Bell’s palsy

Abstract   There is insufficient evidence concerning the efficacy of antiviral treatment of Bell’s palsy (BP). We therefore compared the efficacy of prednisone and famciclovir to prednisone treatment alone in BP. A total of 167 consecutive patients with untreated acute BP were included. Severity of BP was evaluated using the House-Brackmann scale (HBS) and virus antibody tests (herpes simplex virus, varicella zoster virus) were performed. Patients admitted on even dates were treated with prednisone (“P group”) and patients admitted on odd dates were treated with prednisone and famciclovir (“P+F group”). 117 patients completed the follow-up after 3 months or later (67 P/51 P+F). While most patients showed at least partial recovery with both treatment types, improvement of at least 4 grades in the HBS was more common in the “P+F group” (29.4 % vs. 11.9 %), whereas smaller changes of less than 3 grades were more common in the “P group” (29.9 % vs. 17.6 %; Chi-square test, p = 0.02). Patients with complete BP (HBS grade of 5 or 6) had significantly better chances of reaching normal function if treated with famciclovir additionally instead with prednisone alone (73.7 % vs. 47.1 %; Cochran-Armitage trend test, p = 0.03). These results suggest that the combined treatment of famciclovir and prednisolone should be considered (at least) in patients with severe BP.     

Prevalence of Bell’s palsy in Qena Governorate,Egypt

Background and purpose: There have been few studies to estimate the prevalence of Bell’s palsy (BP) in Arab countries. A community-based study was conducted to estimate the prevalence, incidence rates, precipitating factors, and outcome of BP in Qena Governorate, Egypt.

Subjects and methods: A door-to-door survey was carried out, with random sampling of 10 districts, involving 9303 inhabitants, 51.1% males and 48.9% females. Seventeen subjects were positive in screening questionnaire and referred to Qena University hospital and were subjected to a full clinical examination, House Brackmann’s Facial grading system.

Results: In a total population of 9303 individuals, 15 cases were confirmed as having BP giving a prevalence rate (PR) 161/10⁵ for all ages 95%CI (80–243). It was slightly but not significantly higher among women and the rural community. The incidence rate of BP was 107/10⁵. The highest age-specific rate was 40–49 years age. The most frequent precipitating factors for an episode of BP were exposure to air draft in 40%, physical stress (13.3%), and upper respiratory tract infection (13.3%). Moreover, 46.7% had predisposing risk factors, DM and hypertension in 33.3%. Sixty percent of cases had complication and poor outcome.

Conclusion: The overall prevalence and incidence rates of BP in Qena governorate were high. This could be related to the variation in day and night temperature in our community and the susceptibility to air draft exposure during the night. The high frequency of poor outcome among studied cases suggests that better local guidelines should be implemented to recognize and treat BP.     

The etiology of Bell’s palsy: a review

Journal of Neurology - Bell’s palsy is the most common condition involving a rapid and unilateral onset of peripheral paresis/paralysis of the seventh cranial nerve. It affects...     

Vagus somatosensory evoked potentials are delayed in Alzheimer’s disease,but not in major depression

In Alzheimer’s disease (AD), the degeneration of brainstem nuclei is different from major depression (MD). Thus, vagus somatosensory evoked potentials (VSEP) proposed for the functional assessment of brainstem nuclei should show prolonged latencies in AD but not in MD. In 55 AD patients, 57 MD patients and two age-matched control groups evoked potentials were recorded upon stimulation of the auricular branch of the vagus nerve. In the AD, not in the MD group, latencies were significantly longer as compared to controls. Thus, the method of VSEP could contribute to the important differential diagnosis of AD and MD in elderly patients.     

Degeneration of the vestibular nerve in unilateral Meniere’s disease evaluated by galvanic vestibular-evoked myogenic potentials

Objective

The staging system of Meniere’s disease utilizes audiograms to probe cochlear dysfunction. We explored the addition of galvanic vestibular-evoked myogenic potentials (VEMP) to further explore vestibular function.

Oberlin’s procedure in children with obstetric brachial plexus palsy

Purpose

Most cases of obstetric brachial plexus palsy (OBPP) involve C5 and C6 nerve roots (Erb’s palsy). In those cases, re-establishing the elbow flexion is the primary goal of surgery. The partial transfer of the ulnar nerve to the musculocutaneous nerve (Oberlin’s procedure) is widely used in adults, but incipient in children. The purpose of this study is to describe the results obtained with such procedure as regards the improvement of the elbow flexion and donor nerve morbidity.

Method

Thirteen children aged 9 to 15 months underwent Oberlin’s procedure. They were assessed preoperatively and 1 year postoperatively using the active movement scale and also according to the functionality of the affected limb. All of them were evaluated because of the possibility of movement loss resulting from the donor nerve. We used the non-parametric, statistic Wilcoxon signed rank test (α = 0,05) method.

