Sir Charles Bell
















Research & Current Literature

October 2011

List compiled by Robin Lindsay, M.D.

Terzis, J. K. and K. Anesti (2011). "Experience with developmental facial paralysis: part I. Diagnosis and associated stigmata." Plast Reconstr Surg 128(5): 488e-497e.
BACKGROUND: This study is a thorough literature review of the clinical presentation and evaluation of developmental facial paralysis, with a systematic description of the various stigmata and associated anomalies. It is hoped that this approach will facilitate the differentiation of developmental facial paralysis from other causes of facial paralysis present at birth. METHODS: : Forty-two cases of developmental facial paralysis were identified in a retrospective clinical review (1980 to 2010); 34 were children (80.95 percent; age, 8 +/- 6 years) and eight were adults (19.05 percent; age, 27 +/- 12 years). Thirty-one patients had simple developmental paralysis, and two patients had developmental unilateral lower lip palsy. There were nine patients with associated anomalies or craniofacial syndromes. Five of these patients had multiple cranial nerve deficits. RESULTS: : Analysis of the various stigmata revealed significant correlation between the presence of developmental facial paralysis and amblyopia, hypoplastic facial nerve on imaging or surgical exploration, lower alar atresia, and skin changes (i.e., acne), but not the ear abnormalities. CONCLUSIONS: : Early targeted screening and diagnosis, with prompt specialized treatment, improves the physical and emotional development of children with developmental facial paralysis and reduces the prevalence of amblyopia and other sequelae of the condition, thus facilitating reintegration among their peers. Given the dramatic presentation of this condition, accurate and reliable guidelines are necessary to facilitate early diagnosis, initiate appropriate therapy, and provide support and counseling to the family.

Smouha, E., E. Toh, et al. (2011). "Surgical treatment of Bell's palsy: Current attitudes." Laryngoscope 121(9): 1965-1970.
OBJECTIVES/HYPOTHESIS: To learn the current management of Bell's palsy among practicing otologists and neurotologists and to better define the role of surgical decompression of the facial nerve in the treatment of Bell's palsy. STUDY DESIGN: Survey questionnaire. METHODS: We conducted a survey of members of the American Otological Society and the American Neurotology Society to learn their current practices in the treatment of Bell's palsy. RESULTS: Eighty-six neurotologists responded out of 334 surveys (26%). The majority of respondents obtain magnetic resonance imaging and electrical testing for new patients and treat with a combination of steroids and antiviral agents. More than two thirds of respondents would recommend surgery to patients who met the established electrophysiologic criteria (electroneuronography <10% normal, no spontaneous motor unit action potentials on electromyography within 10 days of onset of complete paralysis). However, only half believe that surgical decompression should be the standard of care, and only half would use a standard middle fossa approach. Lack of evidence was the most commonly cited reason for not recommending surgery. Several respondents wrote that they would leave the option of surgery to the patient. Most important, one third of neurotologists have not performed a surgical decompression for Bell's palsy in the last 10 years, and 95% perform less than one procedure per year. CONCLUSIONS: Disagreement persists among practicing otologists about the role of surgical decompression for Bell's palsy. More convincing clinical evidence will be needed before there is widespread consensus regarding the surgical treatment of this condition.

Hesse, S., C. Werner, et al. (2011). "External lid loading for the temporary treatment of paresis of the M. orbicularis oculi: a case report." Arch Phys Med Rehabil 92(8): 1333-1335.

This clinical note re-introduces external lid loading with the help of a lead weight for the temporary treatment of lagophthalmos. Although simple and effective, the technique is rarely used. Instead of wearing a monoculus, the patient uses an individually tailored lead weight (0.8-mm thickness, 1.0-2.0g) stuck on the lid to enable its closure. Spontaneous ptosis indicates a too-heavy weight. With the musculus (M.) levator palpebrae intact, lid lifting is possible. The effect is gravity dependent; therefore, the patient has to wear the monoculus at night. To minimize the risk for lead intoxication, the surface of the weight is varnished. In the case of persistent M. orbicularis oculi paresis, internal lid loading can follow. Since 1997, a total of 152 lagophthalmos cases have been treated. All patients could close the lid immediately. Almost half the patients had to readjust the weight several times per day because of hooded eyelids. Compliance was high, and partial or complete restoration of M. orbicularis oculi function occurred in 60% of cases. In some subjects, restoration of the M. orbicularis oculi was faster than for the M. orbicularis orbis. External lid loading for the temporary treatment of lagophthalmos is simple and effective. Compared with a monoculus, vision is unimpaired and the aesthetic is more appropriate for most patients. Faster restoration of the M. orbicularis oculi hints at a potentially facilitatory effect of the weight.

