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Objectives: To characterize the effect of facial reanimation using masseteric nerve transfer on the masseter muscle itself, examining whether there is any demonstrable atrophy postoperatively., Methods: Electronic medical records of adult patients who underwent facial reanimation using masseteric nerve transfer at our institution over a 15-year period were reviewed. To account for the impact of postoperative radiation, randomly selected patients who underwent radical parotidectomy without nerve transfer and received postoperative radiation served as controls in a 1:1 fashion against those who underwent masseteric nerve transfer with postoperative radiation., Results: Twenty patients were identified who underwent masseteric nerve transfer and had sufficient pre- and postoperative imaging to assess masseter volume (mean age 58.2, 60% female). Of the four patients who did not receive postoperative radiation, each demonstrated masseteric atrophy on the side of their nerve transfer, with a mean reduction in masseter volume of 20.6%. The remaining 16 patients were included in the case-control analysis accounting for radiation. When compared with controls, those in the study group were found to have a statistically significant difference in atrophy (p = 0.0047) and total volume loss (p = 0.0002). The overall reduction in masseter volume in the study group was significantly higher compared with the control group, at 41.7% and 16.6%, respectively (p = 0.0001)., Conclusion: Facial reanimation utilizing masseteric nerve transfer appears to result in atrophy of the denervated masseter when compared with the contralateral muscle. This volume deficit may lead to further facial asymmetry for patients undergoing comprehensive reanimation surgery., Level of Evidence: 3 Laryngoscope, 134:4514-4520, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: One of the most severe complications in surgery of parotid tumors is facial palsy. Imaging of the intra-parotid facial nerve is challenging due to small dimensions. Our aim was to assess, in patients with parotid tumors, the ability of high-resolution 3D double-echo steady-state sequence with water excitation (DE3D-WE) (1) to visualize the extracranial facial nerve and its tracts, (2) to evaluate their relationship to the parotid lesion and (3) to compare MRI and surgical findings., Methods: A retrospective study was conducted including all patients with parotid tumors, who underwent MRI from April 2022 to December 2023. Two radiologists independently reviewed DE3D-WE images, assessing quality of visualization of the facial nerve bilaterally and localizing the nerve's divisions in relation to the tumor. MRI data were compared with surgical findings., Results: Forty consecutive patients were included (M:F = 22:18; mean age 56.3 ± 17.4 years). DE3D-WE could excellently visualize the nerve main trunk and the temporofacial division in all cases. The cervicofacial branch was visible in 99% of cases and visibility was good. Distal divisions were displayed in 34% of cases with a higher visibility on the tumor side (p < 0.05). Interrater agreement was high (weighted kappa 0.94 ± 0.01 [95% CI 0.92-0.97]). Compared to surgery accuracy of MRI in localizing the nerve was 100% for the main trunk, 96% for the temporofacial and 89% for the cervicofacial branches., Conclusions: Facial nerve MR-neurography represents a reliable tool. DE3D-WE can play an important role in surgical planning of patients with parotid tumors, reducing the risk of nerve injury., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Repetitive Peripheral Magnetic Stimulation [rPMS] is a non-invasive tool that has a potential therapeutic role in many musculoskeletal disorders. We aimed to demonstrate the therapeutic efficacy of high frequency [rPMS] in acute Idiopathic Facial Nerve Palsy [IFP]. And to study the role of neuromuscular ultrasonography in acute idiopathic facial palsy., Methods: Forty patients, aged above 18 years, diagnosed with unilateral acute [within 7 days of onset] idiopathic facial palsy were enrolled and randomly divided into intervention group [20 patients] and control group. Both groups underwent clinical examination, assessment of facial nerve disability by House-Brackmann grading [HBG] score and Facial Disability Index [FDI] score, ultrasonography of facial nerve of both normal and affected sides at baseline and after 6 weeks, medical treatment and routine rehabilitation therapy. The intervention group were subjected to 10 sessions of high frequency r PMS [5/week for 2 successive weeks] on the affected side., Results: Both [HBG] and [FDI] showed more significant improvement in the intervention group in comparison to the control group after 6 weeks follow up. Ultrasonographic measures of facial nerve in the affected side were significantly larger than non-affected side at baseline. However, those measures significantly decreased after 6 weeks follow up. Surprisingly, the intervention group showed more significant decrease in facial nerve dimeter at proximal portion [without sheath] in comparison to control group., Conclusion: high frequency r PMS have an adjuvant role in treatment of acute idiopathic facial palsy. Also, ultrasonography has beneficial role in evaluation and prognosis of [IFP]., (© 2024. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Background: Fifteen-and-a-Half Syndrome is an uncommon clinical presentation characterized by the coexistence of one-and-a-half syndrome and bilateral facial palsy. In this study, we provide a comprehensive description of symptom evolution and imaging changes in a patient with Fifteen-and-a-Half Syndrome., Case Presentation: A 54-year-old male presented with sudden onset of one-and-a-half syndrome, which gradually progressed to fifteen-and-a-half syndrome. The final diagnosis was confirmed to be pontine infarction which occurred at the midline of the pontine tegmentum., Conclusion: This case highlights the diverse and progressive early clinical manifestations associated with Fifteen-and-a-half Syndrome. Currently, all reported cases of this syndrome are linked to brainstem infarction; however, early differential diagnosis is crucial to ensure prompt initiation of appropriate treatment for affected patients., (© 2024. The Author(s).)