Results

There was a significant improvement in the active elbow flexion between pre- and postoperative periods. Eleven children presented functional improvement. All of them maintained negative cookie test 1 year after the surgery. We did not observe any loss related to the donor nerve in terms of wrist flexion.

Conclusion

The results suggest that Oberlin’s procedure can be an effective and safe alternative to treat elbow flexion in Erb’s palsy.

     

Acupuncture and vitamin B12 injection for Bell’s palsy: no high-quality evidence exists

OBJECTIVE:

To assess the efficacy of acupuncture combined with vitamin B₁₂ acupoint injection versus acupuncture alone to reduce incomplete recovery in patients with Bell’s palsy.

DATA RETRIEVAL:

A computer-based online retrieval of Medline, Web of Science, CNKI, CBM databases until April 2014 was performed for relevant trials, using the key words “Bell’s palsy or idiopathic facial palsy or facial palsy” and “acupuncture or vitamin B₁₂ or methylcobalamin”.

STUDY SELECTION:

All randomized controlled trials that compared acupuncture with acupuncture combined with vitamin B₁₂ in patients with Bell’s palsy were included in the meta-analysis. The initial treatment lasted for at least 4 weeks. The outcomes of incomplete facial recovery were monitored. The scoring index varied and the definition of healing was consistent. The combined effect size was calculated by using relative risk (RR) with 95% confidence interval (CI) using the fixed effect model of Review Manager.

MAIN OUTCOME MEASURES:

Incomplete recovery rates were chosen as the primary outcome.

RESULTS:

Five studies involving 344 patients were included in the final analysis. Results showed that the incomplete recovery rate of Bell’s palsy patients was 44.50% in the acupuncture combined with vitamin B₁₂ group but 62.57% in the acupuncture alone group. The major acupoints were Taiyang (EX-HN5), Jiache (ST6), Dicang (ST4) and Sibai (ST2). The combined effect size showed that acupuncture combined with vitamin B₁₂ was better than acupuncture alone for the treatment of Bell’s palsy (RR = 0.71, 95%CI: 0.58–0.87; P = 0.001), this result held true when 8 patients lost to follow up in one study were included into the analyses (RR = 0.70, 95%CI: 0.58–0.86; P = 0.0005). In the subgroup analyses, the therapeutic effect in patients of the electroacupuncture subgroup was better than in the non-electroacupuncture subgroup (P = 0.024). There was no significant difference in the incomplete recovery rate by subgroup analysis on drug types and treatment period. Most of the included studies were moderate or low quality, and bias existed.

CONCLUSION:

In patients with Bell’s palsy, acupuncture combined with vitamin B₁₂ can reduce the risk of incomplete recovery compared with acupuncture alone in our meta-analysis. Because of study bias and methodological limitations, this conclusion is uncertain and the clinical application of acupuncture combined with vitamin B₁₂ requires further exploration.     

Abnormal auditory evoked potentials in Déjérine-Sottas disease

Summary Two cases of hereditary motor sensory neuropathy type III (Déjérine-Sottas disease) examined by audiological, vestibular and electrophysiological methods are reported. In both cases there were signs of vestibular and acoustic central pathway involvement, shown by vestibular examination and by the study of auditory evoked potentials. The presence of central involvement in this hereditary neuropathy suggests central as well as peripheral myelin alteration.

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Zusammenfassung Es wird über zwei Fälle von hereditärer motorischer und sensorischer Neuropathie vom Typ-III (Déjérine-Sottas-Krankheit) berichtet, welche otoneurologisch und elektrophysiologische eingehend untersucht wurden. In beiden Fällen fand man Hinweise dafür, daß die vestibulären und akkustischen zentralen Bahnen mitbetroffen sind. Dies läßt darauf schließen, daß bei dieser Erkrankung die Myelinstrukturen nicht nur in den peripheren Nerven sondern auch im Zentralorgan betroffen sein können.

     

Vestibular compensation: the neuro-otologist’s best friend

Why vestibular compensation (VC) after an acute unilateral vestibular loss is the neuro-otologist’s best friend is the question at the heart of this paper. The different plasticity mechanisms underlying VC are first reviewed, and the authors present thereafter the dual concept of vestibulo-centric versus distributed learning processes to explain the compensation of deficits resulting from the static versus dynamic vestibular imbalance. The main challenges for the plastic events occurring in the vestibular nuclei (VN) during a post-lesion critical period are neural protection, structural reorganization and rebalance of VN activity on both sides. Data from animal models show that modulation of the ipsilesional VN activity by the contralateral drive substitutes for the normal push–pull mechanism. On the other hand, sensory and behavioural substitutions are the main mechanisms implicated in the recovery of the dynamic functions. These newly elaborated sensorimotor reorganizations are vicarious idiosyncratic strategies implicating the VN and multisensory brain regions. Imaging studies in unilateral vestibular loss patients show the implication of a large neuronal network (VN, commissural pathways, vestibulo-cerebellum, thalamus, temporoparietal cortex, hippocampus, somatosensory and visual cortical areas). Changes in gray matter volume in these multisensory brain regions are structural changes supporting the sensory substitution mechanisms of VC. Finally, the authors summarize the two ways to improve VC in humans (neuropharmacology and vestibular rehabilitation therapy), and they conclude that VC would follow a “top-down” strategy in patients with acute vestibular lesions. Future challenges to understand VC are proposed.     

