Sir Charles Bell
















Research & Current Literature

June 2011

List compiled by Robin Lindsay, M.D.


Fukuda, M., M. Oishi, et al. (2011). "Intraoperative facial nerve motor evoked potential monitoring during skull base surgery predicts long-term facial nerve function outcomes." Neurol Res 33(6): 578-582.
OBJECTIVES: This study was designed to clarify whether facial nerve motor evoked potentials (FNMEPs) elicited by transcranial electrical stimulation during skull base surgery are useful for predicting long-term facial nerve function. METHODS: We analyzed FNMEP findings in 35 patients with skull base tumors. Mean follow-up was 24.4 months. Corkscrew electrodes positioned at C3 or C4 and Cz were used to deliver supramaximal stimuli. FNMEPs were recorded from the orbicularis oculi and oris muscles. RESULTS: The correlation between the final-to-baseline FNMEP ratio and initial or long-term facial nerve function was examined. Initial post-operative facial nerve function correlated significantly with the FNMEP ratios in the orbicularis oculi (r=-0.53, P<0.005) and orbicularis oris (r=-0.80, P<0.001) muscles. The correlations between FNMEP ratios and facial nerve function remained significant during long-term follow-up (orbicularis oculi muscle: r=-0.43, P<0.05; orbicularis oris muscle: r=-0.71, P<0.001). All patients in whom the FNMEP ratio in the orbicularis oculi muscles remained above 50% were assigned to the satisfactory facial nerve function (House-Brackmann Grades i and ii) group at the final examination. DISCUSSION: FNMEP monitoring can predict facial nerve function not only immediately after surgery but also long-term.

Fu, L., C. Bundy, et al. (2011). "Psychological distress in people with disfigurement from facial palsy." Eye (Lond).
AimsPsychological distress is well documented in people with facial disfigurement. However, the prevalence of psychological distress in patients with facial palsy has not been studied. This study aims to establish the prevalence of psychological distress and the extent of anxiety and depression in a sample of facial palsy patients from the Northwest of England.MethodA total of 103 participants with facial palsy completed a questionnaire pack comprising the Illness Perception Questionnaire-Revised (IPQ-R), a demographic questionnaire, and the Hospital Anxiety and Depression Scale (HADS). The severity of participants' facial palsy was measured by the House-Brackmann scale.ResultsIn all, 32.7 and 31.3% of the sample had significant levels of anxiety and depression, respectively. The mean age of participants was 59, and 35.9% had grade 6 facial palsy. Significant associations were found between participants' perception of consequences, duration, timeline, and the level of distress. No significant associations were found between clinical severity of facial palsy and levels of distress. Females had significantly higher levels of anxiety compared with males.ConclusionsThere was a significant level of distress in this study group. The levels of psychological distress were higher than the levels found in other outpatient attenders. There were significant associations between participants' illness perceptions and their level of distress.Eye advance online publication, 1 July 2011; doi:10.1038/eye.2011.158.

Kanerva, M., L. Jonsson, et al. (2011). "Sunnybrook and House-Brackmann systems in 5397 facial gradings." Otolaryngol Head Neck Surg 144(4): 570-574.
OBJECTIVES: To study the correlation between Sunnybrook and House-Brackmann facial grading systems at different time points during the course of peripheral facial palsy. STUDY DESIGN: Prospective multicenter trial. SETTING: Seventeen otorhinolaryngological centers. SUBJECTS AND METHODS: Data are part of the Scandinavian Bell's palsy study. The facial function of 1920 patients with peripheral facial palsy was assessed 5397 times with both Sunnybrook and House-Brackmann (H-B) facial grading systems. Grading was done at initial visit, at days 11 to 17 of palsy onset, and at 1 month, 2 months, 3 months, 6 months, and 12 months. Statistical evaluation was by Spearman correlation coefficient and box plot analysis. RESULTS: Spearman correlation coefficient varied from -0.81 to -0.96, with the weakest correlation found at initial visit. Box plot analysis for all assessments revealed that Sunnybrook scores were widely spread over different H-B grades. With 50% of the results closest to the median, Sunnybrook composite scores varied in H-B grades as follows: H-B I, 100; H-B II, 71 to 90; H-B III, 43 to 62; H-B IV, 26 to 43; H-B V, 13 to 25; and H-B VI, 5 to 14. CONCLUSION: Gradings correlated better in follow-up assessments than at initial visit. As shown by the wide overlap of the grading results, subjective grading systems are only approximate. However, a conversion table for Sunnybrook and H-B gradings was obtained and is included in the article. It can be used for further development of facial grading systems.

