Idiopathic Paralysis Research Articles

Combination of Manual Acupuncture, Penetrating Needling, and Electroacupuncture to Treat Bell's Palsy.

Bell's palsy is an acute idiopathic paralysis of lower motor neurons on only 1 side of the face without any identifiable etiology. The condition affects a patient's physical, social, and psychologic health. It is important for the patient to recover quickly and minimize the risk of long-term sequelae. Therefore, researchers recommend a combination of several therapeutic modalities to shorten the disease's course and improve curative effects. A 34-year-old woman had with right facial weakness. She was diagnosed with House-Brackmann grade III Bell's palsy and received medical therapy. She was also given manual acupuncture at GB-20, BL-2, ST-36, LI-4, TE-5 bilateral, and GV-20. Penetrating needling was given at GB-14 toward Ex-HN-3, ST-7 toward SI-18, SI-18 toward LI-20, ST-6 toward ST-4, and ST-5 toward ST-4 on the affected area, with a 30-minute needle retention. Electroacupuncture (EA) was delivered at ST-7-SI-18, ST-6-ST-5, GB-14-Ex-HN-5, and ST-4-CV-24, with a dense-disperse wave, at a frequency of 10/50 Hz for 20 minutes. She had treatment sessions twice per week, for a total of12 sessions. From her 7th to 12th visit, this patient had reached House-Brackmann grade I. No adverse effects occurred. In this patient, a combination of acupuncture penetrating needling technique and EA played a role to shorten her recovery time and minimize the risk of sequelae of Bell's palsy. The treatment combination used in this case report can be considered in other clinical cases.

Acyclovir with Steroid and Steroid Alone in the Treatment of Idiopathic Facial Nerve Palsy: A Randomised Double-blinded Clinical Study from a Tertiary Care Centre, Chennai, India

Introdutcion: Idiopathic palsy of facial nerve is an acute disease which causes lower motor neuron palsy characterised by facial asymmetry leads to psychological effects and limits one’s social life. Steroids are very effective in the management of Bell’s palsy. The usage of antiviral is still in debate due to the idiopathic aetiology of Bell’s palsy. Aim: To evaluate the efficacy of acyclovir with steroid and steroid alone in the management of Bell’s palsy with respect to the recovery time. Materials and Methods: The randomised double-blinded study was conducted in the Department of Otorhinolaryngology, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India, from September 2021 to February 2022 among 100 patients with idiopathic facial nerve palsy. Patients were divided into two groups, 50 patients in each. One group treated with acyclovir (400 mg oral five times daily) and methylprednisolone (1 mg/kg/ day), and other group treated with steroid alone. Both the groups received physiotherapy in the Department of Physiotherapy and taught about home facial exercises. The patients were on regular follow-up for 6 months to monitor the time of the recovery. HouseBrackmann grading system was used for initial assessment and monitor the recovery of the patient. The improvement of House-Brackmann grade to I or II was considered a satisfactory recovery. The association between two groups were assessed by Chi-square test (χ2 ), repeated measures and paired t-test. The statistical significance was considered when p-value<0.05. Results: Out of 100 patients, 52 patients were male and 48 were female, while the age range was 19-58 years. At 2 months, 43 (86%) patients recovered in the combination group and 41 (82%) in the steroid alone group (p-value=0.0038). At 6 months, 48 (96%) patients recovered in the combination group and 42 (84%) in the steroid alone group (p-value=0.178). The overall recovery rate was higher in the combination group (96%) compared to steroid alone group (84%). Conclusion: The combination of acyclovir with steroids in the treatment of Bell’s palsy has better recovery compared to steroid alone therapy.

