissure width during attempts at full eye closure (NC, 0.06; P = .03). A mathematical association between eFACE-measured facial features and overall expert-graded disfigurement in facial paralysis has been established. For those using the eFACE grading scale, predictions of the specific effects of various interventions on expert-rated disfigurement are now possible and may guide therapy. NA.

Cognitive Flexibility in Primary Dystonia.

Objectives Although primary dystonia is typically characterized as a movement disorder, it is also associated with cognitive alterations in the domain of executive functioning which may arise from changes in cortico-basal ganglia circuits. Specifically, in comparison to healthy controls, patients with dystonia show deficits in neuropsychological tests of cognitive flexibility. However, it is unclear whether cognitive inflexibility is caused by the pathomechanisms underlying primary dystonia or by confounding factors such as depression or symptom-related distraction.Methods The present study aimed to eliminate these confounds by examining cognitive flexibility in dystonia patients and in patients with similar motor symptoms but without a comparable central pathophysiology. Eighteen patients with primary blepharospasm, a common form of dystonia affecting the muscles around the eyes, and 19 patients with hemifacial spasm, a facial nerve disorder causing similar eyelid spasms, completed a computerized version of the Wisconsin Card Sorting Test (cWCST). The two groups were further compared on tests of global cognitive functioning, psychiatric symptoms, health status, and impulsiveness. Results Blepharospasm patients committed significantly more errors on the cWCST than patients with hemifacial spasm. Group differences were most pronounced with regard to integration errors, a measure of rule-inference processes on the cWCST. Integration errors were also associated with impulsiveness in patients with blepharospasm. Conclusions Primary blepharospasm is related to deficits in cognitive flexibility, even when blepharospasm patients are compared with patients who suffer from motor symptoms of non-dystonic origin. Our results support the possibility that cognitive inflexibility results from the specific pathophysiological processes underlying primary dystonia. (JINS, 2016, 22, 662-670).

Lifestyle and oral facial disorders associated with sleep bruxism in children

Objective: The aim of the study was to investigate the routine, sleep history, and orofacial disorders associated with children aged 3–7 years with nocturnal bruxism.Methods: Children (n = 66) were divided into groups of parent reported nocturnal bruxism (n = 34) and those without the disorder (n = 32). Data about the child’s routine during the day, during sleep and awakening, headache frequency, temporomandibular joint (TMJ), and hearing impairments were obtained through interviews with parents/caregivers. Electromyography examination was used to assess the activity of facial muscles. Multiple logistic regression (MLR), chi-square test, and t-test analyses were performed.Results: MLR revealed association of nightmares (p = 0.002; OR = 18.09) and snoring (p = 0.013; OR = 0.14) with bruxism. Variables related to awakening revealed an association with bruxism (p < 0.05). Parents of the main group (children with nocturnal bruxism) reported more complaints of orofacial pain, facial appearance, and headache occurrence (p < 0.05). Auditory and muscle disorders were not significant variables (p > 0.05).Conclusion: Nightmares and snoring are associated with nocturnal bruxism in children. Bruxism in children elicits consequences such as headache, orofacial pain, and pain related to awakening.

Treatment Approaches in Facial Nerve Disorders

Treatment Approaches in Facial Nerve Disorders

Orofacial pain due to rare interosseous hemangioma first diagnosed as secondary to trauma.