Background: The aim of our study was to retrospectively analyze FDG PET/CT data in patients with facial nerve palsy (FNP) for the presence of the monocle sign., Patients and Methods: A total of 85 patients with unilateral FNP were included into our study, thereof 73 with peripheral FNP and 12 with central FNP. FDG uptake (SUV max , SUV mean , total lesion glycolysis) was measured in both orbicularis oculi muscles (OOMs). FDG uptake of paretic and nonparetic muscles was compared in patients with FNP (Wilcoxon test and Mann-Whitney U test) and was also compared with FDG uptake in 33 patients without FNP (Mann-Whitney U test). SUV max ratios of OOM were compared. A receiver operating characteristic curve and Youden Index were used to determine the optimal cutoff SUV max ratio for the prevalence of contralateral peripheral FNP., Results: The SUV max ratio of OOM was significantly higher in patients with peripheral FNP compared with patients with central FNP and those without FNP (1.70 ± 0.94 vs 1.16 ± 0.09 vs 1.18 ± 0.21, respectively; P < 0.001). The SUV max ratio of OOM yielded an area under the curve (AUC) of 0.719 (95% confidence interval, 0.630-0.809), with an optimal cutoff of 1.41, yielding a specificity of 94.4% and a sensitivity of 44.1% for identifying contralateral peripheral FNP. One hundred percent specificity is achieved using a cutoff of 1.91 (sensitivity, 29.4%)., Conclusions: Asymmetrically increased FDG uptake of the OOM (the "monocle sign") indicates contralateral peripheral FNP. A nearly 2-fold higher SUV max represents a practically useful cutoff., Competing Interests: Conflicts of interest and sources of funding: M.H. received grants and speaker honoraria from GE Healthcare, a fund by the Alfred and Annemarie von Sick legacy, and a grant from the clinical research priority program Artificial Intelligence in Oncological Imaging Network of the University of Zurich. All other authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The masseteric nerve is one of the main options to neurotize free muscle flaps in irreversible long-term facial paralysis. Several preoperative skin-marking techniques for the masseteric nerve have been proposed to limit the surgical dissection area, shorten the surgical time, and enable a safer dissection. However, these have shown variability among them, and cannot visualize the nerve preoperatively. The authors designed an observational study to validate a high-frequency ultrasound (HFUS) nerve identification technique., Methods: A systematic HFUS examination was designed and performed to visualize the masseteric nerve in 64 hemifaces of healthy volunteers. One-third were randomly selected to undergo an additional HFUS-guided needle electrostimulation to validate the HFUS image., Results: The masseteric nerve was identified by HFUS in 96.9% of hemifaces (95% CI, 0.89 to >0.99) and showed almost perfect agreement with direct needle stimulation as calculated with Cohen kappa coefficient (0.95; 95% CI, 0.85 to 1.00). The masseteric nerve was found within the masseter muscle, in between the deeper muscle bellies, at 18.3 mm (SD ±2.2) from the skin. Only in 12.9% of cases (95% CI, 0.06 to 0.24) did its course become adjacent to the mandible periosteum. Other important features, such as disposition in relation to the parotid gland, or if the nerve was covered directly by a thick intramuscular aponeurosis, could be well observed by HFUS., Conclusion: HFUS enables masseteric nerve identification and can provide the surgeon with specific information on anatomical relations for each examined individual before surgery., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Facial palsy can result in a serious complication known as facial synkinesis, causing both physical and psychological harm to the patients. There is growing evidence that patients with facial synkinesis have brain abnormalities, but the brain mechanisms and underlying imaging biomarkers remain unclear. Here, we employed functional magnetic resonance imaging (fMRI) to investigate brain function in 31 unilateral post facial palsy synkinesis patients and 25 healthy controls during different facial expression movements and at rest. Combining surface-based mass-univariate analysis and multivariate pattern analysis, we identified diffused activation and intrinsic connection patterns in the primary motor cortex and the somatosensory cortex on the patient's affected side. Further, we classified post facial palsy synkinesis patients from healthy subjects with favorable accuracy using the support vector machine based on both task-related and resting-state functional magnetic resonance imaging data. Together, these findings indicate the potential of the identified functional reorganizations to serve as neuroimaging biomarkers for facial synkinesis diagnosis., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction/aims: The study aimed to visualize the changes in the facial muscles of patients with severe facial palsy who showed no improvement for more than 3 months on acute stage., Methods: The 102 patients with severe facial palsy over House-Brackmann grade IV or an 80% degenerative ratio on ENoG at the initial examination, who showed no improvement for more than 3 months on acute stage were indicated to undergo ultrasonography of the face to evaluate the facial muscles., Results: Muscular degeneration was observed in 537/918 muscles (58.5%). Muscle volume shrinkage was observed in 209/918 muscles (22.8%). Fascial adhesions were observed in 209/918 muscles (22.7%). Among all the muscles assessed for degenerative changes, zygomaticus major/minor was the most affected by degenerative changes (91.2%). Degenerative changes were observed in the levator labii superioris muscle in 84.3% patients. The shrinkage was most frequently observed in the zygomaticus major muscle (61/102 patients [59.8%]), followed by the zygomaticus minor muscle (43.1%). Shrinkage of the levator labii suprioris was observed in 24.5% patients. The zygomaticus major/minor muscle had the highest proportion of fascial adhesions in 61.8% and 66.7% patients respectively. The levator labii suprioris muscle showed the lowest proportion of fascial adhesions, with only 7.8% patients being affected., Discussion: This study confirmed that the zygomaticus major, zygomaticus minor, and levator labii suprioris muscles, which raise the corner of the mouth, are the first to degenerate in patients with severe facial paralysis. This study demonstrated that ultrasonography is a simple and non-invasive examination for facial paralysis., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The purpose of this study was to identify significant prognostic factors associated with facial paralysis after vestibular schwannoma (VS) surgery and develop a novel nomogram for predicting facial nerve (FN) outcomes., Methods: Retrospective data were retrieved from 355 patients who underwent microsurgery via the retrosigmoid approach for VS between December 2017 and December 2022. Univariate and multivariate logistic regression analysis were used to construct a radiographic features-based nomogram to predict the risk of facial paralysis after surgery., Results: Following a thorough screening process, a total of 185 participants were included. The univariate and multivariate logistic regression analysis revealed that tumor size (p = 0.005), fundal fluid cap (FFC) sign (p = 0.014), cerebrospinal fluid cleft (CSFC) sign (p < 0.001), and expansion of affected side of internal auditory canal (IAC) (p = 0.033) were independent factors. A nomogram model was constructed based on these indicators. When applied to the validation cohort, the nomogram demonstrated good discrimination and favorable calibration. Then we generated a web-based calculator to facilitate clinical application., Conclusion: Tumor size, FFC and CSFC sign, and the expansion of the IAC, serve as good predictors of postoperative FN outcomes. Based on these factors, the nomogram model demonstrates good predictive performance., (© 2023 The Authors. CNS Neuroscience & Therapeutics published by John Wiley & Sons Ltd.)

