Bell's palsy: aetiology, clinical features and multidisciplinary care.

Bell's palsy is a common cranial neuropathy causing acute unilateral lower motor neuron facial paralysis. Immune, infective and ischaemic mechanisms are all potential contributors to the development of Bell's palsy, but the precise cause remains unclear. Advancements in the understanding of intra-axonal signal molecules and the molecular mechanisms underpinning Wallerian degeneration may further delineate its pathogenesis along with in vitro studies of virus-axon interactions. Recently published guidelines for the acute treatment of Bell's palsy advocate for steroid monotherapy, although controversy exists over whether combined corticosteroids and antivirals may possibly have a beneficial role in select cases of severe Bell's palsy. For those with longstanding sequaelae from incomplete recovery, aesthetic, functional (nasal patency, eye closure, speech and swallowing) and psychological considerations need to be addressed by the treating team. Increasingly, multidisciplinary collaboration between interested clinicians from a wide variety of subspecialties has proven effective. A patient centred approach utilising physiotherapy, targeted botulinum toxin injection and selective surgical intervention has reduced the burden of long-term disability in facial palsy.

Prognostic factors in herpes zoster oticus (ramsay hunt syndrome).

OBJECTIVES: To determine if an accurate prognosis can be made in patients with Herpes zoster oticus (HZO), facial nerve outcomes were assessed at 1-year after onset and compared with symptoms and signs at presentation. STUDY DESIGN: Individual retrospective cohort study of 101 records in a case series (level of evidence: Level 2b). METHODS: Symptoms, signs, audiology, and treatment records were analyzed to determine their association with facial nerve outcome at 1 year. RESULTS: Mean improvement at 1 year for the 101 patients was 3 House-Brackmann (HB) grade units. Initially, severity ranged from HB III to HB VI. Mean recovery was significantly greater for those patients who were initially more affected, although at 1 year, they had still not recovered to the same grade as those initially less affected. Having both incomplete eye closure and a dry eye was associated with less recovery at 1 year. The use of prednisone combined with an antiviral agent, and begun at or after Day 5 of the illness, was related to a better facial nerve outcome. No other symptom, sign, or audiologic feature was of prognostic value. CONCLUSION: All patients with HZO improved facial function to some degree, with the mean gain at 1 year after onset being 3 HB grade units. Improvement was less for patients who initially had both incomplete eye closure and dry eye. The group who received a combination of an antiviral medication with steroids given after 5 days had the best facial nerve outcome.

Infective causes of facial nerve paralysis.

OBJECTIVE: To review the functional recovery in a cohort of patients with facial nerve paralysis (FNP) due to infective cause. STUDY DESIGN: Retrospective review based on patients identified from a prospectively maintained database of patients with FNP. The case notes of identified patients were reviewed. SETTING: Tertiary referral center. PATIENTS: The patients were identified from a database of 1074 patients with FNP. One hundred twenty of the 150 patients identified as having FNP due to an infectious disease caused by herpes zoster oticus were excluded from the study. The remaining 30 patients were included in the study. INTERVENTIONS: Patients were treated both operatively and nonoperatively. Operative treatment included myringotomy and ventilation tube placement, cortical mastoidectomy, modified radical (canal wall down) mastoidectomy, petrous apicectomy, and lateral temporal bone resection. MAIN OUTCOME MEASURES: This study used the House-Brackmann (HB) grade of facial function at 1 year after initial assessment. The patients were identified from a prospectively maintained database of all patients presenting with FNP to a single specialist otolaryngologist (G.R.C.) between June 1988 and April 2005. The database contains information including demographic details, dates of presentation, diagnostic modalities used, diagnosis, interventions, and HB grade. The patients in this series presented between August 4, 1989 and August 26, 2003. RESULTS: Twenty-nine patients with 30 facial nerve paralyses were identified. The causes of FNP were acute otitis media (n = 10); cholesteatoma (n = 10 [acquired, 7; congenital, 3]); mastoid cavity infections (n = 2); malignant otitis externa (n = 2); noncholesteatomatous chronic suppurative otitis media (CSOM; n = 2); tuberculous mastoiditis (n = 1); suppurative parotitis (n = 1); and chronic granulomatosis (n = 1). The patients with noncholesteatomatous CSOM who presented sooner after the onset of facial nerve symptoms had greater facial nerve recovery when assessed using the HB grade at 1 year. CONCLUSION: FNP due to infective causes other than herpes zoster oticus is rare. Patients with noncholesteatomatous CSOM and FNP have a better outcome than those with FNP due to cholesteatoma. Patients with FNP due to acute otitis media tend to have a good prognosis without surgical decompression of the facial nerve being required.

Bilateral conjugacy of movement initiation is retained at the eye but not at the mouth following long-term unilateral facial nerve palsy.

Voluntary eyelid closure and smiling were studied in 11 normal subjects and 11 patients with long-term unilateral facial nerve palsy (FNP). The conjugacy of eyelid movements shown previously for blinks was maintained for voluntary eye closures in normal subjects, with movement onset being synchronous in both eyes. Bilateral onset synchrony of the sides of the mouth was also observed in smiling movements in normal subjects. In FNP patients, initiation of movement of the paretic and non-paretic eyelids was also synchronous, but markedly delayed relative to normal (by 136 ms = 32%). The initiation of bilateral movements at the mouth was similarly delayed, but in contrast to the eyes, it was not synchronous. Central neural processing in the FNP subjects was normal, however, since unilateral movements at the mouth were not delayed. The delays therefore point to considerable additional information processing needed for initiating bilateral facial movements after FNP. The maintenance of bilateral onset synchrony in eyelid closure and its loss in smiling following FNP is an important difference in the neural control of these facial regions. Bilateral conjugacy of eyelid movements is probably crucial for coordinating visual input and was achieved apparently without conscious effort on the part of the patients. Bilateral conjugacy of movements at the sides of the mouth may be less critical for normal function, although patients would very much like to achieve it in order to improve the appearance of their smile. Since the everyday frequency of eyelid movements is considerably greater than that of smiling, it is possible that the preserved eyelid conjugacy in these patients with long-term FNP is merely a product of greater experience. However, if synchrony of movement onset is found to be preserved in patients with acute FNP, then it would suggest that eyelid conjugacy has a privileged status in the neural organisation of the face.