Tzou, C. H., I. Pona, et al. (2011). "Evolution of the 3-Dimensional Video System for Facial Motion Analysis: Ten Years' Experiences and Recent Developments." Ann Plast Surg.
Since the implementation of the computer-aided system for assessing facial palsy in 1999, no similar system that can make an objective, three-dimensional, quantitative analysis of facial movements has been marketed.It has been in routine use since its launch, and it has proven to be reliable, clinically applicable, and therapeutically accurate. With the cooperation of international partners, more than 200 patients were analyzed. Recent developments in computer vision-mostly in the area of generative face models, applying active-appearance models (and extensions), optical flow, and video-tracking-have been successfully incorporated to automate the prototype system.Further market-ready development and a business partner will be needed to enable the production of this system to enhance clinical methodology in diagnostic and prognostic accuracy as a personalized therapy concept, leading to better results and higher quality of life for patients with impaired facial function.

Lin, C. H., C. Wallace, et al. (2011). "Functioning free gracilis myocutaneous flap transfer provides a reliable single-stage facial reconstruction and reanimation following tumor ablation." Plast Reconstr Surg 128(3): 687-696.
BACKGROUND: Ablative orofacial defects incorporating mimetic facial musculature/nerve cause hemifacial expressive dysfunction and considerable morbidity but are rarely reanimated immediately using free functioning gracilis myocutaneous flaps. METHODS: Disrupted buccal branches provided a recipient facial nerve for 24 gracilis reinnervations. An additional 15 free flaps were used for extensive composite defects. Smile outcome was graded according to Terzis' criteria after 2 years of recurrence-free follow-up. The effects of postoperative radiotherapy, integrity of the oral commissure, and double free flaps were compared. RESULTS: Eighteen patients completed 2 years' recurrence-free follow-up; average smile outcome was Terzis grade 4 (mean, 3.8). Resection/reconstruction of the modiolus (five of 18 patients) tended to diminish outcome (Terzis grade 3, mean, 3.0; median, 3; versus Terzis grade 4, mean, 4.1; median, 5) compared with two free flaps performed simultaneously(mean, 3.56 versus 4.14; median, 3 versus 5). Postoperative radiotherapy (eight of 18 patients) had a more modest effect on outcome (Terzis grade 3, mean, 3.3; Terzis grade 4, mean, 4.1; median, 3 versus 5). CONCLUSION: Reconstruction of oncologic defects including expressive facial musculature/nerve with gracilis free functioning muscle transfer can restore oral continence and facial expression primarily. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vakharia, K. T., D. Henstrom, et al. (2011). "Facial Reanimation of Patients with Neurofibromatosis Type 2." Neurosurgery.
BACKGROUND: Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome defined by bilateral vestibular schwannomas. Facial paralysis - either from tumor growth or from surgical intervention - is a devastating complication of this disorder and can contribute to disfigurement and corneal keratopathy. Historically, physicians have not attempted to treat facial paralysis in these patients. OBJECTIVE: We review our clinical experience with free gracilis muscle transfer for the purpose of facial reanimation in patients with NF2. METHODS: Five patients with NF2 and complete unilateral facial paralysis were referred to the facial nerve center at our institution. Charts and operative reports were reviewed; treatment details and functional outcomes are reported. RESULTS: Patients were treated between 2006 and 2009. 3 patients were men and 2 were women. The age of presentation of debilitating facial paralysis ranged from 13 to 50 years old. All patients were treated with a single stage free gracilis muscle transfer for smile reanimation. Each obturator nerve of the gracilis was coapted to the masseteric branch of the trigeminal nerve. Measurement of oral commissure excursions at rest and with smile, preoperatively and postoperatively, revealed improved and near symmetric smile in all cases. CONCLUSION: Management of facial paralysis is oftentimes overlooked when defining a care plan for NF2 patients who typically may have multiple brain and spine tumors. The paralyzed smile may be treated successfully with single stage free gracilis muscle transfer in the motivated patient.