Background: Botulinum toxin injection is the accepted standard treatment for synkinesis and gustatory hyperlacrimation in patients with facial paralysis. However, poor injection accuracy can result in inconsistent treatment outcomes, variable treatment durations, and complications. Ultrasound guidance should increase injection accuracy in the facial region; however, this has not been proven., Methods: Twenty-six hemifaces of nonembalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated using several measures., Results: Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance ( P < 0.001). This was most pronounced in the lacrimal gland (62% versus 8%), depressor anguli oris (100% versus 46%), and mentalis (100% versus 54%) ( P < 0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance versus 29% without ( P < 0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance versus 83% without ( P < 0.01). Twenty-three percent of the landmark-guided depressor anguli oris injections stained the facial artery ( P = 0.22)., Conclusions: Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in the surrounding tissue compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in patients with facial paralysis., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: This study is to evaluate the duration of facial nerve enhancement in gadolinium-enhanced temporal bone MRI after the onset of acute facial palsy., Methods: Gd-enhanced MRI imagines were examined in 13 patients with idiopathic acute facial palsy within 14 days after the onset. The degree of facial nerve function was measured according to the House-Brackmann (H-B) grading system at their first visit at outpatient clinic. The follow-up MRI was taken about 16.5 months (7-24 months) after onset of disease. The degree of facial nerve enhancement was measured with signal intensity (SI) which was quantitatively analyzed using the region-of-interest (ROI) measurements for each segment of the facial nerve. SI was statistically analyzed by comparing SI values of contralateral site and ipsilateral site using the paired t test with SPSS program., Results: The gadolinium enhancement was statistically increased at labyrinthine segment and geniculate ganglion area of facial nerve at initial temporal bone MRI. The gadolinium enhancement was statistically decreased at all the segments of facial nerve except tympanic segment (p < 0.05) at follow-up MRI., Conclusions: The facial nerve enhancement in Gd-enhanced MRI images prolonged more than 21 months of the onset. The newly developed pathologic lesions of acute facial palsy especially occur at the site of labyrinthine and geniculate ganglion., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: The purpose of this study was to identify course of the corticobulbar tract and factors associated with the occurrence of facial paresis (FP) in lateral medullary infarction (LMI)., Methods: Patients diagnosed with LMI who were admitted to tertiary hospital were retrospectively investigated and divided into two groups based on the presence of FP. FP was defined as grade 2 or more by the House-Brackmann scale. Differences between the two groups were analyzed with respect to anatomical location of the lesions, demographic data (age, sex), risk factors (diabetes, hypertension, smoking, prior stroke, atrial fibrillation, and other cardiac risk factors for stroke), large vessel involvement on magnetic resonance angiography, other symptoms and signs (sensory symptoms, gait ataxia, limb ataxia, dizziness, Horner syndrome, hoarseness, dysphagia, dysarthria, nystagmus, nausea/vomiting, headache, neck pain, diplopia, and hiccup)., Results: Among 44 LMI patients, 15 patients (34%) had FP, and all of them had ipsilesional central-type FP. The FP group tended to involve upper (p &lt; 0.0001) and relative ventral (p = 0.019) part of the lateral medulla. Horizontally large lesion was also related to the presence of FP (p = 0.044). Dysphagia (p = 0.001), dysarthria (p = 0.003), and hiccups (p = 0.034) were more likely to be accompanied by FP. Otherwise, there were no significant differences., Conclusion: The results of present study indicate that the corticobulbar fibers innervating the lower face decussate at the upper level of the medulla and ascend through the dorsolateral medulla, where the concentration of the fibers is densest near the nucleus ambiguus., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

The brain magnetic resonance imaging (MRI) findings seen in patients with Bell palsy are abnormal contrast enhancement of affected facial nerves. Previous studies were conducted on a few patients, mainly those who had experienced palsy for several weeks. This study investigated the diagnostic usefulness of MRI by examining MRI findings of acute Bell palsy (within 7 days of symptom onset) in a large cohort. Among the patients with Bell palsy (idiopathic unilateral facial palsy) who visited the hospital, 123 patients who underwent contrast-enhanced MRI of the internal auditory canal within 7 days of symptom onset were reviewed retrospectively. MRI examination results were investigated along with the patient's clinical symptoms and electrodiagnostic test results. Based on the MRI results, the frequency of abnormal contrast enhancement and contrast-enhanced areas were investigated. Of the 123 patients, 13 (11%) had normal brain MRI results, and 110 (89%) had abnormal findings. The frequency of abnormal contrast enhancement was not significantly associated with test timing (P = .56). Of the 110 patients with abnormal findings, 65 (59%) showed contrast enhancement in the labyrinthine segment and 36 (33%) in both the labyrinthine segment and geniculate ganglion. Most patients with Bell palsy who are in the acute phase showed abnormal contrast enhancement in their facial nerves, and similar findings were even observed in the examination conducted on the day of symptom onset. Brain MRI helps in the diagnosis of acute Bell palsy., Competing Interests: The authors have no funding and conflict of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

