The research for the function evaluation of facial nerve and the mechanisms of rehabilitation training

Background:Peripheral facial paralysis (PFP) is a common peripheral neural disease. Acupuncture treatment combined with PFP rehabilitation exercises is a routine method of PFP treatment. This article is to provide a new visual and objective evaluation method for exploring the mechanism and efficacy of acupuncture treatment on PFP, and develop an interactive augmented facial nerve function rehabilitation training system with multiple training models.Methods:This prospective and observational trial will recruit 200 eligible participants for the following study. In the trial, the laser speckle contrast analysis (LASCA) technology will be applied to monitor the microcirculation of facial blood flow during acupuncture, and real-time monitoring algorithms, data sampling, and digital imaging methods will be conducted by machine learning and image segmentation. Then, a database of patient facial expressions will be built, the correlation between surface blood flow perfusion volume and facial structure symmetry will be analyzed, combined with scale assessment and electrophysiological detection. In addition, we will also explore the objectivity and effectiveness of LASCA in the evaluation of facial paralysis (FP), and the changes in blood flow microcirculation before and after acupuncture treatment will be analyzed.Results:The standard image of the facial target area with facial nerve injury will be manually segmented by the convolutional neural network method. The blood flow images of the eyelid, cheek, and mandible of the patients’ affected and healthy side will be compared and evaluated. Laser speckle blood flow symmetry Pr and its changes in FP condition evolution and prognosis outcome will be measured, and relevant characteristic signals values will be extracted. Finally, COX regression analysis method is conducted to establish a higher accuracy prediction model of FP with cross-validation based on laser speckle blood flow imaging technology.Conclusions:We use modern interdisciplinary high-tech technologies to explore the mechanism of acupuncture rehabilitation training in PFP. And we will provide evidence for the feasibility of using the LASCA technique as a typing diagnosis of FP in the acupuncture rehabilitation treatment of PFP.Registration number:ChiCTR1800019463     

Enlargement of Intrathoracic Goiter with Unilateral Phrenic Nerve Paralysis Leading to Cardiopulmonary Arrest

As an intrathoracic goiter expands, it causes airway stenosis and phrenic nerve paralysis, and slight respiratory stimuli can trigger sudden life-threatening hypoventilation. A 78-year-old obese woman with a large intrathoracic goiter was found unconscious with agonal breathing in her room early in the morning. Cardiopulmonary resuscitation restored spontaneous circulation. She underwent surgical removal of the goiter; however, she required long-term mechanical ventilation because of atelectasis due to phrenic nerve paralysis. In patients with large intrathoracic goiters, difficulty breathing on exertion and diaphragm elevation on chest X-ray may be significant findings predicting future respiratory failure.     

Monitoring recovery from diaphragm paralysis with ultrasound

BACKGROUND: Diaphragmatic paralysis is an uncommon, yet underdiagnosed cause of dyspnea. Data regarding the time course and potential for recovery has come from a few small case series. The methods that have been traditionally employed to diagnose diaphragmatic weakness or paralysis are either invasive or limited in sensitivity and specificity. A new technique utilizing two-dimensional, B-mode ultrasound (US) measurements of diaphragm muscle thickening during inspiration (Deltatdi%) has been validated in the diagnosis of diaphragm paralysis (DP). The purpose of this study was to assess whether serial US evaluation might be utilized to monitor the potential recovery of diaphragm function. METHODS: Twenty-one consecutive patients with clinically suspected DP were referred to the pulmonary physiology laboratory. Sixteen patients were found to have DP by US (unilateral, 10 patients; bilateral, 6 patients). Subjects were followed up for up to 60 months. On initial and subsequent visits, Deltatdi% was measured by US. Additional measurements included upright and supine vital capacity (VC), maximal inspiratory pressure (Pimax), and maximal expiratory pressure. RESULTS: Eleven of 16 patients functionally recovered from DP. The mean (+/- SD) recovery time was 14.9 +/- 6.1 months. No diaphragm thickening was noted in those patients who did not recover. Positive correlations were found between improvement in Deltatdi% and interval changes in VC, Pimax, and end-expiratory measurements of diaphragm thickness. CONCLUSIONS: US may be used to assess for potential functional recovery from diaphragm weakness or DP. As in previous series, recovery occurs in a substantial number of individuals, but recovery time may be prolonged.     