The role of event-related potentials in cognitive decline in Alzheimer’s disease

ObjectivesEarly diagnosis and monitoring of disease progression have become vital in clinical practice as disease modifying treatments for Alzheimer’s disease (AD) become available. This one-year prospective study aimed to clarify the usefulness of event-related potentials (ERPs) in cognitive decline and elucidate their cognitive significance in AD.MethodsUsing the Cognitive Abilities Screening Instrument (CASI) and ERPs, probable AD patients, mild cognitive impairment (MCI) patients, and normal controls were recruited.ResultsThe AD and MCI patients had significantly decreased cognitive function and manifested a delay of P300 latency. The P300 latencies demonstrated significantly more prolongation than their baseline values in probable AD and MCI patients, although their CASI scores showed no statistically significant decline. Whereas N100, P200, and N200 components did not reach statistical differences between groups either in the baseline or follow-up assessments and did not show significant change on follow-up.ConclusionThe combination of neuropsychological tests and P300 measurements proved useful in improving reliability and increasing sensitivity to early cognitive decline or disease progression in AD patients.SignificanceThe P300 latency may reflect cognitive decline more sensitively than neuropsychological tests in the longitudinal follow-up of AD patients.     

Habituation of auditory event-related potentials in patients with Behcet’s disease

Abstract Behcets disease is a progressive and/or relapsing-remitting multisystem inflammatory disorder. Involvement of the central nervous system occurs in 10%–29% of cases with Behcets disease. The aim of the present study was to assess the effect of repetitive auditory stimulations on event-related potentials (ERP) in patients with Behcets without neurologic manifestations. The study was performed in 14 patients with Behcets disease and 14 healthy volunteers. ERPs were recorded from Fz, Cz and Pz. The auditory ERPs test was continued until 20 artefact-free rare tones were averaged, which was accepted as one trial block. After six blocks were obtained in a sequential manner, the test was completed. According to the results of the present study, P300 latency changed in different manners over trial blocks in the two groups. P300 latency values showed a progressive increase in the controls; however this was not determined in the Behcets group. Thus, habituation was not observed in the patient group. Because of the lack of habituation related to P300 latency, it may be thought that there is an insidious pathologic process in Behcets disease without neurologic manifestation.     

Auditory event-related potentials in subcortical vascular cognitive impairment and in Alzheimer’s disease

Summary. Background: Few studies exist on ERPs and patients with subcortical vascular cognitive impairment (SVCI). This latter is a quite homogeneous subtype of vascular dementia whose cognitive profile is quite different from that of Alzheimer disease (AD). Aims: The present study aims at comparing the ERPs profile both in patients with SVCI and in patients with AD. Subjects and methods: ERPs and psychometric tests were collected from 39 healthy elderly controls, 51 patients with SVCI and 43 patients with AD. Subjects mentally count high pitched target tones that were randomly intermixed with low pitched frequent tones. We measured ERPs latencies (N1, P2, N2 and P3), and interpeak latencies (N1–P3, N1–P2, N1–N2). Results: Grand averaged potentials in SVCI showed a significant increase of P3 latency. AD patients showed a prolongation of N1, P2, N2, P3 latencies. As far as interpeak latencies are concerned, SVCI patients showed a significant prolongation of N1–P3, AD patients had a significant increase of N1–N2, and N1–P3 intervals. When all patients were considered as a single group, correlation of neuropsychological tests scores showed a significant negative relationship between P300 latency and, respectively, Mini Mental Status Examination, auditive and visual span forward. In both groups, ERPs latency sensitivity, was low, whilst specificity values were quite high. Conclusions: Our finding suggest that these two dementing diseases have different electrophysiologic features that may be related to their specific underlying pathogenetic mechanism; in particular, we hypothesise that, differently from AD, P300 latency prolongation characterizes the early stage of SVCI. So, this ERPs approach could be helpful to detect early alterations of the attentional/working-memory functions in patients with subcortical ischaemic vascular disease.     

