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1.  Bell's palsy 
BMJ Clinical Evidence  2011;2011:1204.
Bell's palsy is characterised by an acute, unilateral, partial, or complete paralysis of the face (i.e., lower motor neurone pattern). The weakness may be partial (paresis) or complete (paralysis), and may be associated with mild pain, numbness, increased sensitivity to sound, and altered taste. Bell's palsy remains idiopathic, but a proportion of cases may be caused by reactivation of herpes viruses from the geniculate ganglion of the facial nerve. Bell's palsy is most common in people aged 15 to 40 years, with a 1 in 60 lifetime risk. Most make a spontaneous recovery within 1 month, but up to 30% show delayed or incomplete recovery.
Methods and outcomes
We conducted a systematic review to answer the following clinical question: What are the effects of treatments in adults and children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiviral treatment, corticosteroids (alone or plus antiviral treatment), hyperbaric oxygen therapy, facial nerve decompression surgery, and facial retraining.
Key Points
Bell's palsy is an idiopathic, unilateral, acute paresis or paralysis of facial movement caused by dysfunction of the lower motor neurone. Up to 30% of people with acute peripheral facial palsy have an alternative cause diagnosed at presentation or during the course of their facial palsy. Alternative causes are higher in children (>50%), warranting specialist evaluation at presentation. Severe pain, vesicles (ear or oral), and hearing loss or imbalance, suggest Ramsay Hunt syndrome caused by herpes zoster virus infection, which requires specialist management. Most people with paresis (partial weakness) make a spontaneous recovery within 3 weeks. Up to 30% of people, typically people with paralysis (complete palsy), have a delayed or incomplete recovery.
Corticosteroids alone improve rate of recovery and the proportion of people who make a full recovery, and reduce cosmetically disabling sequelae, motor synkinesis, and autonomic dysfunction compared with placebo or no treatment.
Antiviral treatment alone is no more effective than placebo and is less effective than corticosteroid treatment at improving recovery of facial motor function and at reducing the risk of disabling sequelae.
For people with paresis at presentation (about 70%), there is no evidence of a clinically important additive effect of adding antivirals to corticosteroid therapy. For people who develop paralysis (about 30%), and may demonstrate a trend towards complete degeneration on electrophysiological testing, it is unknown whether adding antiviral treatment to corticosteroid therapy has a significant additive or synergistic effect.
Hyperbaric oxygen may improve time to recovery and the proportion of people who make a full recovery compared with corticosteroids; however, the evidence for this is weak.
We don't know whether facial nerve decompression surgery is beneficial in Bell's palsy.
Facial retraining may improve recovery of facial motor function scores including stiffness and lip mobility, and may reduce the risk of motor synkinesis in Bell's palsy, but the evidence is too weak to draw conclusions.
Clinical guide Good evidence exists that corticosteroid therapy improves facial palsy in people with Bell's palsy independent of severity at presentation. Treatment is likely to be more effective when started within 72 hours of onset, and less effective after 7 days. Contraindications to corticosteroid therapy exist and adverse effects are more likely following 7 days of treatment. Combination therapy with a corticosteroid and antiviral is no more effective than corticosteroid therapy alone for Bell's palsy; however, combination therapy should be considered when there is evidence of viral infection with herpes zoster, such as zoster sine herpete and Ramsay Hunt syndrome. People presenting with complete facial paralysis should be offered a choice of combination therapy with a corticosteroid and antiviral, because the evidence for therapy without antivirals is not yet definitive for this group and antivirals have few adverse effects. In people presenting with mild facial paresis from Bell's palsy, there is a high rate of spontaneous resolution without treatment. Bell's palsy is a diagnosis of exclusion and clinicians should remain mindful of the causes of facial palsy, including tumour and infection. All children presenting with facial palsy and adults with delayed recovery should be referred for assessment by an otolaryngologist - head and neck surgeon or other appropriate specialist. The authors believe that facial palsy should not be treated only by protocol-driven practice. Bell's palsy is a diagnosis of exclusion, although a search for other causes of facial palsy must not delay treatment of likely Bell's palsy. Patients should have the opportunity to participate in an informed choice in their management where relevant.
PMCID: PMC3275144  PMID: 21375786
2.  Homozygous hemoglobin S (HbSS) presenting with bilateral facial nerve palsy: a case report 
BMC Research Notes  2014;7:729.
Bilateral facial nerve palsy is a relatively rare presentation and often points to a serious underlying medical condition. Several studies have reported presentation of bilateral facial nerve palsy in association with Lyme disease, Guillain-Barre syndrome, systemic lupus erythematosus, human immunodeficiency virus, sarcoidosis, diabetes and Hanson disease. While unilateral facial nerve palsy is sometimes associated with hemiplegia in sickle cell patients, no case of bilateral facial nerve palsy have been reported in the literature.