A 75-year-old woman presenting with unilateral lower motor neurone facial weakness was ultimately diagnosed with an ischaemic stroke at the pontomedullary junction affecting the facial nerve fascicles. Isolated, unilateral, upper and lower facial weakness is typically caused by lesions affecting the facial nerve, such as Bell's palsy, though rarely can be a manifestation of acute ischaemic stroke. It is important for neurologists and emergency providers to determine appropriately which patients with facial weakness require neuroimaging and which do not., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We report a patient with extraordinary pontine infarction-induced contralateral central facial palsy and weakened limb strength., Case Report: This is a 66-year-old man with left arm movement difficulty for 10 days and worsening over the last 1 day. His left nasolabial fold flattening and left arm strength and sensory were decreased. He could not complete the finger-nose test well with his right hand. Magnetic resonance and magnetic resonance angiography tests confirmed his right pontine acute infarction but without large vessel stenosis or occlusion., Conclusion: "Uncrossed paralysis" patients may present with contralateral face and body weakness with pontine infarcts, if the infarct occurs above the level of the facial nucleus head, and may be simmilar with the higher level pontine lesions or cerebrum semisphere infarction, which need particular attention during clinical practice., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Stroke is rarely accompanied with peripheral facial paralysis and supranuclear palsy of the hypoglossal nerve. Both sides of the motor cortex innervate the hypoglossal nucleus; therefore, unilateral lesions of the upper motor neurons rarely result in contralateral lingual paresis. We report a rare case of crossed syndrome with associated hyperacute peripheral hemifacial paralysis and contralateral lingual paresis after a lower pontine tegmentum ischemic stroke., Case Presentation: A 73-year-old man presented with symptoms of hyperacute peripheral hemifacial paralysis. Upon protrusion, the patient's tongue deviated to the contralateral side, without fasciculation or atrophy. Brain imaging showed focal ischemic stroke in the pontine tegmentum. However, lingual hemiparesis and multimodal neuroimaging findings differed., Conclusions: We suggest that cortico-hypoglossal fibers pass through the dorsal pontine. This case of crossed syndrome is a rare report of a lower pontine tegmentum ischemic stroke resembling an upper motor neuron lesion of the contralateral hypoglossal nerve., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: To report a case of alternobaric facial palsy (AFP) with a hyperpneumatized temporal bone and to review the relevant literature in order to propose a new facet of AFP pathogenesis., Methods: A patient with a hyperpneumatized temporal bone was found to have recurrent episodes of facial palsy associated with air travel. Systematic review of PubMed, Cochrane Library, and Embase characterized all articles related to transient facial palsy associated with altitude changes or diving with a focus on demographics and imaging findings., Results: A 25 year-old male was referred for recurrent facial palsy associated with commercial air travel. Imaging demonstrated a hyperpneumatized and well-aerated temporal bone. Total air cell volume was calculated to be 8.59 cc on the affected side. A systematic review of the literature identified 49 cases of AFP. Mean age was 34 years old and 80% were male. Twelve cases had imaging of the temporal bone for evaluation, of which 85% demonstrated at least 1 area of hyperpneumatization. Hyperpneumatization was most frequently encountered in the mastoid, zygomatic root, and inferior petrous apex., Conclusion: Hyperpneumatization of the temporal bone is critical to AFP etiology as it predicts higher middle ear pressure, if atmospheric pressure changes cannot be equilibrated, via reduced efficacy of normal tympanic membrane pressure buffering. This hypothesis helps to better account for the rarity of the condition and male preponderance.

Purpose: We hypothesize that delayed facial paralysis following dental procedures is also associated with viral reactivation. In this study, the brain magnetic resonance imaging (MRI) findings of patients were analyzed to identify the pathogenesis of facial nerve palsy after dental treatment., Materials and Methods: We retrospectively reviewed the medical records of patients with unilateral facial nerve palsy and identified those diagnosed with delayed facial nerve palsy within 30 days of dental treatment. We assessed the clinical characteristics, electrodiagnostic findings, and imaging findings of these patients and looked for MRI findings that support a viral hypothesis for facial palsy., Results: Among 924 patients with facial palsy, 11 (1.2%) had delayed facial paralysis following dental procedures. Patients developed facial palsy at an average of 3.2 days (1-11 days) after undergoing a dental procedure. The internal auditory canal MRI revealed abnormal enhancement of affected facial nerve in nine patients. The intensity and pattern of the enhancement were similar to those of Bell's palsy., Conclusions: Facial palsy can develop within the days following dental procedures, and the MRI results suggest that delayed facial palsy after dental treatment is related to viral reactivation-like Bell's palsy., (© 2022. The Author(s) under exclusive licence to Belgian Neurological Society.)