Park, B. G., J. S. Lee, et al. (2011). "Co-localization of activating transcription factor 3 and phosphorylated c-Jun in axotomized facial motoneurons." Anat Cell Biol 44(3): 226-237.
Activating transcription factor 3 (ATF3) and c-Jun play key roles in either cell death or cell survival, depending on the cellular background. To evaluate the functional significance of ATF3/c-Jun in the peripheral nervous system, we examined neuronal cell death, activation of ATF3/c-Jun, and microglial responses in facial motor nuclei up to 24 weeks after an extracranial facial nerve axotomy in adult rats. Following the axotomy, neuronal survival rate was progressively but significantly reduced to 79.1% at 16 weeks post-lesion (wpl) and to 65.2% at 24 wpl. ATF3 and phosphorylated c-Jun (pc-Jun) were detected in the majority of ipsilateral facial motoneurons with normal size and morphology during the early stage of degeneration (1-2 wpl). Thereafter, the number of facial motoneurons decreased gradually, and both ATF3 and pc-Jun were identified in degenerating neurons only. ATF3 and pc-Jun were co-localized in most cases. Additionally, a large number of activated microglia, recognized by OX6 (rat MHC II marker) and ED1 (phagocytic marker), gathered in the ipsilateral facial motor nuclei. Importantly, numerous OX6- and ED1-positive, phagocytic microglia closely surrounded and ingested pc-Jun-positive, degenerating neurons. Taken together, our results indicate that long-lasting co-localization of ATF3 and pc-Jun in axotomized facial motoneurons may be related to degenerative cascades provoked by an extracranial facial nerve axotomy.

Klingner, C. M., G. F. Volk, et al. (2011). "Time Course of Cortical Plasticity After Facial Nerve Palsy: A Single-Case Study." Neurorehabil Neural Repair.
BACKGROUND: . Functional connectivity is defined as the temporal correlation between spatially remote neurophysiological events. This method has become particularly useful for studying neuroplasticity to detect changes in the collaboration of brain areas during cortical reorganization. METHODS: . In this article, the authors longitudinally studied voxel-based morphometry and resting state functional magnetic resonance imaging 10 times in 1 patient during the course of Bell palsy (idiopathic facial nerve palsy) up to complete clinical recovery. RESULTS: . Morphometric analysis revealed a significant alteration in the face area of the primary motor cortex (M1) contralateral to the paretic face, with an initial increase in gray matter concentration. Functional connectivity analysis between the M1 and other parts of the facial motor network revealed acutely disrupted intrahemispheric connectivity but unaltered interhemispheric connectivity. The disrupted functional connectivity was most pronounced on the day of the onset of symptoms, with a subsequent return toward normal during the course of recovery. This time course was found to differ between the selected parts of the facial motor network. However, the increase in functional connectivity strength preceded clinical recovery in all areas and reached a stable level before the patient fully recovered. CONCLUSION: . These results demonstrate that recovery from facial nerve palsy is complemented by cortical reorganization, with pronounced changes of functional connectivity that precede clinical recovery.

Volk, G. F., M. Pantel, et al. (2011). "Reconstruction of complex peripheral facial nerve defects by a combined approach using facial nerve interpositional graft and hypoglossal-facial jump nerve suture." Laryngoscope 121(11): 2402-2405.
OBJECTIVES/HYPOTHESIS: To describe a modified facial nerve reconstruction technique for complex defects of the facial fan after parotid surgery that avoids synkinesis between upper and lower face. STUDY DESIGN: Retrospective case series. METHODS: Patients who had undergone radical parotidectomy with a large defect of the facial fan, reconstruction of the upper face by facial nerve interpositional graft, and reconstruction of the lower face by hypoglossal-facial nerve jump nerve suture were included in this series. RESULTS: Four patients underwent the modified combined approach after tumor resection and prior to postoperative radiotherapy in three of the four cases. Surgery was combined with an upper lid weight implantation. Regeneration of the face was successful in all cases within 12 to 16 months. Most important, the separated reanimation of the upper and lower face circumvented synkinesis of the upper and lower face. This factor was essential for good functional results. Using the hypoglossal jump technique instead of a classical cross-nerve suture technique prevented the sacrifice of ipsilateral tongue function. CONCLUSIONS: The presented method offers satisfactory results for facial reanimation and avoids synkinesis between the upper and lower face. Using the jump technique instead of a classic hypoglossal transfer as it was described originally for the combined approach avoids long-term sequelae for the tongue. Laryngoscope, 121:2402-2405, 2011.