Extralaryngeal causes of unilateral vocal cord paralysis: Aetiology and prognosis

Introduction and methodologyUnilateral vocal cord paralysis without laryngeal lesions is a relatively frequent entity. It can be the manifestation of numerous diseases of the thorax, neck, skull, or systemic disease. The objective is to study the extralaryngeal aetiology of unilateral vocal cord paralysis, its prognosis, and the relationship of both with different clinical variables. Retrospective study of 116 patients with complete unilateral vocal cord paralysis without laryngeal lesions. The patients underwent cervical-thoracic CT ± evaluation by Neurology with brain MRI to establish the aetiology and were followed-up for at least 1 year. ResultsThe most common extralaryngeal cause of vocal cord paralysis was cervical surgery (46.5%), followed by tumour (24.1%). Idiopathic paralysis was the cause in 15.5%. An association was obtained between sex and aetiology (P < .01), men in relation to malignant pathology and women to iatrogenic disease. Cardiovascular, cerebrovascular, tumour and idiopathic aetiology predominated in elderly patients; while surgical aetiology predominated in younger patients (P < .01). A total of 18.1% recovered vocal cord mobility. The female sex was related to recovery (P < .01). Tobacco and malignant aetiology were related to persistence (P < .01). ConclusionsThe first extralaryngeal cause of unilateral CV paralysis is surgical followed by lung and thyroid neoplasms. There is a great diversity of lesions that can cause the condition, in many cases involving a diagnosis of malignant tumours. Recovery is more frequent in female patients, non-smokers and with benign pathology.

Un pianto stridulo che confonde: non è sempre laringomalacia

The case of a young infant with congenital stridor eventually diagnosed as unilateral idiopathic paralysis of vocal cords is described. The differential diagnosis of congenital stridor is discussed.

Chapter 14 - Phrenic nerve paralysis and phrenic nerve reconstruction surgery

Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.

KABAT INTERVENTIONS INTEGRATED WITH FACIAL EXPRESSIVE AND FUNCTIONAL EXERCISES FOR BETTER AND SPEEDY RECOVERY IN BELL’S PALSY; A PRE-POST DESIGN

Background: Bell’s palsy (BP) is an acute and idiopathic paralysis of the seventh cranial nerve, which has higher incidence rate in Asian countries compared to the western world. Different contemporary physiotherapy interventions have been used in treatment of impairments and functional limitations caused due to the BP. However, traditional usual care is still in practice in context like Nepal, which has to be shifted to evidence-based treatment. Therefore, pres­ent study investigated effectiveness of Kabat intervention integrated with facial expressive and functional exercises in Bell’s palsy. Methods: This pre-post comparative study recruited eight participants of age 22 to 52 years with acute and sub-acute, unilateral, idiopathic BP by purposive sampling. A physiotherapist admin­istered the Kabat intervention integrated with facial expressive and functional exercises for four weeks. Another physiotherapists assessed before as well as after two and four weeks of the treat­ment using Sunny Brook Facial Grading, House-Brackmann grading, lip-length measurement, facial disability and patients’ satisfaction measures. One-way ANOVA with repeated measures was used to analyze data across three points of time. Results: Eight participants with mean age 41.38 years (10.66) completed the study. Significant improvement with high effect sizes (0.82 – 0.95) was found on both outcome measures across the time. There was significant improvement on lip measurement as well. The participants’ satisfaction level was 8.5 (±1.20)/10 with the intervention. Conclusions: The Kabat intervention integrated with facial expressive and functional exercises demonstrated significant improvement in impairments and functional level. Large effect sizes and high level of participants’ satisfaction indicated clinical relevance of the intervention.

Assessment of anti-HSV antibodies in patients with facial palsy in the course of neuroborreliosis.

There are many causes of facial nerve palsy. The most common causes are neuroborreliosis (NB), idiopathic paralysis or Herpes simplex virus (HSV) reactivation. The aim of this study was to characterize patients with facial palsy in the course of NB and to determine whether HSV-1 reactivation takes place during the acute phase of NB. A retrospective analysis of 66 patients with facial nerve palsy was performed. In 38 patients, facial palsy was caused by Borrelia burgdorferi sl infection. Immunological tests for HSV-1, tick-borne encephalitis virus and B burgdorferi sl in serum and cerebrospinal fluid (CSF) were performed. In this analysis, 55.2% of NB patients had right nerve palsy and 21% bilateral palsy; 15.8% of patients had erythema migrans (EM). Lymphocytic meningitis was diagnosed in 92% of patients and Bannwarth's syndrome was diagnosed in 47% of patients. IgM anti-HSV-1 antibodies were detected in four patients with NB and two patients with facial nerve palsy of other origin. IgM anti-HSV-1 antibodies were detected in the CSF of three patients (7.9%) with NB, and one of them had bilateral VII paresis and EM simultaneously. Treatment with ceftriaxone or doxycycline led to complete recovery. Neuroborreliosis should always be considered as a cause of peripheral facial nerve palsy. Peripheral facial nerve palsy is a significant symptom in the course of NB, especially in patients accompanied by meningitis. Pathomechanism of facial nerve paresis has not been well explained so far and may depend on two independent mechanisms in NB, including HSV-1 reactivation.

A method for fast automated assessment of the magnetic resonance parkinsonism index.

In patients with parkinsonian syndromes, and particularly during the early stages of the clinical disease, differentiating between idiopathic Parkinson's disease and progressive supranuclear palsy is challenging. Imaging plays an important role in early diagnosis, and the magnetic resonance parkinsonism index was shown to reliably differentiate between the two entities. Calculation of the index is a time-consuming process. We developed an algorithm allowing its automatic calculation based on 3D T1-weighted images, producing additional color-coded images for verification.

Idiopathic Neuritis of the Trigeminal Nerve in a Dog

Background: Idiopathic trigeminal neuropathy is a peripheral neuropathy whose clinical signs include inability to close the mouth. A neurological examination reveals mainly flaccid paralysis of the masticatory muscles, which may be accompanied by atony/hypotonia of the masseter and temporalis muscles. Altered sensitivity may also be present in very rare cases. This article reports a case of idiopathic trigeminal neuropathy with involvement of the motor and sensory nerve fibers in a dog, describing the clinical symptoms, neurological findings, exclusion of other diseases, and evolution of the condition.Case: A 5-year-old bitch showing signs of difficulty in picking up food, swallowing water, and hypersalivation was taken to a veterinary clinic. According to her owner, these signs had started spontaneously 2 days earlier. A physical examination of the animal revealed only a persistently open mouth, although the mouth opening and closing movements could be performed manually by manipulating the jaw. The patient showed swallowing ability, and her tongue movements were intact. The neurological examination revealed that the animal also presented bilateral absence of nasal sensitivity and absence of palpebral reflex. The animal’s blood test results showed changes only in the CK and AST levels, which were 1,182.60 U/L (reference: 1.5 to 28.4 U/L) and 87.1 IU/L (reference: 6.2 to 13 IU/L), respectively. The animal tested negative for distemper, leishmaniasis, toxoplasmosis and neosporosis. Abdominal ultrasound and thoracic radiography were performed to investigate neoplasia, as well as radiography of the temporomandibular joints, and none of these imaging tests revealed any alterations. A cerebrospinal fluid (CSF) analysis was also within the normal range of reference parameters. In view of the possibility of idiopathic trigeminal neuropathy, prednisolone (Prediderm® 10 mg) was prescribed, to be administered orally in a dose of 0.5 mg/kg at 12 h intervals for 2 days. In addition, the owner was told to provide supportive care by feeding the animal a pasty diet placed directly in the back of its mouth, using a syringe if necessary. An examination of the animal in a follow-up visit to the veterinary clinic 14 days later found that she had recovered completely from her initial condition.Discussion: Among the most common causes of neurogenic flaccid paralysis of the masticatory muscles is idiopathic trigeminal neuropathy, although trigeminal neuropathy secondary to neoplasms and infectious or parasitic diseases may also occur. Because its etiology is of unknown origin, it is essential to exclude other causes of peripheral neuropathies. Moreover, this disorder is characterized by its self-limiting evolution, with spontaneous cure of the clinical condition within two weeks, as was observed in the case reported here. The absence of nasal sensitivity is not usually found in dogs diagnosed with idiopathic trigeminal nerve paralysis. In this case, however, there was involvement of the motor and sensory fibers, since, in addition to flaccid paralysis of the masticatory muscles, nasal sensitivity was also found to be affected. The condition can be treated with corticosteroids when it first appears, simply in order to hasten the animal’s recovery from the disorder. In addition, given the animal’s inability to close its mouth, it is essential to provide supportive care by feeding it with pasty foods and water by hand to ensure it receives adequate nutrition during the course of the disorder.

Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk.

Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle. Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented. All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients. Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.

Centenary of Tretiakoff’s thesis on the morphology of Parkinson’s disease, evolved on the grounds of encephalitis lethargica pathology

ABSTRACTIn his Thèse de Paris (1919) Konstantin Tretiakoff (1892–1956) described the two main morphological lesions in Parkinson’s disease: the loss of pigmented nerve cells in the Substantia nigra and the intracellular inclusion bodies in idiopathic paralysis agitans, calling them “Corps de Lewy,” which already had been described by F. H. Lewy in 1912. Tretiakoff’s findings on idiopathic Parkinson’s disease were confirmed years later by Rolf Hassler in his dissertation on anatomy and pathology of Substantia nigra in Berlin (1938, 1939). German authors in the 1920s underestimated the significance of both findings (Bielschowsky, 1922; Lewy 1923/1924; Spatz 1927), especially Lewy himself. Lewy (1923) and other German neurologists and neuropathologists like Felix Stern (1922, 1928), Goldstein (1922), and Spatz (1927; Luksch & Spatz, 1923) acknowledged the typical Nigra-lesions only for postencephalitic Parkinsonism. It is argued that Tretiakoff’s selective attention for the Substantia nigra was guided by the frequency of epidemic encephalitis lethargica and its preponderance of nigral pathology. This impression can be derived from Tretiakoff’s early paper on that disease (Marie & Tretiakoff, 1918) and from Paul Foley’s opus magnum (2018). Two outstanding neurologists dedicated to this issue are called into memory: Gabrielle Lévy, the successor of Tretiakoff in the Salpêtrière laboratory, and Felix Stern, who died in 1942 as a victim of Nazi terror. The eponym Lewy-bodies went back to Lafora and Tretiakoff (“Corps de Lewy”). Newly expressed doubts about Lewy’s primacy or Lafora’s credit for the eponym (Lafora-bodies since 1911) can be refuted with the studies of Greenfield and Bosanquet (1953) and Greenfield (1963) by illustrating their different staining properties.

Evaluation of the sensitivity of the Psychosocial Scale of Facial Appearance in peripheral facial paralysis.

To investigate the sensitivity and internal consistency of the Psychosocial Scale of Facial Appearance (PSFA) based on the comparison between its results and those from other facial functional assessment instruments: House-Brackmann scale (HBS) and Facial Grading System - and the psychosocial implications measured by the Hospital Anxiety and Depression Scale (HADS). The study was approved by the Research Ethics Committee of the aforementioned Institution under protocols no. 196.977 and 230.982. Thirty-eight adult individuals with Peripheral Facial Palsy (PFP) were submitted to closed interviews in order to evaluate the sensitivity of the questionnaire. Statistical analyses were conducted for each stage of this study. Data were entered in Excel® spreadsheet and analyzed using SPSS 17.0 and AMOS 22.0 for Windows®. Study participants were 38 individuals with PFP aged 19-78 years with predominance of idiopathic paralysis (44.7%). Results of the Cronbach's Alpha coefficient showed strong internal consistency between the thematic groups and the questions; however, Confirmatory Factor Analysis indicated some questions with week causal relationship between thematic groups, namely, questions 5 and 6 of the group Functional Aspects of Face, question 17 of the group Social Aspects, and question 23 of the group Emotional Aspects. This study provided the first steps for the subsidy and support of an instrument designed to investigate the psychosocial aspects associated with PFP, enabling the preparation of questions and their organization into thematic groups. However, further studies are needed to conclude the validation processes.

Facial nerve decompression.

Facial nerve paralysis is a debilitating condition. Bell's palsy and temporal bone trauma are common causes of acute facial palsy, with recurrent idiopathic paralysis and Melkersson-Rosenthal syndrome accounting for a smaller subset of cases. Properly selected patients may benefit from facial nerve decompression. This article will review the relevant literature on facial nerve decompression. The middle cranial fossa approach provides access to the primary site of lesion in Bell's palsy while preserving hearing. Patients with complete facial paralysis secondary to Bell's palsy or temporal bone trauma, more than 90% degeneration on electroneurography testing, and absent voluntary electromyography within 14 days of onset may benefit from facial nerve decompression. Facial nerve decompression may prevent future occurrences of recurrent forms of facial nerve paralysis. The return of facial nerve function following decompression will occur over weeks to months. Appropriately selected patients with facial paralysis secondary to Bell's palsy or temporal bone trauma may benefit from facial nerve decompression. Patients should be counseled regarding the risks of decompression and that the return of maximal facial nerve function may be delayed up to 12 months.