Mantsopoulos, K., G. Psillas, et al. (2011). "Predicting the Long-Term Outcome After Idiopathic Facial Nerve Paralysis." Otol Neurotol.
OBJECTIVE:: To investigate long-term recovery after Bell's palsy and evaluate specific parameters for predicting the long-term outcome of facial weakness. STUDY DESIGN:: Retrospective clinical study combined with long-term follow-up. SETTING:: Tertiary care university hospital (Department of Otorhinolaryngology, Head and Neck Surgery, University of Thessaloniki, Greece). PATIENTS:: Forty-four patients who were followed up 2 to 6 years (mean, 4.01 yr) after the onset of facial weakness. MAIN OUTCOME MEASURES:: The failure rate of complete recovery was studied for age, initial nerve excitability test, electroneurography, initial severity of paralysis, and number of days from onset of facial weakness to the start of medical treatment. RESULTS:: Thirty-two (73%) of 44 patients had a satisfactory outcome, and 12 (27%) had a nonsatisfactory recovery. Initial House-Brackmann grades V/VI and electroneurographically detected degeneration of 90% or more were shown to affect the long-term outcome of facial weakness significantly (p = 0.024 and p = 0.000, respectively). CONCLUSION:: The initial severity of facial weakness and the electroneurographically detected facial nerve degeneration were found to be important factors in predicting the long-term prognosis of Bell's palsy.



Trials. 2011 Jun 21;12(1):158. [Epub ahead of print]
Prednisolone and acupuncture in Bell's palsy: study protocol for a randomized, controlled trial.
Xia F, Han J, Liu X, Wang J, Jiang Z, Wang K, Wu S, Zhao G.
There are a variety of treatment options for Bell's palsy. Evidence from randomized controlled trials indicates corticosteroids can be used as a proven therapy for Bell's palsy. Acupuncture is one of the most commonly used methods to treat Bell's palsy in China. Recent studies suggest that staging treatment is more suitable for Bell's palsy, according to different path-stages of this disease. The aim of this study is to compare the effects of prednisolone and staging acupuncture in the recovery of the affected facial nerve, and to verify whether prednisolone in combination with staging acupuncture is more effective than prednisolone alone for Bell's palsy in a large number of patients.
In this article, we report the design and protocol of a large sample multi-center randomized controlled trial to treat Bell's palsy with prednisolone and/or acupuncture. In total, 1200 patients aged 18 to 75 years within 72 h of onset of acute, unilateral, peripheral facial palsy will be assessed. There are six treatment groups, with four treated according to different path-stages and two not. These patients are randomly assigned to be in one of the following six treatment groups, i.e. 1) placebo prednisolone group, 2) prednisolone group, 3) placebo prednisolone plus acute stage acupuncture group, 4) prednisolone plus acute stage acupuncture group, 5) placebo prednisolone plus resting stage acupuncture group, 6) prednisolone plus resting stage acupuncture group. The primary outcome is the time to complete recovery of facial function, assessed by Sunnybrook system and House-Brackmann scale. The secondary outcomes include the incidence of ipsilateral pain in the early stage of palsy (and the duration of this pain), the proportion of patients with severe pain, the occurrence of synkinesis, facial spasm or contracture, and the severity of residual facial symptoms during the study period.
The result of this trial will assess the efficacy of using prednisolone and staging acupuncture to treat Bell's palsy, and to determine a best combination therapy with prednisolone and acupuncture for treating Bell's palsy. Trial registration This study is registered with (reference no. NCT01201642).

