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Management of the brow remains a challenging, important, and gratifying area in the care of facial paralysis patients. Aged facial paralysis patients generally require surgical management of brow ptosis. Young facial paralysis patients occasionally require surgical management of brow ptosis. Indications for surgical management, treatment options, and surgical approach are discussed. Consideration of factors such as age, forehead furrows, skin type, duration of paralysis, and degree of visual impairment are discussed in the context of treatment planning.
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PMID:Management of the brow in facial paralysis. 1847 Aug 33

Among the major disorders of the lower eyelid due to peripheral facial paralysis are lagophthalmos, eyelid ptosis and ectropion, with or without epiphora. There are several surgical techniques for correcting ectropion and lower eyelid ptosis. This article describes a modification of the classic technique of suspension using tendons, which consists of anchoring the tendon to the frontal apophysis of the maxillary bone and external orbital bone with suture screw anchors. Using the described technique, we obtained significant improvement of epiphora.
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PMID:Surgical correction of lower eyelid paralysis with suture screw anchors. 1901 51

Seventeen patients averaging 51 years of age underwent 23 surgical procedures, including suture suspension for both midface and neck rejuvenations. A 3/0 polypropylene thread with bioabsorbable cones with multiple point fixations in addition to 2 x 0.5-cm polypropylene surgical mesh are used in this technique. The mean postoperative, follow-up time was 9 months. Of the 17 patients, 12 underwent this procedure for midface rejuvenations, 3 for facial palsy, 5 for neck aesthetic procedures, 2 for brow ptosis, and 1 for brow asymmetry. The average number of sutures used for each face was 4 and 2 were used for each neck. The authors present an anatomic study for the safe placement of sutures, the surgical technique, and a microscopic photo documentation of the fibrosis around the suture knot and cone. All patients developed temporary edema. Two patients had a moderate aesthetic improvement of the face, and 1 patient underwent resuspension of the sutures 4 months postsurgery. Overall early patient satisfaction at 9 months was 90%. This technique has the potential to be a useful and effective clinical tool for minimally invasive face and neck rejuvenations.
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PMID:Suture suspension technique for midface and neck rejuvenation. 1938 44

A 77-year-old man non-immunized to tetanus suffered head trauma on the right side when he tumbled from a height of approximately 2m. Five days later, he experienced difficulty in opening his mouth and developed right ptosis. He was referred to our hospital 2 days post-ictus. The patient suffered trismus, and developed right Horner's syndrome with in a week. Symptoms due to multiple cranial nerve palsies were observed: right inferior oblique muscle weakness, reduced right corneal reflex, right facial palsy, dysphagia, and abnormal tongue movements. Neuroimages (computed tomography, magnetic resonance imaging, and angiography) of the basal skull and internal carotid arteries revealed no abnormalities. From the symptoms associated with his infected head wound and clinical follow-up, we suggested that he had cephalic tetanus. We subsequently conducted the following treatments: debridement of the wound, intravenous infusion of antitetanus human immunoglobulin (AHI), intrathecal AHI infusion, and systemic administration of benzylpenicillin. His condition improved with these treatments, and without any complications such as autonomic nervous system dysfunction or classical tetanic spasms. This case suggests that we should consider the possibility of cephalic tetanus when we observe a patient with cranial nerve palsy associated with injury.
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PMID:[Dysfunction of multiple cranial nerves in cephalic tetanus--case report]. 1969 89

Melkersson-Rosenthal Syndrome (MRS) is a rare disorder characterized by orofacial edema, facial palsy, and fissured tongue. A 64-year-old man presented with a fissured tongue and persistent chronic right upper eyelid edema of 15 years duration. The diagnostic biopsy revealed non-necrotizing granulomatous inflammation adjacent to blood and lymphatic vessels. Characteristic granulomas with focal occlusion of dilated lymphatic channels were present. Special stains for fungi, acid-fast microorganisms and bacteria were negative. Ptosis due to a mechanical effect of the persistent eyelid edema required surgical treatment including debulking and advancement of the levator muscle. At 6 months after surgery the patient showed symmetrical eyelid position without edema. The case demonstrates an uncommon presentation of Melkersson-Rosenthal syndrome with prominent upper eyelid edema and lingua plicata, which was initially misdiagnosed. The clinical findings coupled with the characteristic granulomatous lymphangitis present in the biopsy are crucial for a definite diagnosis.
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PMID:Melkersson-Rosenthal Syndrome Presenting as Chronic Eyelid Swelling. 2033 35

Miller Fisher syndrome (MFS) is a triad of total external ophthalmoplegia, ataxia, and areflexia, while botulism has the usual clinical presentation of involvement of cranial muscles and palsies with blurred vision, diplopia, ptosis, dilated pupils, and facial paralysis, caused by a bacterial neurotoxin which attacks proteins involved in presynaptic vesicle release. In this report, we needed to make the differential diagnosis between MFS and botulism in a patient who presented with acute ophthalmoparesis and a history of diarrhea three days before, which started two days after consuming tinned food. Routine laboratory, neurophysiologic, and imaging investigations were normal. A clinical diagnosis of Miller Fisher syndrome was reached by anti-ganglioside GQ1B and GM1 Ig G and M antibody investigations which proved positive. The patient was treated with intravenous immunoglobulin two weeks after (in the late period) the symptoms started and he has recovered completely. Systemic autoimmune diseases should be considered in patients with bilateral ophthalmoparesis. As in the present patient, the evaluation of specific antibodies helps in the diagnosis and thus early effective treatment is possible.
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PMID:Role of anti-GQ1B antibody in differential diagnosis of acute ophthalmoparesis. 2050 43

Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.
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PMID:Noncosmetic periocular therapeutic applications of botulinum toxin. 2061 16

Cephalic tetanus is defined as a combination of trismus and paralysis of one or more cranial nerves. Cranial nerves III, IV, VI, VII, and XII may be affected, but the facial nerve is most frequently implicated. A 64-year-old female visited hospital for left ptosis followed by facial palsy after a left forehead abrasion in a car accident. At nine days post injury, left ptosis developed, left facial palsy developed twelve days post injury, and at fifteen days post injury, trismus and dysphagia developed. The following day, there was progression of symptoms to generalized tetanus, such as dyspnea and generalized rigidity. Videofluoroscopic swallow study showed penetration and aspiration. We report a case of cephalic tetanus with ptosis, facial palsy, and dysphagia, which progressed to generalized tetanus.
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PMID:A case of cephalic tetanus with unilateral ptosis and facial palsy. 2250 53

Prosthetic replacement of the ocular surface ecosystem is a treatment developed by the Boston Foundation for Sight that uses a Food and Drug Administration-approved prosthetic device for the treatment of severe ocular surface disease to improve vision and discomfort in addition to supporting the ocular surface. Facial nerve paralysis has multiple causes including trauma, surgery, tumor, stroke, and congenital lagophthalmos. Subsequent lagophthalmos leading to exposure keratitis has been treated with copious lubrication, tarsorrhapy, eyelid weights, chemodenervation to yield protective ptosis, and palpebral spring insertion. Each of these treatments, however, has limitations and potential complications. The prosthetic replacement of the ocular surface ecosystem device provides a liquid bandage to protect the cornea from eyelid interaction and dessication in addition to improving vision. This report describes 4 patients with exposure keratitis who were successfully treated with prosthetic replacement of the ocular surface ecosystem devices at 2 clinical sites.
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PMID:PROSE treatment for lagophthalmos and exposure keratopathy. 2303 88

We report on two cases of bilateral chorioretinal colobomas with ocular anomalies in patients with CHARGE syndrome. In the first case, a female infant was born at 36 + 5 weeks gestation. At birth, the patient demonstrated a small left eye. Slit-lamp examination revealed colobomas of both irises. Fundus examination showed both chorioretinal colobomas. Brain magnetic resonance imaging (MRI) showed left microphthalmia. Systemic evaluation revealed multiple congenital anomalies: benign external hydrocephalus, esophageal atresia with imperforate anus, atrial septal defect (ASD), ventricular septal defect, patent ductus arteriosis (PDA), and right mild hydronephrosis. In the second case, a male infant was born at 39 + 5 weeks gestation and demonstrated a dysmorphic appearance with an irregular left pupil and ptosis. Fundus examination of both eyes showed large chorioretinal colobomas involving the optic disc and posterior pole. The patient had multi-organ anomalies: right facial palsy, a left short, wide ear with a small lobe, congenital heart defects, such as ASD and PDA, left renal atresia, seizure disorder, and micropenis. Both cases revealed multiple anomalies including nearly all major and minor criteria of CHARGE syndrome which could be life-threatening to neonates. Thus, all neonates with ocular colobomas should have fully and detailed systemic examinations checking all minor criteria and even occasional findings of CHARGE syndrome.
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PMID:Two cases of CHARGE syndrome with multiple congenital anomalies. 2380 50


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