Objective: During the process of neural recovery after facial palsy, distressing sequelae of static and dynamic facial asymmetry develop in patients with facial palsy. A pronounced nasolabial fold is mainly responsible for static facial asymmetry, which leads to many psychological and social problems in patients. Objective and qualitative assessment of facial appearance is critical to determine the severity of sequelae of static facial asymmetry and whether an intervention is effective for treatment. In the present study, an attempt was made to develop three-dimensional analysis method to assess sequelae of static facial asymmetry after facial palsy., Methods: Eight patients with sequelae of facial asymmetry after facial palsy and ten healthy volunteers were enrolled. We used three-dimensional scanning analysis with a portable non-contact optical scanner to obtain three-dimensional surface data from a patient's face and produced a three-dimensional digital model of the face. We then identified a reference plane fixed with the patient's face, and measured the depth of the nasolabial fold of the face., Results: The nasolabial fold of the face on the affected side was significantly deeper than that on the unaffected side in patients with sequelae of static facial asymmetry after facial palsy. However, the depth of the facial nasolabial fold on the right side was not different from that on the left side in healthy volunteers. Affected-unaffected side differences in the depth of the nasolabial fold in patients with sequelae of static facial asymmetry after facial palsy were significantly larger than left-right differences in the depth of the nasolabial fold in healthy volunteers. Two weeks after treatment with botulinum toxin injection to the affected zygomaticus muscles, affected-unaffected side differences in the depth of the nasolabial fold were significantly decreased in the patients. In the patients who received botulinum toxin, the absolute values of affected-unaffected side differences in the depth of the nasolabial fold measured using the three-dimensional scanning analysis showed a significant positive correlation with the visual analog scale scores of facial asymmetry marked by independent doctors., Conclusion: The present findings suggest that affected-unaffected side differences in the depth of the nasolabial fold of the measured using three-dimensional scanning analysis can be used as an index of sequelae of static facial asymmetry. It is also suggested that the index can evaluate whether interventions are effective for the treatment of sequelae., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (Copyright © 2022. Published by Elsevier B.V.)

Background: Facial synkinesis, characterized by unintentional facial movements paired with intentional movements, is a debilitating sequela of Bell palsy., Purpose: Our aim was to determine whether persistent peripheral nerve changes arising from Bell palsy result in persistent altered brain function in motor pathways in synkinesis., Data Sources: A literature search using terms related to facial paralysis, Bell palsy, synkinesis, and fMRI through May 2021 was conducted in MEDLINE and EMBASE. Additionally, an fMRI study examined lip and eyeblink movements in 2 groups: individuals who fully recovered following Bell palsy and individuals who developed synkinesis., Study Selection: Task-based data of the whole brain that required lip movements in healthy controls were extracted from 7 publications. Three studies contributed similar whole-brain analyses in acute Bell palsy., Data Analysis: The meta-analysis of fMRI in healthy control and Bell palsy groups determined common clusters of activation within each group using activation likelihood estimates. A separate fMRI study used multivariate general linear modeling to identify changes associated with synkinesis in smiling and blinking tasks., Data Synthesis: A region of the precentral gyrus contralateral to the paretic side of the face was hypoactive in synkinesis during lip movements compared with controls. This region was centered in a cluster of activation identified in the meta-analysis of the healthy controls but absent from individuals with Bell palsy., Limitations: The meta-analysis relied on a small set of studies. The small sample of subjects with synkinesis limited the power of the fMRI analysis., Conclusions: Premotor pathways show persistent functional changes in synkinesis first identifiable in acute Bell palsy., (© 2022 by American Journal of Neuroradiology.)

Background: Postoperative monitoring after free functional gracilis transfer for smile reconstruction in long-standing facial paralysis is challenging as clinical assessments are limited. Objective: In patients receiving free gracilis transfer for smile reconstruction, we compared the implantable Doppler probe with a handheld Doppler/intraoperative blood flow regarding the reliability in detecting perfusion compromised free flaps. Methods: In a retrospective cohort study we analyzed facial paralysis patients who, after free functional smile reconstruction, were postoperatively monitored using the implantable Doppler probe. Furthermore, we conducted a multiple logistic regression analysis on risk factors for vascular complications. Results: We included 119 patients who received 125 free functional gracilis transfers. The sensitivity of the implanted Doppler probe was 1.0 and the specificity 0.88. There were no false-negative results (negative predictive value = 1.0). The calculated positive predictive value was 0.41. We used a handheld Doppler device to verify signal changes. The combined positive predictive value of both tests was 0.91. Previous surgery in the surgical field was a risk factor for impaired blood flow. Conclusions: The implantable Doppler probe proved to be a reliable tool for postoperative monitoring of free functional gracilis transfer in facial reanimation surgery. Special care should be taken in preoperated patients.

This study focused on the application value of the newly prepared 129Xe nanoprobe-based functional magnetic resonance imaging (fMRI) in exploring the mechanism of the acupuncture treatment for intractable facial paralysis, expected to provide a theoretical reference for the mechanism of acupuncture for the treatment of facial paralysis. In this study, 30 patients with intractable peripheral facial paralysis (experimental group) and 30 healthy volunteers (control group) were selected. All patients were scanned by the newly prepared 129Xe nanoprobe-based fMRI technology, and then brain functional status data and rating data were collected. fMRI scanning results showed that multiple brain regions were activated in the experimental group before treatment, among which the central posterior brain, insula, and thalamus were positively activated, while the precuneus, superior frontal gyrus, and other parts showed signal reduction. After treatment, several brain regions also showed signal enhancement. Comparisons within the healthy control group also showed activation in multiple brain regions, including the lenticular nucleus, inferior frontal gyrus, and superior temporal gyrus, while in the experimental group, no signal changes were detected in these brain regions. At the same time, comparison of fMRI images of patients with intractable peripheral facial paralysis before and after treatment showed that the cerebellar amygdala, superior frontal gyrus, cerebellar mountaintop, and other brain areas were activated, and all showed positive activation. After treatment, the average House-Brackmann (H-B) and Sunnybrook scores of the experimental group were 3.82 and 51, respectively, and the change was significant compared with that before treatment ( P < 0.05). In conclusion, the newly prepared 129Xe nanoprobe-based fMRI scan can reflect the functional changes of cerebral cortex after acupuncture. The acupuncture treatment may achieve its therapeutic effect by promoting the functional reorganization of the cerebral cortex in the treatment of intractable facial paralysis., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Fengyun Fan et al.)