Subjects’ hypnotizability level affects somatosensory evoked potentials to non-painful and painful stimuli

ObjectiveWe evaluated the working hypothesis that the EEG activity associated to non-painful and painful stimuli in condition of waking state (no hypnotic procedure) was related to the hypnotizability level.MethodsHypnotizability level was measured in 16 healthy subjects through the Italian version of the Stanford Hypnotic Susceptibility Scale (SHSS, score: 0–12). EEG data (56 electrodes) were recorded during non-painful and painful electrical stimuli applied to the left index finger. Cortical activity (vertex N1–P2 complex) was compared in subjects with low hypnotizability level (N = 8, SHSS:0–6) vs. subjects with high hypnotizability level (N = 8, SHSS:7–12).ResultsThe amplitude of the N1–P2 complex was lower in the High-hypnotizability compared to the Low-hypnotizability group over primary sensorimotor cortex (C3 and C4 electrodes) and centro-parietal midline areas (Cz and Pz electrodes) for non-painful and painful stimuli. The SHSS showed a statistically significant negative correlation with the vertex N1–P2 complex at C3 and Cz (r = ?0.5, p < 0.05) electrodes for non-painful stimuli.ConclusionCompared to the Low-hypnotizability subjects, High-hypnotizability subjects showed a reduced cortical activity related to non-painful and painful stimuli.SignificanceThe results suggest a relationship between hypnotizability and cortical activity related to non-painful and painful stimuli in the condition of waking state (no hypnotic effect).     

Ocular and cervical vestibular-evoked myogenic potentials to bone conducted vibration in Ménière’s disease during quiescence vs during acute attacks

ObjectiveTwo indicators of otolithic function were used to measure dynamic otolith function in the same patients both during an acute attack of Ménière’s disease (MD) and in the quiescent period between attacks.MethodsThe early negative component (n10) of the ocular vestibular-evoked myogenic potential (the oVEMP) to brief 500 Hz bone conducted vibration (BCV) stimulation of the forehead, in the midline at the hairline (Fz) was recorded by surface EMG electrodes just beneath both eyes while the patient looked up. It has been proposed that the n10 component of the oVEMP to 500 Hz Fz BCV indicates utricular function. It has been proposed that the early positive component (p13) of the cervical vestibular-evoked myogenic potential (the cVEMP) recorded by surface electrodes on both tensed SCM neck muscles to 500 Hz Fz BCV indicates saccular function.ResultsSixteen healthy control subjects tested on two occasions showed no detectable change in the symmetry of oVEMPs or cVEMPs to 500 Hz Fz BCV. In response to 500 Hz Fz BCV 15 early MD patients tested at both attack and quiescent phases showed a dissociation: there was a significant increase in contralesional of n10 of the oVEMP during the attack compared to quiescence but a significant decrease in the ipsilesional p13 of the cVEMP during the attack compared to quiescence.ConclusionsDuring an MD attack, dynamic utricular function in the affected ear as measured by the n10 of the oVEMP to 500 Hz Fz BCV is enhanced, whereas dynamic saccular function in the affected ear as measured by the p13 of the cVEMP to 500 Hz Fz BCV is not similarly affected.SignificanceThe MD attack appears to affect different otolithic regions differentially.     

What might cervical vestibular–evoked myogenic potential abnormalities mean in essential tremor?

Aim/background

Essential tremor (ET) is one of the most common movement disorders. However, its pathogenesis is unclear. Human vestibular reflexes are essential not only for gait and posture but also for goal-directed voluntary movements. In this study, cervical vestibular–evoked myogenic potentials (cVEMPs), the electrophysiological equivalent of the vestibulo-collic reflex was studied in ET patients to understand the interaction between the tremor network and the vestibular neural pathways.

Methods

cVEMPs were recorded in 40 ET patients and 40 age and sex-matched healthy controls (HCs). The latencies of peaks p13 and n23 and peak-to-peak amplitude of p13-n23 were measured.

Results

There was no statistically significant difference between the p13 latencies of the HC and ET groups (p 0.79 and p 0.23 for the right and left sides respectively). n23 latency was shortened bilaterally in the ET group (p 0.009 and p 0.02 for the right and left sides respectively). p13-n23 amplitudes of the ET patients were bilaterally reduced when compared with the HC (p <0.001 and p 0.001 for the right and left sides respectively).

Conclusion

Information provided by vestibular afferents is crucial in the control of voluntary movements in humans. Despite this silent but significant effect, the role of the vestibular system in movement disorders is often overlooked. In this study, it was found that cVEMP responses reflecting the activity of the vestibulo-collic pathway were affected in ET which can be either caused by dysfunctional structures or pathways responsible from ET or an additional disorder of vestibular information processing in these patients.

     

Neuronal spiking in the pedunculopontine nucleus in progressive supranuclear palsy and in idiopathic Parkinson’s disease

Journal of Neurology - The pedunculopontine nucleus (PPN) is engaged in posture and gait control, and neuronal degeneration in the PPN has been associated with Parkinsonian disorders. Clinical...