Background This study reviews recent literature on facial palsy guidelines and provides systematic reviews on related topics of interest. Methods An electronic database search was performed to identify recent guidelines dealing with facial nerve palsy, systematic reviews and recent meta-analysis published between 2011 and 2019 (inclusive). The literature search used the search terms "Bell's palsy," "Ramsay-Hunt syndrome," "Facial palsy," "Facial paralysis," "Facial paresis," "Guideline," "Meta-analysis," "Systematic review," and "Randomized controlled trial." Only studies written in English were used. Results The characteristics of treatment trends for facial palsy have been reviewed over the past decade. The most prominent change noted may be the shift from the conventional House-Brackmann facial nerve grading system to the Sunnybrook and eFACE systems. In addition, the results of serial meta-analyses indicate increasing agreement with the use of surgical decompression of the facial nerve. Beyond steroids or combined steroid-antiviral treatment, various novel drugs and treatments have been tried. For long-standing facial paralysis and postparetic synkinesis sequelae after facial palsy, facial reanimation has been highlighted and the necessity of new paradigms have been raised. Conclusion For peripheral facial paralysis, various changes have been made, not only in the facial nerve grading systems, but also in medical treatments, from surgical procedures to rehabilitation, during the last decade.

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Acute Peripheral Facial Palsy: Recent Guidelines and a Systematic Review of the Literature.

To review current knowledge regarding idiopathic orbital myositis.Recent publications have focused on possible causes of orbital myositis and the process to reach a diagnosis of idiopathic orbital myositis. With inflamed and enlarged extraocular muscles, features to distinguish between competing diagnostic possibilities are based on imaging in the context of history and clinical signs. Idiopathic orbital myositis is characterized by the clinical triad of acute onset of orbital pain exacerbated on eye movement, double vision, and redness or swelling of the eyelids or conjunctiva, along with the radiological finding of homogeneous, fusiform enlargement of one or more extraocular muscles. In atypical or inconclusive clinico-radiological findings for a diagnosis of idiopathic orbital myositis, or where the clinical behavior changes or fails to respond to corticosteroid treatment, a systemic and oncologic work-up and muscle biopsy are warranted to exclude specific local or systemic disease as cause of the inflamed and enlarged muscle. As our understanding of idiopathic orbital myositis evolves, the diagnostic focus is shifting toward earlier identification of underlying local or systemic disease through systemic work-up and muscle biopsy. 

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Idiopathic Orbital Myositis Revisited

Introduction: There is an anatomic explanation for upper lip and midfacial tethering resulting in lack of motion in facial synkinesis. Objective: To measure the effect of perinasal chemodenervation on dental show in the synkinetic population and clarify the anatomic relationship of perinasal musculature. Methods: Literature search was performed on anatomy of the perinasal modiolus, and anatomic evaluation was performed through human anatomic specimen dissection. Photographic outcomes were observed in synkinetic patients receiving chemodenervation to smile antagonists with and without perinasal muscle injections and assessed through naive observer survey. Retrospective outcomes for all patients receiving perinasal chemodenervation was collected utilizing Facial Clinimetric Evaluation Scale, Sunnybrook Facial Grading System (FGS), Facial Disability Index (FDI), and the Synkinesis Assessment Questionnaire. Results: Anatomic dissections demonstrated muscular confluence spanning the nasal sidewall and upper lip tethering the soft tissue to bone. Thirty-four of 53 chemodenervation patients received perinasal Botox experiencing improvement in synkinetic symptoms of the upper lip, nose, and improved dental show as noted on paired t-test for FGS (p = 0.00096), and FDI social p = 0.015) also supported by naive observer surveys (p = 0.03). Conclusions: Human anatomic specimen dissections support a perinasal confluence of musculature with bony attachments that can be successfully treated with chemodenervation in facial synkinesis patients. 