Effect of ventilation by high-frequency oscillation on lung and chest wall mechanics in the dog

High-frequency oscillation (HFO) has been shown to be effective in maintaining gas exchange, but the effects of high-frequency, small-volume ventilation on the mechanical properties of the respiratory system are unknown. A volume displacement plethysmograph was used to study lung volumes and static pressure-volume (PV) curves during HFO in pentobarbital-anesthetized dogs. During long-term studies, adequate gas exchange was maintained with a stroke volume of 2.5 ml/kg and frequencies between 15 and 30 Hz. The effect of 5–7 hours of HFO on lung and chest wall mechanics was studied in 8 dogs. In another 8 dogs the relationship of volume history and respiratory muscle tone to occlusion airway pressure and lung volume during short-term HFO was investigated. With prolonged HFO, a small but significant decrease in total lung capacity occurred by 5 hours and the static respiratory system PV curve shifted slightly to the right. These changes were reversed by muscle paralysis and may be explained by a change in respiratory muscle tone. Static lung compliance and the hysteresis ratio (an index of tissue properties) remained unchanged. The relationship of occlusion airway pressure and lung volume during short-term HFO was dependent on the lung volume history and was influenced by respiratory muscle tone only at low airway pressures. These findings suggest that during prolonged HFO a small increase in chest wall stiffness may result. However, occlusion airway pressure and lung volume at the onset of HFO are mainly dependent on the volume history of the lung. Presented in part at the Fall Meeting of the American Physiological Society, Toronto, Canada, October 12–17, 1980     

Expiratory-Synchronized Sleep in a Quadriplegic Patient Using Inspiratory Neck Muscles To Breathe

In a patient with C3 quadriplegia causing complete diaphragm paralysis who developed inspiratory neck muscles (INM) hypertrophy to sustain ventilation, spontaneous breathing deeply altered sleep architecture, relegating sleep to the expiratory phase of the ventilatory cycle. A polysomnographic recording performed during mechanical ventilation (without INM activity), showed that sleep was abnormal but unaffected by the respiratory cycle. During spontaneous breathing, the polygraphic recordings showed expiratory microsleep episodes, with inspiratory arousals synchronous to bursts of INM activity. This case report illustrates the powerful adaptability of the respiratory and sleep control systems to maintain each vital function.     

In-Vitro Neutralization of the Neurotoxicity of Coastal Taipan Venom by Australian Polyvalent Antivenom: The Window of Opportunity

Coastal taipan (Oxyuranus scutellatus) envenoming causes life-threatening neuromuscular paralysis in humans. We studied the time period during which antivenom remains effective in preventing and arresting in vitro neuromuscular block caused by taipan venom and taipoxin. Venom showed predominant pre-synaptic neurotoxicity at 3 µg/mL and post-synaptic neurotoxicity at 10 µg/mL. Pre-synaptic neurotoxicity was prevented by addition of Australian polyvalent antivenom before the venom and taipoxin and, reversed when antivenom was added 5 min after venom and taipoxin. Antivenom only partially reversed the neurotoxicity when added 15 min after venom and had no significant effect when added 30 min after venom. In contrast, post-synaptic activity was fully reversed when antivenom was added 30 min after venom. The effect of antivenom on pre-synaptic neuromuscular block was reproduced by washing the bath at similar time intervals for 3 µg/mL, but not for 10 µg/mL. We found an approximate 10–15 min time window in which antivenom can prevent pre-synaptic neuromuscular block. This time window is likely to be longer in envenomed patients due to the delay in venom absorption. Similar effectiveness of antivenom and washing with 3 µg/mL venom suggests that antivenom most likely acts by neutralizing pre-synaptic toxins before they interfere with neurotransmission inside the motor nerve terminals.     