Chirurgie bei Läsionen des Nervus facialis

There are numerous reasons for facial palsy, which range from idiopathic palsy (Bell's palsy) to destruction of the facial nerve by a malignant salivary gland tumor. If the chance of spontaneous recovery is low or there is no drug therapy available, surgery is a therapeutical option. Recently, larger studies were published by specialized centers which enable a more individualized therapeutical concept to achieve tone, symmetry and movement of the paralyzed face based on a detailed preoperative assessment. An important therapy target is the improvement of patient´s quality of life. In the present article, we systematically review the important diagnostic steps and, directly derived from this, the indications for surgical options for reanimation of the mimic function. Furthermore, we provide an overview about a variety of postoperative adjuvant measures as well as on new objective assessment tools to evaluate the therapy results.

Development of Bell's Palsy After Treatment With Ipilimumab and Nivolumab for Metastatic Melanoma: A Case Report.

Ipilimumab is a human monoclonal antibody that targets cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), and it is FDA approved for the treatment of unresectable or metastatic melanoma. Immune-related adverse events (irAEs) of gastrointestinal, dermatologic, and endocrine origin are commonly seen, ranging between 18% and 44%, with immune checkpoint inhibitors (anti-CTLA-4 and anti-PD-1/PD-L1). Rare irAEs include neurological, renal, and hematologic toxicities. Bell's palsy is a form of neurological toxicity that presents as an idiopathic paralysis of the muscles on one side of the face. We report a case of Bell's palsy in a 45-year-old male patient who received 1 dose of both ipilimumab and nivolumab for the treatment of metastatic melanoma. After the resolution of symptoms, ipilimumab was permanently discontinued and single-agent nivolumab administered. The patient has remained free of neurological symptoms. This case suggests that Bell's palsy is an irAE induced by ipilimumab.

Time course of recovery of idiopathic vocal fold paralysis.

To clarify the time course of recovery in patients with idiopathic vocal fold paralysis. Retrospective chart review. Medical records for all patients with idiopathic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. Thirty-eight of 55 patients (69%) recovered vocal function. Time course of recovery could be assessed in 34 patients who did not undergo injection augmentation. The mean time to recovery was 152.8 ± 109.3 days (left, 179.8 ± 111.3 days; right, 105.3 ± 93.7 days; P = .088). Two-thirds of patients recovered within 6 months. Probability of recovery declined over time. Five of 22 patients who recovered voice had return of vocal fold motion; 17 did not. The mean time to recovery did not differ between these groups (return of motion, 127.4 ± 132.3 days; no return of motion, 160.1 ± 105.1 days; P = .290). Sixty-nine percent of patients with idiopathic vocal fold paralysis recovered vocal function, two-thirds doing so within 6 months of onset. Age, gender, laterality, use of injection augmentation did not influence recovery rate. Declining probability of recovery over time leads us to consider framework surgery after 6 months in patients with idiopathic paralysis. 4. Laryngoscope, 128:148-152, 2018.

Repeat Imaging in Idiopathic Unilateral Vocal Fold Paralysis: Is It Necessary?

Imaging plays a critical role in the evaluation of patients presenting with unilateral vocal fold paresis or paralysis of unknown etiology. In those with idiopathic unilateral vocal fold paralysis (iUVFP), there is no consensus regarding the need or timing of repeat imaging. This study seeks to establish the rate of delayed detection of alternate etiologies for these patients to determine if and when imaging should be repeated. Retrospective chart review was conducted identifying patients at our institution with vocal fold movement impairment between 1998 and 2014. Idiopathic paralysis was diagnosed if physical examination, laryngoscopy, and initial imaging excluded a cause. Demographic data, length of follow-up, and the presence of late lesions were noted. Time to detection was plotted using the Kaplan-Meier method. Of 3210 patients reviewed, 207 had a diagnosis of iUVFP. Of these patients, 8 went on to develop alternate diagnoses, including pulmonary disease, skull-base and laryngeal neoplasms, and thyroid malignancy. In Kaplan-Meir analysis, 90% remained "idiopathic" at 5 years of follow-up. The mean time to detection was 27 months. Patients initially diagnosed with iUVFP may have an occult cause that later becomes evident. We recommend repeat imaging within 2 years after diagnosis, but this is likely unnecessary beyond 5 years.