Anatomic Considerations of Perinasal Musculature for Improved Dental Show During Smile in Facial Synkinesis

Fat Injection as a Valuable Tool for Lower Eyelid Retraction Management: A Retrospective, Observational, Single Blind and Case—Control Study

ABSTRACT Introduction The idiopathic inflammatory myopathies traditionally comprise dermatomyositis, polymyositis, the anti-synthetase syndromes, immune-mediated necrotizing myopathy and inclusion body myositis. However, there are uncommon localized forms that are less known. In this review, we aimed to cover these uncommon forms. Areas covered We identified rare forms of localized myositis on the basis of list provided by the homepage of the Neuromuscular disease center of Washington University, USA and on the basis of the authors’ knowledge. We searched PubMed® for relevant articles on these forms with the aim of providing as much as possible information on their clinical manifestations as well as guidance on their work-up and treatment. Expert opinion herein, we provide un updated description of rare forms of localized myositis. These forms are often difficult to diagnose because of their localized nature and are sometimes misdiagnosed as tumors. Knowledge about these rare forms of localized myositis can aid in their recognition and treatment.

Rare forms of inflammatory myopathies - part II, localized forms

Histopathologic Findings in Idiopathic Orbital Myositis.

Long-Term Outcomes of Upper Eyelid Loading with Platinum Segment Chains for Lagophthalmos: An Adjustable Approach.

Purpose The submental and neck regions share cutaneous features with the face and are suitable donor sites for facial full-thickness skin grafts (FTSGs). Age-related laxity and skin redundancy in the cervicomental region may be an additional motivator to use its skin. We aim to describe, raise awareness, and remind surgeons of the utilization of submental and anterior neck as sources of FTSG for the periocular region, particularly when traditional donor sites are unavailable. Methods Retrospective case series of 5 patients who underwent periocular FTSG from anterior neck and submental regions between January 2017 and January 2019. All patients had contraindications to the usually preferred graft donor sites. Main outcome measures were surgical functional results and cosmesis. Results Five patients (all female) received FTSGs using anterior neck and submental regions as donor sites. Two patients required skin grafts due to eyelid retraction and anterior lamella shortening; one due to previous multiple basal cell carcinoma excisions with FTSG reconstructions and the other due to chronic Bell's palsy. Three patients required skin grafts for Hughes flap reconstruction after excision of lower eyelid basal cell carcinoma. In all patients, conventional skin donor sites were unavailable or unsuitable due to previous skin grafting, actinic changes, postauricular situated hearing aids or patient's preference. All patients achieved good cosmesis and functional results. None of the patients experienced donor site morbidities. Conclusions Submental and anterior neck regions are useful FTSG donor sites for periocular procedures, particularly in elderly female patients with submental fullness and neck skin redundancy.

Submental and Anterior Neck Originated Full-Thickness Skin Grafts for Periocular Procedures.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory neuropathy, which commonly causes peripheral neuropathy. It has rarely been associated with cranial nerve hypertrophy and neuro-ophthalmic manifestations. Proptosis secondary to cranial nerve hypertrophy has been reported in association with CIDP. The authors present a case of a 67-year-old man with CIDP who presented with bilateral proptosis, strabismus, and episodes of globe subluxation. The proptosis was mainly attributed to significant enlargement of the extraocular muscles, in addition to bilateral enlargement of the trigeminal nerves. There has been no published case of CIDP with associated enlargement of extraocular muscles without a history of underlying hyperthyroidism, inflammation, or malignancy. This may represent a new clinical finding in CIDP and adds to the limited literature on the neuro-ophthalmic and orbital associations of CIDP. The proptosis was managed with an uncomplicated bilateral orbital decompression.

Elad Ben Artsi

Papers

Histopathologic Findings in Idiopathic Orbital Myositis.

Long-Term Outcomes of Upper Eyelid Loading with Platinum Segment Chains for Lagophthalmos: An Adjustable Approach.

Submental and Anterior Neck Originated Full-Thickness Skin Grafts for Periocular Procedures.

Extraocular Muscle Enlargement and Proptosis Associated with Chronic Inflammatory Demyelinating Polyradiculoneuropathy.