Pain is among the most common reasons for patient visits to healthcare providers, especially to dental practitioners. This case illustrates the obligation of the general dentist and specialist to recognize facial pain disorders of nonodontogenic origin, and outlines a paradigm for treatment of this unusual case. A 59-year-old man presented with chronic, progressive right periorbital pain since 2006, of 7 years duration. The initial diagnosis was a fracture of the right outer rim of the orbit secondary to trauma. The patient had undergone a variety of clinical and radiographic evaluations, pharmacologic therapies, and limited surgical procedures with no benefit. The description of his pain varied. Initially complaints were consistent with musculoskeletal pain, ie chronic, localized, aching, and evoked by pressure. It evolved into a neuropathic quality with increasing and spontaneous pain associated with sensory changes. Pain levels, which were initially mild, became moderate to severe. After a detailed review of the patient's history, radiographic records, and a comprehensive clinical evaluation, a CBCT of the maxilla was performed. While not considered a routine radiographic study, CBCT is readily available to the general dentist and specialist. CBCT was indicated in this case and revealed a rare interosseous hemangioma of the maxilla. The portion of the maxilla containing the lesion was surgically removed and a prosthetic replacement was placed. At 12 months after the procedure the patient remains pain free.

Intratemporal facial nerve ultrastructure in patients with idiopathic facial paralysis. Viral infection evidence study

AbstractThe etiology of idiopathic peripheral facial palsy (IPFP) is still uncertain; however, some authors suggest the possibility of a viral infection. Aimto analyze the ultrastructure of the facial nerve seeking viral evidences that might provide etiological data. Material and MethodsWe studied 20 patients with peripheral facial palsy (PFP), with moderate to severe FP, of both genders, between 18-60 years of age, from the Clinic of Facial Nerve Disorders. The patients were broken down into two groups - Study: eleven patients with IPFP and Control: nine patients with trauma or tumor-related PFP. The fragments were obtained from the facial nerve sheath or from fragments of its stumps - which would be discarded or sent to pathology exam during the facial nerve repair surgery. The removed tissue was fixed in 2% glutaraldehyde, and studied under Electronic Transmission Microscopy. ResultsIn the study group we observed an intense repair cellular activity by increased collagen fibers, fibroblasts containing developed organelles, free of viral particles. In the control group this repair activity was not evident, but no viral particles were observed. ConclusionThere were no viral particles, and there were evidences of intense activity of repair or viral infection.

Acupuncture for melasma in women: a systematic review of randomised controlled trials.

Melasma is a common facial skin disorder seen in women. Manual acupuncture (MA) is widely used alone or in combination with conventional treatments for melasma in China. To assess the effectiveness and safety of MA for melasma, and explore the range of treatments applied. Six databases were searched systematically for randomised controlled trials (RCTs) on acupuncture for melasma in women up to November 2014. RevMan software was used for data analysis. The Cochrane tool of Risk of Bias was used to assess the methodological quality of the RCTs. Eight RCTs involving 587 women were included. Seven studies used the encircling needling method, four studies used the quick needling method and four studies used intensive needle manipulations. Five studies provided individualised acupuncture treatments. Points used with highest frequency were SP6, ST36 and SP10. MA was compared with oral tranexamic acid, vitamin C and E, vitamin C and tamoxifen, topical 20% azelaic acid, hydroquinone, vitamin A and no treatment. Studies were too heterogeneous to conduct a meta-analysis. For global outcome measures, seven trials showed that MA groups were significantly better than the conventional treatments either with a better cure rate or with a better combined cure rate and markedly effective rate, and one trial did not (MA vs vitamin A). No acupuncture-related adverse events were reported. MA appeared to be beneficial and safe for women with melasma, but insufficient evidence was found to reach conclusions. The encircling needling method, the quick needling method, intensive needle manipulations and individualised points' selection were widely used. Well-designed trials are required. PROSPERO Systematic review registration: CRD42013006396.

A Pilot Study of Diagnostic Neuromuscular Ultrasound in Bell's Palsy.