Facial nerve dysfunction is common in patients with Bell's palsy, trauma, tumour, or iatrogenic injuries. Imaging assessment is the most convenient method for patients and their treating physician. With developments in artificial intelligence (AI), manual work will be replaced. In this study, a database of facial images of patients with oral and maxillofacial diseases was set up to develop a facial nerve functional assessment system based on AI. This database was then used to evaluate the accuracy of a state-of-the-art algorithm for facial landmark detection named 'HRNet'. Utilizing this database and with appropriate human intervention, HRNet was used in facial annotation. The accuracy of annotations was evaluated through the normalized mean error. A total of 912 images were collected from 300 people; 546 of these images had abnormal features including defects, swelling, scars, or facial paralysis. The accuracy for the abnormal group was lower than that for the normal group before and after training, but improvements in accuracy were identified in both groups post-training. In conclusion, this new database demonstrates the ability of HRNet to localize facial landmarks in patients with oral and maxillofacial diseases. More images for training should be added to this database to diversify it in the future., (Copyright © 2021 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Resting-state functional magnetic resonance imaging (rs-fMRI) is widely applied to explore abnormal functional connectivity (FC) in patients with post-facial paralysis synkinesis (PFPS). However, most studies considered steady spatial-temporal signal interactions between distinct brain regions during the period of scanning., Objective: In this study, we aim to investigate abnormal dynamic functional connectivity (dFC) in PFPS patients., Methods: We enrolled 31 PFPS patients and 19 healthy controls. All participants underwent rs-fMRI. Sliding windows approach was applied to construct dFC matrices. Next, these matrices were clustered into distinct states using the k-means clustering algorithm., Results: We found that it was not the dFC patterns, but rather the temporal properties including the mean dwell time (MDT) and occurrence frequencies, that showed a significant difference between PFPS patients and healthy controls. Two randomly clustered dFC states were recognized for both groups. Among them, State 1 showed significantly lower connectivity compared to State 2 in patients group. Compared to healthy controls, the duration spent by the PFPS patients in the state with lower connectivity significantly increased and is positively correlated with the better facial function., Conclusions: In conclusion, aberrant dFC is a fundamental feature of brain dysfunction in PFPS patients, which is associated with the facial nerve function. These findings may contribute to a better understanding of the abnormal brain reorganization mechanisms in PFPS patients., (Copyright © 2021. Published by Elsevier Inc.)

Background: The course of the corticobulbar tract (CBT) to the facial nucleus has been investigated by some previous studies. However, there are some unclear points of the course of the CBT to the facial nucleus. This study aimed to elucidate the detailed course of the CBT to the facial nucleus through the analysis of lateral medullary infarction (LMI) cases., Methods: The neurological characteristics and magnetic resonance imaging findings of 33 consecutive patients with LMI were evaluated. The location of the lesions was classified rostro-caudally (upper, middle, or lower) and horizontally. Further, we compared the neurological characteristics between the groups with and without central facial paresis (FP)., Results: Eight (24%) patients with central FP ipsilateral to the lesion were identified. Dysphagia and hiccups were more frequently observed in the group with central FP than in the group without central FP. In patients with central FP, middle medullary lesions and those including the ventral part of the dorsolateral medulla were more frequently observed. Contrastingly, patients with lesions restricted to the lateral and dorsal regions of the dorsolateral medulla did not present with central FP., Conclusion: The results of this study indicate that the CBT to the facial nucleus descends with the corticospinal tract at least to the middle portion of the medulla, and then ascends to the facial nucleus through the medial and ventral areas of the dorsolateral medulla after decussation.

Glial tumors in the cerebellopontine angle (CPA) are uncommon and comprise less than 1% of CPA tumors. We present four cases of pilocytic astrocytoma of the CPA (PA-CPA) that were treated in our department. Patients who received surgical treatment for PA-CPA from January 2004 to December 2019 were identified by a computer search of their files from the Department of Neurosurgery, Tübingen. Patients were evaluated for initial symptoms, pre- and postoperative facial nerve function and cochlear function, complications, and recurrence rate by reviewing surgical reports, patient documents, neuroradiological data, and follow-up data. We identified four patients with PA-CPA out of about 1500 CPA lesions (~ 0.2%), which were surgically treated in our department in the last 16 years. Of the four patients, three were male, and one was a female patient. Two were adults, and two were children (mean age 35 years). A gross total resection was achieved in three cases, and a subtotal resection was attained in one case. Two patients experienced a moderate facial palsy immediately after surgery (House-Brackmann grade III). In all cases, the facial function was intact or good (House-Brackmann grades I-II) at the long-term follow-up (mean follow-up 4.5 years). No mortality occurred during follow-up. Three of the patients had no recurrence at the latest follow-up (mean latest follow-up 4.5 years), while one patient had a slight recurrence. PA-CPA can be safely removed, and most complications immediately after surgery resolve in the long-term follow-up.