Lee, W. S. and J. Kim (2011). "Revised Surgical Strategy to Preserve Facial Function After Resection of Facial Nerve Schwannoma." Otol Neurotol.
HYPOTHESIS:: Early nerve-sparing tumor resection is designed to minimize facial deficits associated with facial nerve schwannomas. This report aimed to determine optimal treatment approaches and timing in patients with facial nerve schwannomas, especially those with good facial function. BACKGROUND:: Clinical decision making is complicated in patients with good facial nerve function because classical surgical treatment consists of excision of the tumor along with the involved nerve segment, followed by grafting or primary anastomosis, which can result in permanent facial deficits. METHODS:: Since 1995, we have conducted a nerve-preserving technique on 15 patients with facial nerve schwannomas to obtain better results after our experience with the 10 patients who underwent tumor resection and/or facial nerve reconstruction before 1995 and evaluated the surgical outcomes of all 25 patients between 1990 and 2008. The House-Brackmann (HB) grading system for facial nerve function was used to assess preoperative and postoperative functions with follow-up magnetic resonance imaging to monitor for tumor recurrence. RESULTS:: At the final functional assessment, 7 patients had no change in facial function, 2 had improved, and 6 had worsened. Specifically, 4 patients had normal facial function, 8 had HB Grade II, and 3 had HB Grade III. To date, no clinical or radiologic evidence of recurrence has been detected in any of the patients, all of whom underwent postoperative enhanced magnetic resonance imaging at least 3 years after surgery. CONCLUSION:: Facial nerve-preserving technique is recommended for resection of facial nerve schwannomas, especially in patients with good preoperative facial function. Compared with the resection-and-reconstruction technique, this method can prevent delays in presurgical deterioration of the neural fascicle and may result in better postoperative facial function.

Borschel, G. H., D. H. Kawamura, et al. (2011). "The motor nerve to the masseter muscle: An anatomic and histomorphometric study to facilitate its use in facial reanimation." J Plast Reconstr Aesthet Surg.
INTRODUCTION: The motor nerve to the masseter muscle is increasingly being used for facial reanimation procedures. However, many surgeons have been reluctant to use this versatile source of axons because of difficulty in locating it intraoperatively. In this study we conducted a detailed assessment of its gross and microscopic anatomy and develop a simple, reliable method for locating this nerve. METHODS: We defined the anatomy of the nerve to the masseter, in particular its relationship to common surgical landmarks such as the auricular tragus and the zygomatic arch, and determined its intramuscular anatomy. We also performed a histomorphometric analysis. RESULTS: The anatomy of the motor nerve to the masseter was consistent. A convenient starting point for its dissection was found 3.16 +/- 0.30 cm anterior to the tragus at a level 1.08 +/- 0.18 cm inferior to the zygomatic arch. The nerve was located 1.48 +/- 0.19 cm deep to the superficial muscular aponeurotic system (SMAS) at this point. Relative to the zygomatic arch, the nerve formed an angle of 50 +/- 7.6 degrees as it coursed distally into the masseter muscle. The distance from the arch to the first branch of the motor nerve to the masseter was 1.33 +/- 0.20 cm. The histomorphometric analysis demonstrated that the motor nerve to the masseter contained an average of 2775 +/- 470 myelinated fibers. CONCLUSIONS: Successful intraoperative location of the motor nerve to the masseter is facilitated by knowledge of its anatomy relative to standard surgical landmarks. A consistent and convenient starting point for dissection of this nerve is found 3 cm anterior to the tragus and 1 cm inferior to the zygomatic arch. The nerve contains over 2700 myelinated fibers, demonstrating its usefulness as a source of motor innervation for facial reanimation.

Fishman, J. M. (2011). "Corticosteroids effective in idiopathic facial nerve palsy (Bell's Palsy) but not necessarily in idiopathic acute vestibular dysfunction (Vestibular Neuritis)." Laryngoscope 121(11): 2494-2495.

Michaelidou, M., M. Herceg, et al. (2011). "Correlation of functional recovery with the course of electrophysiological parameters after free muscle transfer for reconstruction of the smile in irreversible facial palsy." Muscle Nerve 44(5): 741-748.
Introduction: The aim of this study was to determine whether processes of denervation and reinnervation, as measured by electrodiagnostic methods, correlate with clinical function, as measured by three-dimensional (3D) video analysis and whether electrodiagnostic data can serve as a prognostic indicator. Methods: Eighteen patients with facial palsy were investigated by 3D video analysis, needle electromyography, and electrical muscle testing at 6, 12, and 18 months after free muscle transplantation for smile reconstruction. Results: Electrophysiological parameters determined 6 months postoperatively correlated significantly with the index of dynamic symmetry 12 and 18 months postoperatively. Conclusions: Processes of reinnervation can be detected earlier by electrophysiological analysis than by quantified clinical analysis. Pathological spontaneous activity alone and combined assessment with motor unit action potentials in the early postoperative stage are strong prognostic indicators. Muscle Nerve, 2011.