Neuromuscular ultrasound of the cranial nerves is an emerging field which may help in the assessment of cranial neuropathies. The aim of this study was to evaluate the role of neuromuscular ultrasound in Bell's palsy. A second objective was to assess the possibility of any associated vagus nerve abnormality. Twenty healthy controls and 12 Bell's palsy patients were recruited. The bilateral facial nerves, vagus nerves, and frontalis muscles were scanned using an 18 MHz linear array transducer. Facial nerve diameter, vagus nerve cross-sectional area, and frontalis thickness were measured. Mean facial nerve diameter was .8 ± .2 mm in controls and 1.1 ± .3 mm in patients group. The facial nerve diameter was significantly larger in patients than controls (P = .006, 95% CI for the difference between groups of .12-.48), with a significant side-to-side difference in patients as well (P = .004, 95% CI for side-to-side difference of .08-.52). ROC curve analysis of the absolute facial nerve diameter revealed a sensitivity of 75% and a specificity of 70%. No significant differences in vagus nerve cross-sectional area or frontalis thickness were detected between patients and controls. Ultrasound can detect facial nerve enlargement in Bell's palsy and may have a role in assessment, or follow-up, of Bell's palsy and other facial nerve disorders. The low sensitivity of the current technique precludes its routine use for diagnosis, however, this study demonstrates its validity and potential for future research.

Intra-operative monitoring of two facial muscles in hemifacial spasm surgery

BackgroundHemifacial spasm (HFS) is a chronic facial nerve disorder characterized by spontaneous muscle contractions. Microvascular decompression (MVD) is the neurosurgical treatment of choice. Intraoperative neurophysiologic monitoring (IOM) during MVD can help determine when adequate decompression is performed. MethodsMVD with IOM was performed on 16 patients with HFS that included recording the abnormal lateral spread response (LSR) in lower facial muscles, considered as neurophysiologic marker of HFS. Two lower facial muscles were monitored as opposed to a standard monitoring of a single muscle. ResultsAll patients underwent preoperative thin cut MRI confirming the presence of neurovascular conflict. Patients underwent small retrosigmoid craniotomy and MVD. In 13 cases, the LSR guided the surgeon to continue MVD until the response was unobtainable from all recorded lower facial muscles. In four of those (30%), the LSR persisted on one of the recorded muscle and prompted further exploration and decompression until complete disappearance of LSR in all recorded muscles. In two cases, the LSR disappeared after dural opening and never recurred during the procedure, therefore the completion of MVD was based on non reappearance of LSR. In one case, the LSR persisted despite apparent complete decompression of the nerve. Fourteen patients had complete relief of their symptoms after surgery, one had partial improvement and the one with persistent LSR was unchanged. ConclusionEvaluation of the LSR by monitoring of two lower facial muscles provides valuable neurosurgical guidance during MVD for HFS. This simple modification of intra-operative monitoring may improve prediction of satisfactory MVD and HFS resolution.

CLINICAL SYMPTOMS ON PATIENTS WITH APHASIA CAUSED BY CEREBRAL HEMISPHERE HEMORRHAGE AFTER THE ACUTE PERIOD

Objective: To survey the clinical symptoms on patients with aphasia caused by cerebral hemisphere hemorrhage after the acute period. Subjects: 30 patients were diagnosed aphasia caused by cerebral hemisphere hemorrhage after the acute period in the Traditional Medicine Department of Bach Mai Hospital, from 12/2012 to 12/2013. Method: Cross – sectional descriptive study. Results: The average of age was 59.53 ± 11.19. Male/Female was 2.33. The most common symptoms: paralysis on one side of the body (100%), central facial nerve paralysis (66.7%), sensation disorders (36.7%), bladder or bowel control problems (23.3%). Type of aphasia: nonfluent aphasia/fluent aphasia: 2/1. The degree of damage: 66.7% of patients with severe aphasia (Goodglass and Kaplan) and 100% of patients with severe neurological damage (Orgogozo). The classification according to traditional medicine: Stroke involving the viscera is accounted for 56.7%, stroke involving the meredians type is accounted for 43.3%, excess type is accounted for 53.3%, deficiency type is accounted for 46.7%. Conclusion: Patients with aphasia caused by cerebral hemisphere hemorrhage after the acute period happen frequenty in 50 – 69 years old, men more than women, nonfluent aphasia (transcortical motor aphasia, Broca’s aphasia); stroke involving the viscera and excess type. Keywords: Aphasia, aphasia caused by cerebral hemisphere hemorrhage.