Purpose:  To determine the predictive value of 3-dimensional spoiled gradient-echo volumetric interpolated breath-hold examination (VIBE) using subtraction to evaluate the short-term effect of therapy for facial palsy., Materials and Methods:  We included 97 patients with idiopathic facial palsy (52 male, 45 female; aged 50.7 ± 19.4 years) who underwent MR imaging with a contrast agent after starting therapy. The mean interval between onset and therapy was 1.55 ± 1.69 days, between therapy and MR imaging was 3.19 ± 2.78 days, and between MR imaging and assessment of the therapeutic effect was 3.50 ± 0.71 days. The degree of therapeutic effect was determined using a 4-grade scale based on the House-Brackmann scale for grading facial nerve function. Two radiologists reviewed VIBE with pre- and postcontrast subtraction using the 4-point scale. We evaluated the diagnostic performance and compared the degree of therapeutic effect and enhancement of facial nerves that were divided into 5 segments bilaterally., Results:  We identified 98 facial palsy initially and significant enhancement in 55 facial nerves after the start of therapy and residual palsy in 87. Sensitivity for all facial palsy was 62.0 %, specificity was 90.9 %, positive predictive value was 98.2 %, negative predictive value was 23.3 %, and accuracy was 65.3 %. Eleven patients recovered completely, 1 showed significant enhancement, and the remaining 10 did not show significant enhancement of the facial nerve., Conclusion:  VIBE has a potential to predict the prognostic outcome and assess facial palsy after the start of therapy., Key Points:   · Three-dimensional spoiled gradient-echo volumetric interpolated breath-hold examination (VIBE) using subtraction can be useful to predict residual facial palsy after initial therapy.. · Strong enhancement of the facial nerve on VIBE using subtraction was associated with residual facial palsy after the start of therapy.. · Patients with a favorable prognosis did not show strong enhancement.., Citation Format: · Tomita H, Detmar K, Nakajima Y et al. Predictive Value of VIBE using Subtraction to Evaluate Idiopathic Facial Palsy after Starting Therapy. Fortschr Röntgenstr 2020; 192: 1183 - 1189., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Tolosa-Hunt syndrome is characterized by unilateral retro-orbital headaches and cranial nerve palsies, usually involving cranial nerves III-VI. It is rare for other cranial nerves to be involved, although this has previously been reported. We report a 19-year-old woman presenting with typical features of Tolosa-Hunt syndrome but ultimately developing bilateral facial nerve palsies and enhancement of both facial nerves on magnetic resonance imaging. The patient presented with unilateral retro-orbital headaches and palsies of cranial nerves III-VI. She was diagnosed with Tolosa-Hunt syndrome but was non-compliant with her corticosteroid treatment due to side effects. She returned with progressive left followed by right facial nerve palsy. Her corresponding follow-up magnetic resonance imaging scans showed sequential enhancement of the left and right facial nerves. She ultimately had clinical improvement with IV methylprednisolone. To our knowledge, Tolosa-Hunt syndrome associated with bilateral facial nerve palsy and corroborative facial nerve enhancement on magnetic resonance imaging has not previously been described. Moreover, our patient's clinical course is instructive, as it demonstrates that this atypical presentation of Tolosa-Hunt syndrome can indeed respond to corticosteroid treatment and should not be mistaken for other entities such as Bell's palsy.

Facial weakness is a symptom commonly associated to lack of facial muscle control due to neurological injury. Several diseases are associated with facial weakness such as stroke and Bell's palsy. The use of digital imaging through mobile phones, tablets, personal computers and other devices could provide timely opportunity for detection, which if accurate enough can improve treatment by enabling faster patient triage and recovery progress monitoring. Most of the existing facial weakness detection approaches from static images are based on facial landmarks from which geometric features can be calculated. Landmark-based methods, however, can suffer from inaccuracies in face landmarks localization. In this study, We also experimentally evaluate the performance of several feature extraction methods for measuring facial weakness, including the landmark-based features, as well as intensity-based features on a neurologist-certified dataset that comprises 186 images of normal, 125 images of left facial weakness, and 126 images of right facial weakness. We demonstrate that, for the application of facial weakness detection from single (static) images, approaches that incorporate the Histogram of Oriented Gradients (HoG) features tend to be more accurate.

The eight-and-a-half syndrome (EHS)-defined by the combination of a seventh cranial nerve palsy and an ipsilateral one-and-a-half syndrome-is a rare brainstem syndrome, which localises to the caudal tegmental region of the pons. We present a case of the EHS secondary to an inflammatory lesion on a previously healthy 26-year-old woman, with a literature review emphasising the relevance of aetiological assessment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate the prevalence of bony dehiscence in the tympanic facial canal in patients with acute otitis media with facial paresis compared to those without facial paresis., Method: A retrospective case-control study was conducted on acute otitis media patients with facial paresis undergoing high-resolution temporal bone computed tomography., Results: Forty-eight patients were included (24 per group). Definitive determination of the presence of a bony dehiscence was possible in 44 out of 48 patients (91.7 per cent). Prevalence of bony dehiscence in acute otitis media patients with facial paresis was not different from that in acute otitis media patients without facial paresis (p = 0.21). Presence of a bony dehiscence was associated with a positive predictive value of 66.7 per cent in regard to development of facial paresis. However, an intact bony tympanic facial canal did not prevent facial paresis in 44.8 per cent of cases (95 per cent confidence interval = 34.6-55.6)., Conclusion: Prevalence of bony dehiscence in acute otitis media patients with facial paresis did not differ from that in acute otitis media patients without facial paresis. An intact tympanic bony facial canal does not protect from facial paresis development.