Exploring the utility of whole‐exome sequencing as a diagnostic tool in a child with atypical episodic muscle weakness

The advent of whole‐exome next‐generation sequencing (WES) has been pivotal for the molecular characterization of Mendelian disease; however, the clinical applicability of WES has remained relatively unexplored. We describe our exploration of WES as a diagnostic tool in a 3½‐year old female patient with a 2‐year history of episodic muscle weakness and paroxysmal dystonia who presented following a previous extensive but unrevealing diagnostic work‐up. WES was performed on the proband and her two parents. Parental exome data was used to filter potential de novo genomic events in the proband and suspected variants were confirmed using di‐deoxy sequencing. WES revealed a de novo non‐synonymous mutation in exon 21 of the calcium channel gene CACNA1S that has been previously reported in a single patient as a rare cause of atypical hypokalemic periodic paralysis. This was unexpected, as the proband's original differential diagnosis had included hypokalemic periodic paralysis, but clinical and laboratory features were equivocal, and standard clinical molecular testing for hypokalemic periodic paralysis and related disorders was negative. This report highlights the potential diagnostic utility of WES in clinical practice, with implications for the approach to similar diagnostic dilemmas in the future.     

单节段颈椎间盘突出症前路减压术后上肢近端麻痹的研究

 目的 探讨单节段颈椎间盘突出症(cervical disc herniation ,CDH)行前路减压术后继发上肢近端麻痹(proximal upper limb palsy ,PULP)的发作特征及危险因素。方法 回顾性分析颈椎管前路减压分别联合融合或非融合固定术,治疗235例单节段CDH患者资料,术后随访时间均在12个月以上。术前PULP组和非PULP组一般资料比较,差异均无统计学意义。按照术前临床表现,分为以脊髓型和神经根型损害两组。减压节段包括C_3/4、C_4/5、C_5/6和C_6/7椎间隙。分别比较不同手术节段或术前定位体征亚组间术后PULP发生率。以C₅椎体为界,比较其上(下)椎间水平减压术后总体PULP发生率。结果 术后26例PULP患者均接受非手术治疗,末次随访均获得基本缓解。除C_4/5椎间隙和C₅髓节外,其余节段减压术后亦可继发PULP。C₅椎体上(下)各两个椎间减压术后PULP发生率和中下水平4个颈椎间隙减压术后PULP发生率比较,差异均无统计学意义。术前脊髓型表现者,术后PULP发生率高于神经根型表现者,差异有统计学意义。结论 术前为上运动神经元通路损害为主要表现者,CDH前路减压术后更易继发PULP。PULP发作应与固有束神经元体系的早期、可逆和暂时损害密切相关。     

A nasolabial fold reset technique for enhancing midface lifts in facial reanimation: Three-dimensional volumetric analysis

Despite successfully gaining excursion after free muscle transfer for facial palsy, soft tissue asymmetry, especially around the nasolabial fold (NLF) and medial cheek, is a troublesome problem in elderly patients. An NLF reset technique that enhances midface lifts has been introduced to overcome this problem.Our study included 43 consecutive patients who underwent facial reanimation surgery with free functional muscle transfer between March 2015 and July 2017. Of these, 20 patients underwent conventional procedures and 23 underwent our NLF reset technique. Postoperative oral commissure excursion and symmetry at rest and while smiling were quantified using FACEgram (Facial Assessment by Computer Evaluation) software. To detect soft-tissue changes after surgery, three-dimensional analysis was performed using Morpheus®, a 3D, LED-based, white-structured-light scanner.The NLF group had a significantly larger postoperative mean excursion at rest (control 25.32 ± 2.80 mm vs NLF 27.42 ± 3.60 mm; p = 0.047). The mean horizontal length ratios (affected-to-healthy) revealed better symmetry in the NLF group (resting 1.05 ± 0.22, smiling 0.97 ± 0.19; p = 0.201). The three-dimensional midface volume difference was significantly lower in the NLF group. The NLF reset technique produced improved surgical outcomes.An incision made along a mirrored NLF can influence midface lifting in patients with facial palsy, with the soft tissue concentrated in the lower face mobilized superomedially.