Unilateral Benign Masseteric Hypertrophy: Surgical Intervention and Case Report

Hypertrophy is related to an enlargement caused by a growth in the size but not in the number of cells. Generalized masticatory muscle hypertrophy may affect the temporalis muscle, masseters, and medial pterygoids in a variety of combinations. Masseter hypertrophy is recognized as a rare disorder and persistent asymptomatic enlargement of one or both masseter muscles. Etiology for benign masseteric hypertrophy is unknown in most of the cases so considered as idiopathic. Although numerous factors such as facial asymmetry, trismus, protrusion, bruxism, clenching, malocclusion, or temporomandibular disorders have been reported on the basis of clinical examination and cited previous literatures but have not proven still. This article reports a case of unilateral benign masseter hypertrophy with retrognathic mandible in which surgical intervention was rendered to the patient by using a combination approach.

Another Scale for the Assessment of Facial Paralysis? ADS Scale: Our Proposition, How to Use It.

Several authors in the years propose different methods to evaluate areas and specific movement's disease in patient affected by facial palsy. Despite these efforts the House Brackmann is anyway the most used assessment in medical community. The aims of our study is the proposition and assessing a new rating Arianna Disease Scale (ADS) for the clinical evaluation of facial paralysis. Sixty patients affected by unilateral facial Bell paralysis were enrolled in a prospective study from 2012 to 2014. Their facial nerve function was evaluated with our assessment analysing facial district divided in upper, middle and lower third. We analysed different facial expressions. Each movement corresponded to the action of different muscles. The action of each muscle was scored from 0 to 1, with 0 corresponding from complete flaccid paralysis to muscle's normal function ending with a score of 1. Synkinesis was considered and evaluated also in the scale with a fixed 0.5 score. Our results considered ease and speed of evaluation of the assessment, the accuracy of muscle deficit and the ability to calculate synkinesis using a score. All the three observers agreed 100% in the highest degree of deficit. We found some discrepancies in intermediate score with 92% agreement in upper face, 87% in middle and 80% in lower face, where there were more muscles involved in movements. Our scale had some limitations linked to the small group of patients evaluated and we had a little difficulty understanding the intermediate score of 0.3 and 0.7. However, this was an accurate tool to quickly evaluate facial nerve function. This has potential as an alternative scale to and to diagnose facial nerve disorders.

Pierre Robin sequence: case report, the relevance of autopsy

Pierre Robin sequence is a neonatal disorder characterized by micrognathism, glossoptosis and cleft palate. We reported an autopsy case of a child whose malformations of the oropharynx were identified only at birth. The child was extremely preterm with severe neonatal depression and poor recovery, and the orofacial alterations prevented the correct treatment. There was facial disorder characterized by micrognathia associated with cleft palate and posterior displacement of the tongue, compressing the vallecula, structurally compatible with glossoptosis. This autopsy surpassed the scientific and epidemiological relevance, allowing the family genetic counseling and close monitoring of a subsequent pregnancy.

Safety of onabotulinum toxin a injection to the central upper eyelid and eyebrow regions.

To evaluate the safety of onabotulinum toxin A injected into the central upper eyelid and eyebrow regions. The authors retrospectively reviewed the charts of all patients undergoing onabotulinum toxin A injection to the central upper eyelid and eyebrow between February, 2012, and November, 2012. Age, gender, indication, injection sites, number of central units, total number of units, and occurrence of adverse events were all recorded. A total of 300 procedures on 88 patients were performed, in whom the central upper eyelid and/or central eyebrow was injected with onabotulinum toxin A. There were 68 female and 20 male patients. Average age was 68.7±13.3 years (range, 42-92 years). Indications for central eyelid/eyebrow treatment included blepharospasm (34 patients, 176 procedures), hemifacial spasm (21 patients, 40 procedures), facial nerve disorders (2 patients, 9 procedures), and facial rhytides/eyebrow ptosis (31 patients, 75 procedures). The amount of neurotoxin injected into the central eyelid and eyebrow ranged from 2 to 12.5 units per encounter. Complications included diplopia (4% of total encounters), lagophthalmos (1% of total encounters), blepharoptosis (1% of total encounters), and blurry vision (1% of total encounters). Minor local effects, including bruising, bleeding, pain, and mild swelling, were recorded in 3.3% of total encounters. Placement of onabotulinum toxin A into the central upper eyelid and eyebrow is associated with a low rate of blepharoptosis. Central eyelid and eyebrow neurotoxin injection can be safely added to the regimen when treatment calls for chemodenervation of the central orbicularis oculi.