Case presentation
A 29-year-old black African woman who is a known homozygous haemoglobin S (HbSS) presented with bilateral facial nerve palsy. She had the said condition 2 months post delivery of her first child and reported for physiotherapy 3 months post incidence. The pre-treatment House Brackmann Facial Grading Scale (HBFGS) Scores were 3 for right side and 4 for left side. This patient was not on any medication for the facial palsy. After 4 sessions of combination therapy consisting of faradism, facial exercises and massage there was remarkable improvement in the neurological status of the facial muscles. The post treatment House Brackmann Facial Grading Scale score was 2 bilaterally.
Bilateral facial nerve palsy may be an initial presentation of sickle cell anemia patients in the absence of other overt clinical presentations. Therefore sickle cell anemia should be considered among others, in the differential diagnosis of bilateral facial nerve palsy. Furthermore, this case report has highlighted the important role of physiotherapy in the management of bilateral facial nerve palsy.
PMCID: PMC4221729  PMID: 25319400
3.  Inferior alveolar nerve block: Alternative technique 
Inferior alveolar nerve block (IANB) is a technique of dental anesthesia, used to produce anesthesia of the mandibular teeth, gingivae of the mandible and lower lip. The conventional IANB is the most commonly used the nerve block technique for achieving local anesthesia for mandibular surgical procedures. In certain cases, however, this nerve block fails, even when performed by the most experienced clinician. Therefore, it would be advantageous to find an alternative simple technique.
Aim and Objective:
The objective of this study is to find an alternative inferior alveolar nerve block that has a higher success rate than other routine techniques. To this purpose, a simple painless inferior alveolar nerve block was designed to anesthetize the inferior alveolar nerve.
Materials and Methods:
This study was conducted in Oral surgery department of Vinayaka Mission's dental college Salem from May 2009 to May 2011. Five hundred patients between the age of 20 years and 65 years who required extraction of teeth in mandible were included in the study. Out of 500 patients 270 were males and 230 were females. The effectiveness of the IANB was evaluated by using a sharp dental explorer in the regions innervated by the inferior alveolar, lingual, and buccal nerves after 3, 5, and 7 min, respectively.
This study concludes that inferior alveolar nerve block is an appropriate alternative nerve block to anesthetize inferior alveolar nerve due to its several advantages.
PMCID: PMC4173425  PMID: 25885503
Aanesthesia; inferior alveolar nerve block; mandible
4.  Pontine stroke presenting as isolated facial nerve palsy mimicking Bell's palsy: a case report 
Isolated facial nerve palsy usually manifests as Bell's palsy. Lacunar infarct involving the lower pons is a rare cause of solitary infranuclear facial paralysis. The present unusual case is one in which the patient appeared to have Bell's palsy but turned out to have a pontine infarct.
Case presentation
A 47-year-old Asian Indian man with a medical history of hypertension presented to our institution with nausea, vomiting, generalized weakness, facial droop, and slurred speech of 14 hours' duration. His physical examination revealed that he was conscious, lethargic, and had mildly slurred speech. His blood pressure was 216/142 mmHg. His neurologic examination showed that he had loss of left-sided forehead creases, inability to close his left eye, left facial muscle weakness, rightward deviation of the angle of the mouth on smiling, and loss of the left nasolabial fold. Afferent corneal reflexes were present bilaterally. MRI of the head was initially read as negative for acute stroke. Bell's palsy appeared less likely because of the acuity of his presentation, encephalopathy-like imaging, and hypertension. The MRI was re-evaluated with a neurologist's assistance, which revealed a tiny 4 mm infarct involving the left dorsal aspect of the pons. The final diagnosis was isolated facial nerve palsy due to lacunar infarct of dorsal pons and hypertensive encephalopathy.
The facial nerve has a predominant motor component which supplies all muscles concerned with unilateral facial expression. Anatomic knowledge is crucial for clinical localization. Bell's palsy accounts for around 72% of facial palsies. Other causes such as tumors and pontine infarcts can also present as facial palsy. Isolated dorsal infarct presenting as isolated facial palsy is very rare. Our case emphasizes that isolated facial palsy should not always be attributed to Bell's palsy. It can be a presentation of a rare dorsal pontine infarct as observed in our patient.
PMCID: PMC3141723  PMID: 21729278
5.  Intraoperative Facial Nerve Monitoring During Cochlear Implant Surgery 
Medicine  2015;94(4):e456.
