The role of botulinum toxin A neuromodulator in the management of synkinesis in facial palsy.

Facial palsy describes the denervation of the facial nerve leading to a difficulty of facial animation and expression. Facial synkinesis is the result of complex pathological nerve regeneration following damage to the facial nerve axons. Synkinesis in facial palsy can be managed using facial neuromuscular rehabilitation, botulinum toxin neuromodulators and surgical treatment options. Botulinum toxin A can be used as an adjunct to other treatment options to manage synkinesis. This article will explore the role of botulinum toxin A in the management of sykinesis in facial palsy including the clinical assessment, injection location (muscles targeted), dosages, treatment interval and longterm results. It will also include surgical management options.

Psychological Aspects of Facial Palsy.

This article discusses the psychological effects of facial palsy (FP) in adults. FP is the abnormal functioning of facial muscles resulting from temporary or permanent damage of the facial nerves. Following facial paralysis, patients can develop motor and psychosocial functioning issues impacting quality of life. In addition, real or perceived judgment in social settings of those with FP increases the risk of low self-esteem, anxiety, and depression. Currently, most available research focuses on surgical patients and suggests a lack of psychological support throughout the affliction. A multidisciplinary approach when treating patients with FP can help improve the patient's quality of life.

The Emerging Role of Artificial Intelligence Tools for Outcome Measurement in Facial Reanimation Surgery: A Review.

Importance: Surgeons treating facial paralysis with reanimation surgery measure the outcomes of surgery and adjust treatment to each patient's needs. Our objective is to review the current subjective facial paralysis assessment tools and the emerging computer-based objective analysis, which may involve artificial intelligence. Observations: In recent years, many new automated approaches to outcome measurement in facial reanimation surgery have been developed. Most of these tools utilize artificial intelligence to analyze emotional expression and symmetry of facial landmarks. Other tools have provided automated approaches to existing clinician-guided scales. Conclusions: Newly developed computer-based tools using artificial intelligence have been developed to both improve existing clinician-graded scales and provide new approaches to facial symmetry and emotional expressivity analysis.

Voluntary and Spontaneous Smile Quantification in Facial Palsy Patients: Validation of a Novel Mobile Application.

Introduction: Restoration of spontaneous smiling is a key goal in facial reanimation. A major obstacle to quantifying recovery of spontaneous smiling is the current lack of a uniform and objective means of smile quantification. Objective: To compare the facial movements during smiling in patients with facial paralysis as measured by an automated application and human observers. Methods: Video recordings of 25 patients with unilateral facial palsy (FP) watching humorous videos were utilized. Application-derived smile timestamping was compared with manual observer interpretation. Internal reliability of measurements was evaluated through a test-retest approach. Results: Application-derived smile identification demonstrated almost perfect agreement with manual interpretation (kappa 0.861, p < 0.001). There was no statistically significant difference in mean number of smiles between detection method (p = 0.354). Automated smile identification demonstrated a high degree of specificity (95.4%), accuracy (93.1%), positive-predictive value (94.7%), and negative-predictive value (91.8%). This method demonstrated a high degree of reliability (kappa 0.864, p < 0.01). Conclusion: The novel "SmileCheck" mobile phone application performed accurate and reliable smile quantification in FP patients in comparison with manual observation.

Tranexamic acid in otorhinolaryngology - A contemporary review.

Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.

Bell's palsy during pregnancy and the post-partum period: A contemporary management approach.

Bell's palsy during pregnancy and the immediate post-partum period represents a unique clinical entity requiring an individualised management approach. Whilst the exact link between Bell's palsy and pregnancy is still unclear, the majority of cases occur in the third trimester and immediate post-partum period. These patients have been demonstrated to experience worse long term outcomes and are less likely to receive early corticosteroid therapy. This review suggests a contemporary management algorithm to ensure that these patients receive early therapy that is safe for the patient and foetus and meets the unique physical needs of the expecting or new mother.

A Non-inferiority Trial: Safety and Efficacy of Topical 1:1000 versus 1:10 000 Epinephrine in Sino-nasal Surgeries.

OBJECTIVE: This study aimed to test the non-inferiority of topical 1:1000 epinephrine compared to topical 1:10 000 with regard to intraoperative hemodynamic stability, and to determine whether it produced superior visibility conditions. METHODS: A single-blinded, prospective, cross-over non-inferiority trial was performed. Topical 1:1000 or topical 1:10 000 was placed in 1 nasal passage. Hemodynamic parameters (heart rate, systolic and diastolic blood pressures, and mean arterial pressure) were measured prior to insertion then every minute for 10 minutes. This was repeated in the contralateral nasal passage of the same patient with the alternate concentration. The surgeon graded the visualization of each passage using the Boezaart Scale. The medians of the greatest absolute change in parameters were compared using a Wilcoxon Rank-Signed test and confidence intervals were calculated using a Hodges-Lehman test. The non-inferiority margin was pre-determined at 10 bpm for heart rate and 10 mmHg for blood pressures. A Wilcoxon Rank-Signed test was used to assess superiority in visualization. RESULTS: Thirty-two patients were enrolled and after exclusions, nineteen were assessed (mean age = 35.63 ± 12.49). Differences in means of greatest absolute change between the 2 concentrations were calculated (heart rate = 2.49 ± 1.20; systolic = -1.51 ± 2.16; diastolic = 2.47 ± 1.47; mean arterial pressure = 0.07 ± 1.83). In analyses of medians, 1:1000 was non-inferior to the 1:10 000. There was a significant difference (-0.58 ± 0.84; P = .012) in visualization in favor of topical 1:1000. CONCLUSION: Topical 1:1000 epinephrine provides no worse intraoperative hemodynamic stability compared to topical 1:10 000 but affords superior visualization and should be used to optimize surgical conditions.