Tzou, C. H. and M. Frey (2011). "Evolution of 3D Surface Imaging Systems in Facial Plastic Surgery." Facial Plast Surg Clin North Am 19(4): 591-602.

Recent advancements in computer technologies have propelled the development of 3D imaging systems. 3D surface-imaging is taking surgeons to a new level of communication with patients; moreover, it provides quick and standardized image documentation. This article recounts the chronologic evolution of 3D surface imaging, and summarizes the current status of today's facial surface capturing technology. This article also discusses current 3D surface imaging hardware and software, and their different techniques, technologies, and scientific validation, which provides surgeons with the background information necessary for evaluating the systems and knowledge about the systems they might incorporate into their own practice.

Matsumine, H., R. Sasaki, et al. (2011). "Surgical procedure for transplanting artificial nerve conduits for peripheral nerve regeneration." Plast Reconstr Surg 128(2): 95e-97e.

Baba, S., K. Kondo, et al. (2011). "Bell's Palsy in Children: Relationship Between Electroneurography Findings and Prognosis in Comparison With Adults." Otol Neurotol.

OBJECTIVES:: To investigate the correlation between electroneurography (ENoG) findings and the prognosis of Bell's palsy in children compared with adults. METHODS:: Twenty-two children and 92 adults with Bell's palsy who underwent ENoG between 8 days and 4 weeks from the onset of symptoms were retrospectively enrolled. The time to maximal recovery and rate of favorable recovery (House-Brackmann grade I or II) was assessed. Children (C) and adults (A) were further subdivided into low (<10%) or high (>==10%) subgroups according to their ENoG values (affected versus unaffected side) at initial evaluation. The numbers in each subgroup were as follows: C-low (n = 8), A-low (n = 21), C-high (n = 14), and A-high (n = 71). RESULTS:: Of the 22 children assessed, 2 of the 4 patients who showed a total loss of evoked potentials on the affected side (0% ENoG value) exhibited an unfavorable recovery. The remaining 20 patients achieved a favorable recovery eventually. Patients in group C-low reached a maximal recovery of facial movement significantly later than those in group C-high (p < 0.001). Time to maximal recovery of facial movement in group A-low was later than that in group C-low, although the difference was not statistically significant (p = 0.15). The patients in group A-high reached a maximal recovery significantly later than those in group C-high (p < 0.05). CONCLUSION:: Bell's palsy seems to recover earlier in children than adults when matched for severity. The presence of an identifiable response in ENoG, irrespective of its amplitude, may indicate a favorable recovery of facial movement in children.

Azuma, T., K. Nakamura, et al. (2011). "Mirror Biofeedback Rehabilitation after Administration of Single-Dose Botulinum Toxin for Treatment of Facial Synkinesis." Otolaryngol Head Neck Surg.
Objective. The efficacy of facial biofeedback rehabilitation with a mirror after administration of a single dose of botulinum A toxin on facial synkinesis was examined in patients with chronic facial palsy.Study Design. Prospective clinical study.Setting. University hospital.Subjects and Methods. The present study includes 8 patients with Bell palsy and 5 with herpes zoster oticus showing facial synkinesis. A single dose of botulinum A toxin was used as the initial process of facial rehabilitation. Patients then continued a daily facial biofeedback rehabilitation with a mirror at home. They were instructed to keep their eyes symmetrically open using a mirror during mouth movements. The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry of eye opening width during mouth movements (% eye opening).Results. After administration of a single dose of botulinum A toxin, temporary relief of facial synkinesis was observed in all patients. Patients were then instructed to continue the facial biofeedback rehabilitation with a mirror for 10 months. The mean values of the percent of eye opening during 3 designated mouth movements that included lip pursing /u:/, teeth baring /i:/, and cheek puffing /pu:/ increased significantly after 10 months when the effects of botulinum A toxin had completely disappeared.Conclusion. These findings demonstrate that facial biofeedback rehabilitation with a mirror after administration of a single dose of botulinum A toxin is a long-lasting treatment of established facial synkinesis in patients with chronic facial palsy.

Wood, M. D., S. W. Kemp, et al. (2011). "Outcome measures of peripheral nerve regeneration." Ann Anat 193(4): 321-333.
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.










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