Iatrogenic facial nerve injury is one of the most severe complications of cochlear implantation (CI) surgery. Intraoperative facial nerve monitoring (IFNM) is used as an adjunctive modality in a variety of neurotologic surgeries. The purpose of this retrospective study was to assess whether the use of IFNM is associated with postoperative facial nerve injury during CI surgery. The medical charts of 645 patients who underwent CI from 1999 to 2014 were reviewed to identify postoperative facial nerve palsy between those who did and did not receive IFNM. Four patients (3 children and 1 adult) were found to have delayed onset facial nerve weakness. IFNM was used in 273 patients, of whom 2 had postoperative facial nerve weakness (incidence of 0.73%). The incidence of facial nerve weakness was 0.54% (2/372) in the patients who did not receive IFNM. IFNM had no significant effect on postoperative delayed facial palsy (P = 1.000). All patients completely recovered within 3 months after surgery. Interestingly, all 4 cases of facial palsy received right CI, which may be because all of the surgeons in this study used their right hand to hold the drill. When right CI surgery is performed by a right-handed surgeon, the shaft of the drill is closer to the inferior angle of the facial recess, and it is easier to place the drilling shaft against the medial boundary (facial nerve) when the facial recess is small. The facial nerve sheaths of another 3 patients were unexpectedly dissected by a diamond burr during the surgery, and the monitor sounded an alarm. None of these 3 patients developed facial palsy postoperatively. This suggests that IFNM could be used as an alarm system for mechanical compression even without current stimulation. Although there appeared to be no relationship between the use of monitoring and delayed facial nerve palsy, IFNM is of great value in the early identification of a dehiscent facial nerve and assisting in the maintenance of its integrity. IFNM can still be used as an additional technique to optimize surgical success.
PMCID: PMC4602960  PMID: 25793243
6.  Anesthetic efficacy of the supplemental X-tip intraosseous injection using 4% articaine with 1:100,000 adrenaline in patients with irreversible pulpitis: An in vivo study 
Pain management remains the utmost important qualifying criteria in minimizing patient agony and establishing a strong dentist–patient rapport. Symptomatic irreversible pulpitis is a painful condition necessitating immediate attention and supplemental anesthetic techniques are often resorted to in addition to conventional inferior alveolar nerve block.
The purpose of the study was to evaluate the anesthetic efficacy of X-tip intraosseous injection in patients with symptomatic irreversible pulpitis, in mandibular posterior teeth, using 4% Articaine with 1:100,000 adrenaline as local anesthetic, when the conventional inferior alveolar nerve block proved ineffective.
Materials and Methods:
X-tip system was used to administer 1.7 ml of 4% articaine with 1:100,000 adrenaline in 30 patients diagnosed with irreversible pulpitis of mandibular posterior teeth with moderate to severe pain on endodontic access after administration of an inferior alveolar nerve block.
The results of the study showed that 25 X-tip injections (83.33%) were successful and 5 X-tip injections (16.66%) were unsuccessful.
When the inferior alveolar nerve block fails to provide adequate pulpal anesthesia, X-tip system using 4% articaine with 1:100,000 adrenaline was successful in achieving pulpal anesthesia in patients with irreversible pulpitis.
PMCID: PMC4252923  PMID: 25506137
Articaine; inferior alveolar nerve block; intraosseous anesthesia; X-tip
7.  Comparison of success rate and onset time of two different anesthesia techniques 
Using local anesthetic is common to control the pain through blocking the nerve reversibly in dental procedures. Gow-Gates (GG) technique has a high success rate but less common. This study aimed to compare the onset time and success rate in GG and standard technique of inferior alveolar nerve block (IANB).
Material and Methods
This descriptive, single blind study was consisted of 136 patients (59 males and 77 females) who were randomly received GG or IANB for extraction of mandibular molar teeth. Comparisons between the successes of two anesthetic injection techniques were analyzed with Chi-square test. Incidence of pulpal anesthesia and soft tissue anesthesia were analyzed with Kaplan-Meier method. Mean onset times of pulpal anesthesia, soft tissue and lip numbness were analyzed with Log-Rank test. Comparisons were considered significant at P≤0.05 by using SPSS software ver.15.
The incidence of pulpal anesthesia in the IANB group (canine 49.3%, premolar 60.3%) were not significantly different from the GG group (canine 41.3%, premolar 74.6%) (P=0.200 and P=0.723). The success rate in the IANB group (80.82%) was not significantly different from the GG group (92.02%) (P=0.123). Furthermore, onset time of lip and buccal soft tissue numbness in GG group (3.25, 4.96 minutes) was quite similar to IANB group (3.22, 4.89 minutes) (all Pvalues >0.05).
Although this study demonstrated higher clinical success rate for GG than IANB technique, no significant differences in success rates and onset time were observed between two techniques.
Key words: Anesthesia, Inferior alveolar nerve, nerve block, success rate.