Does Botulinum Toxin Therapy Improve Quality of Life in Patients with Facial Palsy?

OBJECTIVES: To review the current literature for the efficacy of botulinum toxin therapy to improve quality of life in patients with facial palsy. METHODS: A comprehensive systematic literature search was performed of the Medline, EMBase, PubMed and Cochrane Library databases. The population of interest was patients with facial palsy and the intervention of interest was botulinum toxin injection. The primary outcome of this review was quality of life outcomes before and after treatment. RESULTS: Six studies were included for review. Outcome data were not amenable to meta-analysis due to the heterogeneity of outcome measures. There was an overall trend towards improvement in quality of life after botulinum toxin therapy with the majority of studies demonstrating a statistically significant benefit. The aspects of life in which patients saw benefit varied amongst studies. No patient factors were identified to predict which sub-cohort would likely have the greatest benefit from therapy. Two studies reported adverse effects to be common however minor in nature. CONCLUSION: This review presents contemporary evidence that botulinum toxin is of benefit to the quality of life of patients with facial palsy. Additional larger randomised control trials would aid clinicians in quantifying the benefit of such therapies for patients with facial palsy. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

High Altitude Alternobaric Facial Palsy: Case Series and Systematic Review of the Literature.

BACKGROUND: Alternobaric facial palsy (AFP) is a rare phenomenon which occurs in patients with Eustachian tube dysfunction, a dehiscent facial canal, and subsequent compression induced ischemic neuropraxia of the facial nerve upon exposure to atmospheric pressure changes. There are few documented cases of AFP and most relate to underwater diving. There is limited understanding in the literature of AFP in the setting of high altitude, leading to a potential for misdiagnosis and inappropriate management. OBJECTIVE: We present two cases of transient, recurrent, unilateral facial palsy at high altitude and perform a systematic review of the available literature. DATA SOURCES: Full-text articles indexed to Medline, EMBase, and PubMed, and associated reference lists. DATA EXTRACTION: Data was extracted into standardized data extraction forms. DATA SYNTHESIS: Binomial proportions and Fischer's exact test were used to analyze sex distribution and relationship between sex and side of palsy, and number of episodes experienced. METHODS: Systematic review using PRISMA guidelines with meta-analysis. RESULTS: We identified 19 cases in the literature relating to AFP in patients at high altitude and present two new cases. CONCLUSION: AFP is an uncommon but important diagnosis. We present two cases and systematically review the literature to discuss the diagnosis and management of AFP.

Computed tomographic analysis of outer calvarial thickness for osseointegrated bone-anchored hearing system insertion.

INTRODUCTION: Osseointegrated bone-anchored hearing systems (BAHSs) are a useful tool in auditory rehabilitation for single-sided deafness and conductive/mixed hearing loss. They rely on adequate osseointegration of titanium implants, which can be limited by calvarial thickness. This study examines adult computed tomographic (CT) temporal bone normative data for calvarial thickness in the areas commonly recommended for BAHS insertion and identifies hazards that may compromise the osseointegration process. METHODS: Prospective analysis of 100 consecutive adult helical CT scans. Calvarial thickness was measured in axial and coronal planes 5.5 cm posterior to the superior external auditory canal at 6 vertical points (EAC, +1 cm, +2 cm, +3 cm, +4 cm, and +5 cm). Other parameters measured include temporal bone pneumatization and the presence of suture lines, bone marrow, and vascular structures. RESULTS: A total of 195 temporal bones were examined in 100 patients. Mean patient age was 60.9 years, of whom 54.4% were men and 45.6% were women. Mean calvarial thickness was greatest at +1 cm above the EAC level (6.3 mm) and thinnest at +4 cm (5.1 mm). Of temporal bones, 55% had at least 1 site thinner than 4 mm and 21% had at least 1 site thinner than 3 mm. Air cells and suture lines were more likely to be encountered within 2 cm above the EAC level, and marrow space is more likely to be encountered 3 to 4 cm above the EAC level. DISCUSSION: Selecting a position 3 to 4 cm above the level of the EAC is more likely to result in dural exposure for a 3-mm BAHS abutment, especially in men. Selecting a position near the level of the EAC provides thicker bone, but the surgeon is more likely to encounter suture line or enter mastoid air cells. Preoperative CT imaging may be a useful tool in evaluating calvarial thickness and hazards when planning BAHS insertion in the adult population.