Physiotherapy rehabilitation of the smile after long-term facial nerve palsy using video self-modeling and implementation intentions.

OBJECTIVE: To improve smiling after long-term facial nerve palsy (FNP). Physiotherapy rehabilitation of an adapted (more symmetrical) smile was investigated in FNP subjects 1 year post-onset, using video self-modeling (video replay of only best adapted smiles) and implementation intentions (preplanning adapted smiles for specific situations). STUDY DESIGN AND SETTING: Prospective, blinded clinical trial. Facial-Nerve-Palsy Clinic. RESULTS: After video self-modeling: 1) reaction time (RT) to initiation of adapted smiles became 224 ms faster whereas RT for everyday (asymmetrical) smiles became 153 ms slower; 2) adapted smiles were completed 544 ms faster; 3) adapted smiles had higher overall quality, movement control, and symmetry ratings; and 4) Facial Disability Index scores also improved. Implementation intentions after video self-modeling ensured transfer of adapted smile to everyday situations. CONCLUSION: Following intervention the smile improved, with significant changes in availability, execution speed, and quality. SIGNIFICANCE: This study supports these rehabilitation techniques to maximize quality of smiling following FNP. EBM RATING: B-2b.

Reliability of the "Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis.

OBJECTIVE: To investigate the extent of within-system reliability and between-system correlation for the "Sydney" and "Sunnybrook" systems of grading facial nerve paralysis, and to examine the interobserver reliability and agreement of the "House Brackmann" grading system. STUDY DESIGN: A fixed-effects reliability study in which 6 otolaryngologists viewed videotapes of patients with facial nerve paralysis. SETTING: University and medical Centers. PATIENTS: Patients with unilateral lower motor neurone facial nerve dysfunction greater than 1 year after onset, none of whom had undergone surgical reanimation procedures. Intervention Twenty-one patients with facial nerve paralysis were videotaped while they performed a protocol of facial movements. Six otolaryngologists viewed the videotapes and scored them with the Sydney and Sunnybrook systems, and then gave a House Brackmann grade. MAIN OUTCOME MEASURE: The 3 systems of grading facial nerve paralysis were evaluated and compared with the use of intraclass correlation coefficients, Pearson's weighted kappa, and percentage exact agreement values. RESULTS: The Sydney and the Sunnybrook systems had good intrasystem reliability and high intersystem association for the assessment of voluntary movement. Grading of synkinesis was found to have low reliability both within and between systems. The House Brackmann system had substantial reliability as shown by weighted kappa but had a percentage exact agreement of 44%. CONCLUSIONS: For clinical grading of voluntary movement, there is good correlation between ratings given on the Sydney and Sunnybrook systems, and within each system there is good reliability. The assessment of synkinesis was far less reliable within, and less related between, systems. Although the reliability of the House Brackmann system was found to be high, examination of individual grades revealed some wide variation between trained observers.

Expression of emotion and quality of life after facial nerve paralysis.

OBJECTIVE: To investigate the facial expression of emotion and quality of life in patients after long-term facial nerve paralysis. STUDY DESIGN: Cross-sectional. SETTING: Facial nerve paralysis clinic. PATIENTS: Twenty-four patients with facial nerve paralysis and 24 significant others (partner, relative, friend). INTERVENTION: Patients were assessed using Sunnybrook, Sydney, and House-Brackmann grading scales and SF-36, Glasgow Benefit Inventory, and Facial Disability Index quality-of-life measures. RESULTS: When patients identified themselves as either effective or not effective at facially communicating each of Ekman's primary emotions (happiness, disgust, surprise, anger, sadness, and fear), 50% classified themselves as not effective at expressing one or more of the six emotions. Significant others of the not effective patients rated the emotions as more difficult for their partner-patients to communicate facially than did the significant others of effective patients. The SF-36 quality-of-life survey revealed lower social functioning relative to physical functioning for not effective patients. From the Sunnybrook Facial Grading System, more synkinesis was found for those patients not effective at expressing happiness, less brow and eye movement for patients not effective at expressing sadness, and less voluntary movement for those not effective with surprise. CONCLUSION: Movement deficits associated with expressing specific emotions and an association with quality-of-life measures were identified in patients with long-term facial nerve paralysis who saw themselves as not effective at facial expression of emotions. To improve management of emotional expression in patients with facial nerve paralysis, a broader approach is recommended, linking the practitioner's treatment goals with patient-driven outcome goals.

Three-dimensional quantification of the symmetry of normal facial movement.

OBJECTIVE: This study examined the right to left symmetry of the displacement of three-dimensional movement of the human face. METHODS: Displacement data on 42 subjects was collected and analyzed with the Expert Vision Motion Analysis System. Right and left three-dimensional facial displacements were quantified. RESULTS: Significantly greater left than right three-dimensional displacement across the whole face was measured. The three-dimensional displacement difference ranged from 0.48 mm to 2.28 mm between the right and left sides of the face. The 2-cm inferior pupil markers during the nose wrinkle expression had significantly greater left than right displacement. CONCLUSION: The ranges of displacement differences, along with the mean three-dimensional displacement measures, must be accounted for in the creation of a baseline of the range of normal facial movement.