Unilateral facial palsy in a newborn is rarely caused by a developmental defect. It occurs either isolated or in the context of a syndrome. This article describes a multidisciplinary approach towards unilateral, isolated congenital facial palsy along with a literature review. We report six patients, three boys and three girls, who presented with a unilateral facial palsy at birth. Clinical assessment was performed by an ear-nose-throat (ENT) surgeon, a pediatric neurologist, and an ophthalmologist. Magnetic resonance imaging (MRI) of the posterior fossa and computerized tomography (CT) of the temporal bone were requested to exclude structural anomalies of the facial nerve. Imaging revealed the underlying cause in five patients out of six (80%), showing an ipsilateral facial nerve aplasia or hypoplasia. These findings point towards an underlying developmental defect and underscore the importance of MRI in the diagnostic work-up. Surgical and non-surgical therapies were discussed with the parents.Conclusion: Congenital unilateral facial palsy caused by a developmental defect outside the context of a syndrome is rare. A multidisciplinary approach is recommended to differentiate between various causes and to initiate timely treatment.What is Known:• Congenital facial palsy is mostly caused by environmental/external fcators.• However in rare cases it can be developmental defect.What is New:• This paper describes 6 cases of isolated congenital facial palsy related to a developmental defect and presents the largest case series in the literature caused by aplasia/hypoplasia of the facial nerve.• MRI and CT-imaging allow for an assessment of the facial nerve at the root entry zone of the brainstem and along its course through the middle ear or the face. Moreover, they proved to be helpful in differentiating between several causes of congenital facial palsy.

Facial paralysis (FP) is a loss of facial movement due to nerve damage. Most existing diagnosis systems of FP are subjective, e.g., the House-Brackmann (HB) grading system, which highly depends on the skilled clinicians and lacks an automatic quantitative assessment. In this paper, we propose an efficient yet objective facial paralysis assessment approach via automatic computational image analysis. First, the facial blood flow of FP patients is measured by the technique of laser speckle contrast imaging to generate both RGB color images and blood flow images. Second, with an improved segmentation approach, the patient's face is divided into concerned regions to extract facial blood flow distribution characteristics. Finally, three HB score classifiers are employed to quantify the severity of FP patients. The proposed method has been validated on 80 FP patients, and quantitative results demonstrate that our method, achieving an accuracy of 97.14%, outperforms the state-of-the-art systems. Experimental evaluations also show that the proposed approach could yield objective and quantitative FP diagnosis results, which agree with those obtained by an experienced clinician., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2020 Chaoqun Jiang et al.)

We report three cases of unilateral F-FDG uptake in the orbicularis oculi muscle in subjects with contralateral peripheral facial nerve palsy. We argue that this asymmetric uptake pattern in fact reflects lack of metabolism on the side affected by facial nerve palsy, owing to denervation. Since the unilateral periorbital uptake resembles a monocle, we chose to call this finding the monocle sign. The monocle sign should not be confused with inflammation or tumor, but should prompt a neurological assessment for facial nerve palsy and a potential underlying disease.

Background: Diagnosis of central or peripheral facial palsy (FP) is traditionally based on clinical evaluation. This study aims at investigating the relationship between clinical evaluation of FP and lesion location as visible on Magnetic Resonance Imaging (MRI) in patients with Multiple Sclerosis (MS) for the purpose of adding supporting evidence to the diagnosis of central or peripheral FP in these patients., Methods: A retrospective study was conducted on data from patients who underwent MS treatment between January 2016 and January 2019 at the MS Center of Wayne State University, MI, USA, and presented with at least one episode of FP during the observational period. The following data was collected from each patient: demographics, time from MS onset, side of FP, FP type (central or peripheral, as clinically evaluated), FP onset, FP treatment, amount of recovery of normal facial movements, time elapsed from beginning of FP treatment, number of FP recurrences, lesions presence/absence and location as visible on MRI. Correlation analysis was performed to assess to which extent clinical evaluation of FP correlated with presence of MRI lesions in different locations., Results: Eighteen patients were included in this study. In thirteen patients (72.2%) FP was classified as peripheral. Among them only five (38.4%) displayed one or more lesions in the pons. Correlation between presence of lesions in the pons and presence of peripheral FP was statistically significant (p = 0.02). Correlation between presence of lesions in the cortex (observed in 61.5% of patients with FP clinically evaluated as peripheral) and presence of FP clinically evaluated as peripheral was also statistically significant (p = 0.01). Finally, presence of lesions in the cortex was significantly correlated with presence of FP clinically evaluated as central (p = 0.02)., Conclusions: FP clinically classified as peripheral may be caused by central lesions in the cortex or pons and not only by peripheral facial nerve damage. In MS patients, FP may appear at the onset of the disease and be misdiagnosed as Bell 's palsy. Clinicians should carefully approach FP diagnosis and perform a brain as well as temporal bone MRI before pursuing pharmacological treatment., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Subdural lymphomas are a rare subtype of primary central nervous system lymphomas that can radiographically mimic epidural blood and pose a diagnostic challenge. They can complicate treatment if not preemptively identified., Methods: We present a case report of a subdural lymphoma that mimicked a compressive subdural hematoma, and we review the PubMed database for similar cases., Results: A 77-year-old woman presented with a transient left facial droop and what appeared to be a subdural hematoma on computed tomography scan. The patient underwent surgery, during which grossly abnormal solid epicortical adherent tissue was noted instead of the expected appearance of a subdural hematoma. An intraoperative biopsy was suggestive of lymphoma, and the surgery was converted to a craniectomy. Pathology confirmed the diagnosis of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. The patient underwent radiotherapy with no complications or recurrence. Magnetic resonance imaging demonstrated complete resolution of the mass at 3 months after treatment, at which time the patient underwent a synthetic cranioplasty. Seven case reports of primary dural lymphomas mimicking subdural blood were found, with variable pathologic subclassifications., Conclusions: Although rare, a primary dural lymphoma can be mistaken for a subdural hematoma on computed tomography scan. The most common subtype is low-grade extranodal marginal zone lymphomas. It is important to keep these diseases in the differential diagnosis, especially when there is incongruence between imaging and the clinical picture, as earlier detection correlates to a stronger therapeutic response., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht.