since joining uh P. And I. We have developed um one of the very few centers for facial nerve disorders um in southern California and on the West coast. Um This is an area of um patient care that I'm very passionate about. And so I'd like to uh hopefully provide some insights into the management of facial paralysis and how we can better take care of these patients. I know a lot of these patients are seeing you in urgent cares in your primary practices. And um I'd like to go through some of the things that we can do to help these patients who don't recover completely. And so why is the face important? Well, it defines our identity. It provides both verbal and nonverbal communication and emotional expression is universal and highly conserved among species. This has been known since the time of Charles Darwin if not before. Um And what does this mean when it says it's highly conserved? Well, our survival depends on being able to communicate. And so if you are trying to find a mate or you're trying to um respond to somebody who's just by using your smile or just by blinking um and showing that you can communicate with them. If you're unable to do that, the observer may not be able to respond properly and may just walk on and just ignore you or may get the wrong impression of you. And so being able to communicate um emotionally is extremely important and allows us to evolve and to continue through natural selection. And so what are the functional deficits of facial paralysis. Well this woman here has complete left sided paralysis. What you can see here in the upper faces, she has brought oasis in a visual field defect from the brow blocking her vision. She's unable to blink effectively. This would lead to dry eye irritation, epiphany A or chronic tearing. She could potentially develop an exposure keratitis and go blind. If not managed properly, nasal obstruction is commonly seen in these patients, especially in the older ones because they're mid face is so heavy and it's no longer being suspended by the ligaments and muscles of the face and it just collapses and blocks their airway. And in the lower face obviously we can we are concerned with the inability to smile but also eating, drinking, speaking articulating are all affected. So how do we as observers view the face? Well, this is a study that performed electro retina grams. And they followed people's eyes and they tracked them in the first three seconds after seeing images. The dark are the bright red is where most of the time was spent by the observer. And so what you'll see here is in the images on the left, in the normal and the repose and smile that the observer is focusing directly on the central triangle. The area between the eyes and nose and the mouth. Now, when you look at the patient on the right, when she's at rest, her face is fairly symmetric, She's young. There's not a lot of inconsistency and the observer can focus on that triangle, but when she smiles, our observation is distorted and our that central triangle is shifted to the right and that quick millisecond of of movement and the observer's attention being taken away. You can see that you're no longer focusing the red that we see. That was on the other image or on the image above is no longer focusing on the eyes or the mouth properly. And so we know that patients with deformities are considered more uh disfigured and bothersome by observers just on questionnaires. But we found the location of disfigurement is very important. And those a large central disfigurement are much more uh bothersome for observers and those that are found laterally on the face or elsewhere. What psychological factors are associated facial paralysis? Well, um there is a significant contribution to social disability and functional impairment from facial paralysis. Patients with facial paralysis, uh complaint of social isolation and depressive symptoms and 65%, which is 3-5 times our general population. A quick anecdote actually during covid patients with facial paralysis were pulled and were actually found to feel a lot better uh from a quality of life standpoint because they weren't interacting with people as much and they were able to uh you know, block their cameras on zoom. So it is a very interesting finding and I think a pandemic will um maybe give us some new information on these patients. How is quality of life affected? Well, there's a dramatic impact on patient reported quality of life patients with facial paralysis When asked. On health utility outcome scores ranked themselves below somebody with molecular blindness and on par with end stage renal disease. And HIV this study is a little outdated, but I think at the time HIV was still a terminal illness and end stage renal disease obviously means you're on dialysis. And so patients are significantly impaired when you think about it. They're willing to sacrifice eight years of their life with paralysis for a normal face and they would undergo a procedure with a 21% chance of death just to reverse the paralysis. So one in five chance of death just to reverse the paralysis. If you think about how um dramatic that is. I think the percentage of patients who died during anesthesia or died during surgery is probably less than .01% today. Um And so that's a significant increase in risk. They're willing to take A large percentage of patients. Um 20-30% who are deemed cured by their providers still report report subjective symptoms and these are the patients will see in our offices, the ones who have basically been told, Okay, you're fine, you're better. Um it's time to move on with your life and they still have significant issues. So what are the most common causes of parole official paralysis. While there's the infectious cause we're all familiar now with Bell's palsy, which we believe is secondary to a herpes simplex reinfection, Ramsay Hunt um reactivation of the varicella zoster um otitis media. We do see from time to time a few times a year and then lime disease, not so much on the West coast but commonly more on the East Coast. Um penetrating trauma, temporal bone fractures can also cause acute facial paralysis. Uh tumors uh in the middle ear, close to toma or um in the uh in the brainstem as well as tumors on the nerve or metastatic cancer. Skin cancer is a common cause of facial paralysis or Perata tumors. And then in Children you can see it in congenital syndromes or from birth trauma. So I'll focus primarily on Bell's palsy and Ramsay Hunt today and these are the most commonly seen. Um So Bell's policy is the most common cause of facial paralysis. 20 to 30 out of 100,000 people are infected. We do believe that there tend to be epidemics of this. So they do come in clusters. Um and it's believed to be related to the HSV one reactivation which causes swelling of the facial nerve when I describe this to patients, I I describe it as the nerve living in the bone behind the ear which you can see by this arrow when the nerve is inflamed, it actually expands. But the bone around it doesn't move. So when you think about that the bone, the bone is actually crushing that expanding inflamed nerve and then downstream activities shut off and it's the amount of time that it takes for the nerve to recover. Not regenerate because they're not not regrow obviously but to recover and regenerate um is important because the faster that is achieved, the less likely they will have long term side effects. So this is a patient of mine who presented very acutely right after she developed Bell's palsy. You can see here um when you look at her facial movements um the left side of her face is not moving as well as the right side or at all. Um And she can't close her eye when she tries to you can still see her pupil which you know shows you that her eyes are very high at risk for injury. Um these patients will typically present with the program, you'll have the burning pain in or behind the ear, reduced taste sensation, reduce tear production and then they'll develop acute paralysis within 24-72 hours. They'll have a sensitivity to sound or hyper cruces And in most patients they will recover within a few weeks to months if they recover within 1-2 weeks with the steroids and antivirals they typically don't have any long term sequelae but about 15% of them will take more than 2-3 months to recover and we'll have um what we call psychokinesis which I'll discuss in a moment. The standard treatment for these patients within 72 hours on set is to initiate a high predniSONE taper. We mentioned it earlier with DR um Anwar when treating patients with anosmia, I'm sure Dr Volker, one of the other doctors will mention it with a sensory acute sensory neural hearing loss. Um But facial paralysis is in Bell's palsy are no different. You want to put them on a 60 mg predniSONE taper for five days and then taper for five days. So 10 days total, you would like to initiate antiviral therapy with Valtrex within 72 hours or acyclovir. Um and this is to treat the post herpetic neuralgia after 72 hours. The data doesn't really support it. Um You do first and foremost want to mention eye protection, so artificial tears, lubrication and moisture chamber, saran wrap, taping it shut whatever you can prevent that I from getting injured as it can be a nightmare to manage later on. Um and if patients don't recover within three months or six months, you do want to perform imaging because um at that point, even if they haven't had any yet, you do need to start thinking that there could be another cause of this and you have to worry, make sure there's no tumor there. Now, as I mentioned, 10 to 15% of patients will develop some kinesis. Oh, I'm sorry. On a case by case basis if patients don't recover after a month, I will usually get them on a second round of steroids. I don't typically put them on a second round of antivirals. Although if it's a multiple cranial neuropathy and and you know, if if if you feel like it's it's helpful you can do that. But if it's a primarily a facial nerve issue, a second round of steroids for 10 or 14 days usually isn't a bad idea if they haven't had significant recovery, Ramsay Hunt syndrome will briefly talk about this. It's due to the various Selig zoster virus reactivation. These patients are typically more sick than your typical Bell's palsy patients. Bell's palsy by definition should not cause hearing loss, that she could not cause vertigo. But Ramsay Hunt will um All right, ken. And it can also cause all the cranial neuropathy is I've seen patients with vocal cord paralysis, um swallowing issues. I've seen patients with tongue issues, hipaa glassell nerve. And so it is much more severe illness. And that being said, it also is less likely to recover completely. And so patients who develop Ramsay Hunt um should should know or when I see them. I will tell them that the likelihood of a complete recovery is is not that high. The treatment is essentially the same. So this is a patient, the one I showed you earlier. So you can see here, she had a complete recovery. She started regenerating within 2-3 weeks and so before and after. She's able to um generate uh complete eye closure, which she was not before, and also able to have a full smile. Now I mentioned the word synchronous is several times. What is that? We'll sink. Genesis is the mis wiring of nerves after trauma or nerve injury and it results in involuntary muscular movements, accompanying voluntary movements. And so if this is a beautiful diagram of what the facial nerve looks like before someone has facial paralysis, this is how I typically described the nerve afterwards or what we what, what what it feels like to patients. Um and we'll go through what this means. So these are patients with post recovery sink genesis as you can see here. Uh and they've all been told by their doctors that they're fine and they're recovering and so for better or worse, you know, they show up in our office and and we really do want to ask are they really cured? Well, I would, I would be very, very strongly say no, the person on the right every time she smiles her whole face contorts the right, I completely shuts and you can see in the middle as well, she has the person in the middle has a left sided facial paralysis when she tries to smile as much as she can, she's unable to and then similarly the patient all the way on the right um when she tries to smile, her right eye closes her right corner of her mouth, doesn't lift as much as it does now it does move a little bit. But again um you know, we live in a very uh dynamic world and um this uh inability to move and convey emotion is um very troublesome for these patients. So some of the examples here you can see it rests this patient on the right, she has increased tone. What does that mean? It means that her muscles are always on their active. You can see how deep that creases in her nasal labial sulcus from the nose down to the corner of her mouth. This is her at rest with just a gentle smile. Um She's able her right eye starts activating and shutting down. And then when she makes a big smile, the whole right side of her face contorts. And what this is really meaning is that the involuntary muscles are moving on the left side of her face. She makes a beautiful smile when she smiles, her eye doesn't close that much. Her cheeks generate upward trajectory and her neck doesn't do anything, but on the right side her neck is pulling down, her muscles are acting um completely pulling and pushing against each other are opposing each other. Um And then the muscles around the eye are completely uh closing as well. And so what do we do to treat these patients well? We have multiple options. Um We can do physical therapy or facial retraining. There are several experts in the area um that can offer this usually physical therapists, occupational therapists we can perform directed uh Chemo D. Innovation. Sorry I shouldn't say Botox there which is a key mode. Innovation therapy zoom in Botox to support any of these medications can be approved by insurance for this and then it's very selective cases. There are surgeries that we can offer. However these are for the most of your patients. And where can we provide this treatment well. Um And this is not just done in our office neurologists and um other plastic surgeons can offer this as well. Um We try to treat areas to create symmetry. So we can treat the frontal this muscle or the forehead on both sides. The corre gators, um The articular occupy of the affected side to prevent it from shutting. Um We can treat uh the chin, the mentalities depressing muscles and the neck. The platte Esma. The area that we do not want to treat is in the mid face. So I typically don't treat anywhere from below the orbital rim to the corner of the mouth as um uh The product that we use is a liquid and it's very easy to for that liquid to spread. And then you would ultimately cause a paralysis. Now I know that there are neurologists who do E. M. G. And neurosurgeons who are using AMG and they're able to do very precise injections especially for patients who have hemi facial spasm. I have just not found that to be as useful in the sink kinetic patients. Um This is an example of a patient you can see here he was treated with human innovation on the right and the left and this is an example of showing you where he was treated. So he got his treatments into the left eye to help it from closing as much. And then he also was treated on the contra lateral face um to help improve the um to help improve symmetry. So we'll treat both sides of the face, not just the not just the affected side. Now this is a woman who I showed you a few slides ago with the severe synchronous is she actually underwent surgery herself. Her sickness was so severe that we actually decided to go in and cut the aberrant nerves that were functioning improperly. And so this is a very sophisticated and nerve racking surgery. Honestly going in. I I'm I taught myself as a facial nerve repairing surgeon, not a facial nerve cutting surgeon but in some cases you have to do that. And so here you can see before and after photos of her um while she still has some tension on the right mid face you can see that her right eye is much more open after surgery her neck is much more relaxed. Her lower lip is no longer being pulled up at rest and then when she smiles she's also helped able to have a much more relaxed face. And so this was essentially a surgery we went in, we mapped out all of our nerves, we stimulated them inter operatively using a nerve stimulator and found which ones were acting properly. And when I say properly, I mean we know as surgeons we know which nerves are gonna have the corner of the mouth elevate and we should know what, we know which ones are going to have them depressed. And so when we stimulate the nerve and it acts to pull the mouth down when we know it should pull up, we tagged those and as long as we have enough nerve branches that are doing the right thing, we can go ahead and safely cut the ones that aren't. And so this is a close up of her mouth, it's not perfect but just allowing her to be able to show one or two more teeth on a smile, made a huge impact in her quality of life. Um So when we talk about patients with chronic paralysis uh we do have some other options. We have. This is all the more sophisticated surgeries, the microvascular techniques that dr Griffith was talking about. We can use nerve transfers from the hipaa glassell nerve which controls the tongue or the mass that the nerve which controls the um the massacre muscle. And so these are just some dissection. Um An atomic examples of showing how we dissect this nerve. And this is a before and after of a patient. She underwent radical prostatectomy. Um And at the time was not prepared for a nerve repair by her primary surgeon um which can happen. And then she presented to us, we performed a massacre nerve transfer And then dr Krauss from the neuro ophthalmology group did eyelid reconstruction and you can see she has an incredible result. She's able to smile by biting down and generate that smile. This is a gentleman who had a radical prostatectomy as well. We performed an interposition graft where we harvested a graft from his leg. A nerve graft from his leg and put it between his proximal and distal facial nerve stumps as well as gave him the maciver nerve and he's able to, this is him six months after surgery. Some other techniques we can use were wood in combination with DR Volker where we would trace out the facial nerve as it goes into the skull base and we can drop it down into the neck and were able to show um by moving your tongue. Were able to have patients have uh symmetry at rest and then um I generate a smile as well by moving the tongue. The last few photos are where we do combination surgeries where we do the nerve to the massacre as well as the hipaa glassell nerve. This was a young girl who had a brain tumor. She presented one year after a complete paralysis. And we were able to, within four months have her generate a beautiful smile by biting down and moving her tongue. Now we don't always do nerve grafts. Um Some patients, this is a very patient specific type of procedure. And so we we have some patients who decide they don't want to wait 3 to 4 months for the recovery. This was a relatively young at heart woman from Palm Springs who was going to be driving 2 to 3 hours for every post op visit. And she was you know, after one year of being paralyzed was you know, ready to move on with her life. So she elected to have a muscle transfer surgery. And so this is a six week post op photo of her where we we took the temporal attendant transfer. We made a decision um In her left nasal labial fold, we tunneled to the coordinated process and brought this tendon down. And so when she bites down, she's able to smile there and she's very pleased with that. And so um these are, these are surgeries that are, there's not a one size fits all. Um And this is a young girl. This is probably the most sophisticated procedure we do where we actually transplant muscle from another part of their body with an artery vein and the nerve she was born with congenital paralysis of unknown origin. You can see here her left eye is larger, Her mid face doesn't elevate and her nose is collapsed. So we transplanted a muscle from her thigh, the Godzilla's muscle with an artery and vein. And we were able to then use the nerve from her master to help generate her smile. Um And this is again for patients with chronic facial paralysis. Um And uh she's um one year post op here. So in summary, Bell's palsy is the most common cause of facial paralysis uh for the primary care physicians and neurologists um In the audience, if anyone has delayed recovery greater than two or three months, um they can develop chronic psychokinesis um which is which may also benefit from medical or surgical treatment in certain patients. Ah Chronic facial paralysis that being greater than 12-18 months, does require surgical intervention in the acute phase of facial paralysis, in which it's not um Medically managed nerve transfers can be performed in the chronic phase, patients may require under to undergo regional or distant muscle transfers for animation. Uh And facial paralysis does not just affect adults. It can affect Children as well. And so this is a young boy who had a temporal bone fracture and we were able to um with the help of dr Volker um reduce the fracture on the bone and also did a nerve transfer on this patient. And so you can see here we're able to regain his symmetry. But thank you very much for your for your time influences. So dr Kochar any thoughts what your approach is with a patient who gets recurrent facial nerve paralysis. Like other current Bell's palsy. Um So it's very very very rare. Um In my practice it seems to be fairly common but it's it's exceptionally rare. Um The first thing I would do if it's on the same side is I would definitely recommend re imaging the patient. Um I would say that you know because it's so rare you do want to make sure that there is not a tumor. The imaging I would recommend for that patient would not just be an M. R. I. Of the face, but I would also get an M. R. I. Of the of the brain and look at the internal auditory canal. Bless you. Um Just because you want to make sure you're not missing something along the facial nerve at any point. Um If that was negative and you know, the patient is otherwise healthy, I think um repeating the steroids and antivirals and our our key. Um And and likewise if it's if it's bilateral, I think you know, you're less likely to have or if it's a contra lateral side a new a new facial problems on the other side, it's less likely that it's a tumor, but I would probably still image them just to be safe. Um There are very very few and rare syndromes that can cause recurrent facial paralysis. But I do have a couple of patients that have had it for the third or fourth time um and fairly young. So um it can be it can be pretty debilitating for those patients. I'm not even sure how to ask this, but um when that person had congenital, you know, nerve paralysis I guess you figured it was peripheral at some point. 20 MG. Okay. At what point do you know where to you know transplant it, how do you do you know how far back does it go? But where it could actually work? You know? How did you figure that out? You mean as far as the nerve transplant that got her face to work? Well that patient with the congenital, we actually took the muscle from her thigh. So we essentially recreate the function of all of her mid facial muscles. And so in chronic paralysis created 12 or 18 months the muscles of atrophied because they're no longer getting stimulation. So in that patient and that young girl uh you know, she may have had very very small zygomatic major minor muscles. Um But they were they weren't functioning. So we recreated, we basically basically replace those muscles using the using the transfer. My question was more, how did you know at what point to attach the nerve it would work again it was a nerve, well we didn't use the facial nerve this time. In that case we used the mass of the nerve and so her facial nerve is not functioning. But yeah, exactly, that's a good question. Yeah. Sorry about that. You know when we do see patients and you know 2-3 months are when do you feel that that patient used? We're talking about surgery. You put acute phase. What does that mean? So that was the chronic phase. So in the um if you know that the nerve is injured. So sorry that, yeah, so if you know the nerve is injured, if it's a patient with Bell's palsy, they would not be a surgical candidate. But if you know a patient has had temporal bone fracture if a patient has had a previous surgery um and we know the nerve is cut or we have a high suspicion We would want to do a nerve transfer within the 1st 12 months if we think that the nerve if they're still considered a complete or near complete paralysis. Um In that case. All right, thank you guys very much. All right, so we have a we have a scheduled break now. So um please visit with some of the sponsors outside. Um There is uh and you'll be able to see the balloon that is used for your station to dilation. And also there's an implant for nasal valve dysfunction. Um One side note is, is the awareness of options for patients when we were looking to recruit dr Kochar recall the couple of our neurosurgeons and neurologists in the community and we asked, what do you do with patients that have a persistent facial nerve paralysis? And they didn't know. They said, well there's really nothing you can do well today there is and now you are aware that when you do have those patients and they may be in your practice and now you know that you have an option for them to get rehabilitated and get their facial function and movement back. So that's fantastic. Thank you. Let's take a five minute break and then we'll start up after that.
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