Analysis of mimic facial movements based on motion capture

Mimic facial expressions and emotions represent one of the most important human skills of nonverbal communications [1, 2]. In pathological situations which include facial disorders, in facial palsy rehabilitation or in the new field of facial transplantation, it is important to have accurate knowledge and measurement data of this particular movement. Thus, the biomechanical understanding of this skill might help clinicians and physiotherapist in their endeavour. In fact, until now, facial mimic disorders diagnosis and rehabilitations are based on qualitative and subjective observations [3].

An Additional Patient With 3q27.3 Microdeletion Syndrome

The 3q27.3 microdeletion syndrome has been recently delineated in 7 subjects from 5 families sharing a 1.4 Mb smallest region of overlap. This condition appears recognizable by the association of Marfanoid habitus, mild but distinctive facial dysmorphism, intellectual disability, psychosis, and mood disorder. Here, we describe an additional 17-year-old man with an ~7.7-Mb deletion encompassing the 3q27.3 microdeletion critical region, previously run undetected at standard karyotyping. The constellation of major clinical findings overlaps with those reported in the 7 previously published patients and thus confirms the existence of a strongly recognizable syndrome linked to imbalance of 3q27.3. The role of AHSG and, possibly, of other genes in determining the 3q27.3 microdeletion habitus is discussed by comparison of the deleted segments. The involvement of adjacent loci and genes, such as OPA1 and GP5, may contribute in this patient to novel satellite features, such as optic atrophy and subclinical coagulopathy.

Clinical features and treatment status of hemifacial spasm in China

Background Hemifacial spasm (HFS) is a facial nerve disorder characterized by episodic involuntary ipsilateral facial muscle contraction. Information on Chinese patients with HFS has not been well-characterized. This study aimed to evaluate the clinical feature and the treatment status of HFS across China. Methods A cross-sectional study including 1003 primary HFS patients had been carried out in 15 movement disorder clinics in China in 2012. The investigated information was acquired from questionnaires and medical records including demographic data, site of onset, aggravating and relieving factors, treatments prior to the investigation, etc. Results In this study, the ratio of male to female was 1.0:1.8, the mean age at onset was (46.6±11.5) years. About 1.0% patients were bilaterally affected. The most often site of initial onset was the orbicularis oculi muscle. The most often affected sites were orbicularis oculi, zygomatic, and orbicularis oris muscles. Stress/anxiety and relaxation were most often aggravating and relieving factors, respectively; 2.3% patients had family history, 28.4% cases were combined with hypertension, and 1.4% patients were with trigeminal neuralgia. Botulinum toxin type A (BTX-A) injection was the most commonly used treatment, followed by acupuncture and oral medication. BTX-A maintained the highest repeat treatment ratio (68.7%), while 98.4% patients gave up acupuncture. The mean latency of BTX-A effect was (5.0±4.7) days, the mean total duration of the effect was (19.5±11.7) weeks, and 95.9% patients developed improvements no worse than moderate in both severity and function. The most common side effect was droopy mouth. Conclusions The onset age of HFS in China is earlier than that in western countries. The most often used two treatments are BTX-A injection and acupuncture, while the latter kept the poor repeat treatment ratio because of dissatisfactory therapeutic effect.