Wood, M. D., S. W. Kemp, et al. (2011). "Outcome measures of peripheral nerve regeneration." Ann Anat.
Animal models of nerve compression, crush, and transection injuries of peripheral nerves have been subject to extensive study in order to understand the mechanisms of injury and axon regeneration and to investigate methods to promote axon regeneration and improve functional outcomes following nerve injury. Six outcome measures of regenerative success including axon and neuron counts, muscle and motor unit contractile forces, and behavior are reviewed in the context of nerve injury types, crush, transection and nerve repair by direct coaptation, or transection and repair via a nerve graft or conduit. The measures are evaluated for sciatic, tibial, common peroneal, femoral, single nerve branches such as the soleus nerve, and facial nerves. Their validity is discussed in the context of study objectives and the nerve branch. The case is made that outcome measures of axon counts and muscle contractile forces may be valid during the early phases of axon regeneration when regenerating sprouts emerge asynchronously from the proximal nerve stump and regenerate towards their denervated targets. However, care must be taken especially when experimental interventions differentially affect how many neurons regenerate axons and the number of axons per neuron that sprout from the proximal nerve stumps. Examples of erroneous conclusions are given to illustrate the need for researchers to ensure that the appropriate outcome measures are used in the evaluation of the success of peripheral nerve regeneration.

Sun, F., K. Zhou, et al. (2011). "Repair of facial nerve defects with decellularized artery allografts containing autologous adipose-derived stem cells in a rat model." Neurosci Lett 499(2): 104-108.
The purpose of this study was to investigate the effects of a decellularized artery allograft containing autologous adipose-derived stem cells (ADSCs) on an 8-mm facial nerve branch lesion in a rat model. At 8 weeks postoperatively, functional evaluation of unilateral vibrissae movements, morphological analysis of regenerated nerve segments and retrograde labeling of facial motoneurons were all analyzed. Better regenerative outcomes associated with functional improvement, great axonal growth, and improved target reinnervation were achieved in the artery-ADSCs group (2), whereas the cut nerves sutured with artery conduits alone (group 1) achieved inferior restoration. Furthermore, transected nerves repaired with nerve autografts (group 3) resulted in significant recovery of whisking, maturation of myelinated fibers and increased number of labeled facial neurons, and the latter two parameters were significantly different from those of group 2. Collectively, though our combined use of a decellularized artery allograft with autologous ADSCs achieved regenerative outcomes inferior to a nerve autograft, it certainly showed a beneficial effect on promoting nerve regeneration and thus represents an alternative approach for the reconstruction of peripheral facial nerve defects.

Numthavaj, P., A. Thakkinstian, et al. (2011). "Corticosteroid and antiviral therapy for Bell's palsy: a network meta-analysis." BMC Neurol 11: 1.
BACKGROUND: Previous meta-analyses of treatments for Bell's palsy are still inconclusive due to different comparators, insufficient data, and lack of power. We therefore conducted a network meta-analysis combining direct and indirect comparisons for assessing efficacy of steroids and antiviral treatment (AVT) at 3 and 6 months. METHODS: We searched Medline and EMBASE until September 2010 using PubMed and Elsviere search engines. A network meta-analysis was performed to assess disease recovery using a mixed effects hierarchical model. Goodness of fit of the model was assessed, and the pooled odds ratio (OR) and 95% confidence interval (CI) were estimated. RESULTS: Six studies (total n = 1805)were eligible and contributed to the network meta-analysis. The pooled ORs for resolution at 3 months were 1.24 (95% CI: 0.79 - 1.94) for Acyclovir plus Prednisolone and 1.02 (95% CI: 0.73 - 1.42) for Valacyclovir plus Prednisolone, versus Prednisolone alone. Either Acyclovir or Valacyclovir singly had significantly lower efficacy than Prednisolone alone, i.e., ORs were 0.44 (95% CI: 0.28 - 0.68) and 0.60 (95% CI: 0.42 - 0.87), respectively. Neither of the antiviral agents was significantly different compared with placebo, with a pooled OR of 1.25 (95% CI: 0.78 - 1.98) for Acyclovir and 0.91 (95% CI: 0.63 - 1.31) for Valacyclovir. Overall, Prednisolone-based treatment increased the chance of recovery 2-fold (95% CI: 1.55 - 2.42) compared to non-Prednisolone-based treatment. To gain 1 extra recovery, 6 and 26 patients need to be treated with Acyclovir and prednisolone compared to placebo and prednisolone alone, respectively. CONCLUSIONS: Our evidence suggests that the current practice of treating Bell's palsy with AVT plus corticosteroid may lead to slightly higher recovery rates compared to treating with prednisone alone but this does not quite reach statistical significance; prednisone remains the best evidence-based treatment.









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