Abstract #1161: Idiopathic Hypokalemic Paralysis Successfully Treated with Sympathomimetic Amines

Abstract #1161: Idiopathic Hypokalemic Paralysis Successfully Treated with Sympathomimetic Amines

Ophthalmic profile and systemic features of pediatric facial nerve palsy

Facial nerve palsy (FNP) occurs less frequently in children as compared to adults but most cases are secondary to an identifiable cause. These children may have a variety of ocular and systemic features associated with the palsy and need detailed ophthalmic and systemic evaluation. This was a retrospective chart review of all the cases of FNP below the age of 16 years, presenting to a tertiary ophthalmic hospital over the period of 9 years, from January 2000 to December 2008. A total of 22 patients were included in the study. The average age at presentation was 6.08 years (range, 4 months to 16 years). Only one patient (4.54%) had bilateral FNP and 21 cases (95.45%) had unilateral FNP. Seventeen patients (77.27%) had congenital palsy and of these, five patients had a syndromic association, three had birth trauma and nine patients had idiopathic palsy. Five patients (22.72%) had an acquired palsy, of these, two had a traumatic cause and one patient each had neoplastic origin of the palsy, iatrogenic palsy after surgery for hemangioma and idiopathic palsy. Three patients had ipsilateral sixth nerve palsy, two children were diagnosed to have Moebius syndrome, one child had an ipsilateral Duane's syndrome with ipsilateral hearing loss. Corneal involvement was seen in eight patients (36.36%). Amblyopia was seen in ten patients (45.45%). Neuroimaging studies showed evidence of trauma, posterior fossa cysts, pontine gliosis and neoplasms such as a chloroma. Systemic associations included hemifacial macrosomia, oculovertebral malformations, Dandy Walker syndrome, Moebius syndrome and cerebral palsy FNP in children can have a number of underlying causes, some of which may be life threatening. It can also result in serious ocular complications including corneal perforation and severe amblyopia. These children require a multifaceted approach to their care.

Clinical factors underlying a single surgery or repetitive surgeries to treat superior oblique muscle palsy.

The purpose of this study is to know clinical factors underlying either a single surgery or repetitive surgeries, required to treat superior oblique muscle palsy. Retrospective review was made on 246 consecutive patients with idiopathic (n = 212) or acquired (n = 34) superior oblique muscle palsy who underwent surgeries in 8 years at one institution. Idiopathic palsy included congenital and decompensated palsies while acquired palsy included traumatic and ischemic palsies. Clinical factors, compared between groups with a single surgery (n = 203) and two or more surgeries (n = 43), were surgical methods, sex, age at surgery, horizontal, vertical, and cyclotorsional deviations, and stereopsis at near fixation. Inferior oblique muscle recession on paretic side was chosen in about 60% of the single-surgery and repetitive-surgery group as an initial surgery, followed by inferior rectus muscle recession on non-paretic side. The age at surgery was significantly older, vertical and cyclotorsional deviations were significantly larger in the repetitive-surgery group, compared with the single-surgery group (P = 0.01, P < 0.001, P = 0.02, Mann–Whitney U-test, respectively). The 95% confidence interval of vertical deviations was 15–17 prism diopters in the single-surgery group and 23–28 prism diopters in the repetitive surgery group. Significant differences in vertical deviations were replicated also in subgroups of patients with either idiopathic or acquired palsy. In conclusions, the 95% confidence interval of vertical deviations, determined by alternate prism and cover test, would be used as a common benchmark for predicting either a single surgery or repetitive surgeries, required to treat idiopathic and acquired superior oblique muscle palsy, in the process of obtaining the informed consent.