PMCID: PMC4523259  PMID: 25858085
8.  Delayed Facial Paralysis following Uneventful KTP Laser Stapedotomy: Two Case Reports and a Review of the Literature 
Case Reports in Medicine  2014;2014:971362.
Facial palsy that occurs immediately after middle ear surgery (stapedectomy, stapedotomy, and tympanoplasty) can be a consequence of the local anesthetics and it regresses completely within a few hours. In the case of delayed facial palsy, the alarming symptom occurs several days or even weeks after uneventful surgery. The mechanism of the neural dysfunction is not readily defined. Surgical stress, intraoperative trauma, or laceration of the chorda tympani nerve with a resultant retrograde facial nerve edema can all be provoking etiological factors. A dehiscent bony facial canal or a multiple microporotic fallopian canal (microtrauma or laser effect) can also contribute to the development of this rare phenomenon. The most popular theory related to the explanation of delayed facial palsy at present is the reactivation of dormant viruses. Both the thermal effect of the laser and the elevation of the tympanomeatal flap can reactivate viruses resting inside the ganglion geniculi, facial nerve, or facial nuclei. The authors report the case histories of a 55-year-old female, and a 45-year-old male who presented with a delayed facial palsy following laser stapedotomy. The clinical characteristics, the therapeutic options, and the possibility of prevention are discussed.
PMCID: PMC4243476  PMID: 25435882
9.  Removal of a broken needle using three-dimensional computed tomography: a case report 
Inferior alveolar nerve block obtained maximum anesthetic effect using a small dose of local anesthetic agent, which also has low a complication incidence. Complications of an inferior alveolar nerve block include direct nerve damage, bleeding, trismus, temporary facial nerve palsy, and etc. Among them, the major iatrogenic complication is dental needle fracture. A fragment that disappears into the soft tissue would be hard to remove, giving rise to a legal problem. A 31-year-old woman was referred for the removal of a broken needle, following an inferior alveolar nerve block. Management involved the removal of the needle under local anesthesia with pre- and peri-operative computed tomography scans.
PMCID: PMC3858135  PMID: 24471054
Broken dental needle; Inferior alveolar nerve block; Cone-beam computed tomography; Foreign body migration
10.  Bell's palsy and partial hypoglossal to facial nerve transfer: Case presentation and literature review 
Idiopathic facial nerve palsy (Bell's palsy) is a very common condition that affects active population. Despite its generally benign course, a minority of patients can remain with permanent and severe sequelae, including facial palsy or dyskinesia. Hypoglossal to facial nerve anastomosis is rarely used to reinnervate the mimic muscle in these patients. In this paper, we present a case where a direct partial hypoglossal to facial nerve transfer was used to reinnervate the upper and lower face. We also discuss the indications of this procedure.
Case Description:
A 53-year-old woman presenting a spontaneous complete (House and Brackmann grade 6) facial palsy on her left side showed no improvement after 13 months of conservative treatment. Electromyography (EMG) showed complete denervation of the mimic muscles. A direct partial hypoglossal to facial nerve anastomosis was performed, including dissection of the facial nerve at the fallopian canal. One year after the procedure, the patient showed House and Brackmann grade 3 function in her affected face.
Partial hypoglossal–facial anastomosis with intratemporal drilling of the facial nerve is a viable technique in the rare cases in which severe Bell's palsy does not recover spontaneously. Only carefully selected patients can really benefit from this technique.
PMCID: PMC3347494  PMID: 22574255
Bell's palsy; facial palsy; hypoglossal–facial anastomosis; nerve transfer
11.  Facial nerve compression by the posterior inferior cerebellar artery causing facial pain and swelling: a case report 
We report an unusual case of facial pain and swelling caused by compression of the facial and vestibulocochlear cranial nerves due to the tortuous course of a branch of the posterior inferior cerebellar artery. Although anterior inferior cerebellar artery compression has been well documented in the literature, compression caused by the posterior inferior cerebellar artery is rare. This case provided a diagnostic dilemma, requiring expertise from a number of specialties, and proved to be a learning point to clinicians from a variety of backgrounds. We describe the case in detail and discuss the differential diagnoses.
Case presentation
A 57-year-old Caucasian woman with a background of mild connective tissue disease presented to our rheumatologist with intermittent left-sided facial pain and swelling, accompanied by hearing loss in her left ear. An autoimmune screen was negative and a Schirmer’s test was normal. Her erythrocyte sedimentation rate was 6mm/h (normal range: 1 to 20mm/h) and her immunoglobulin G and A levels were mildly elevated. A vascular loop protocol magnetic resonance imaging scan showed a loop of her posterior inferior cerebellar artery taking a long course around the seventh and eighth cranial nerves into the meatus and back, resulting in compression of her seventh and eighth cranial nerves. Our patient underwent microvascular decompression, after which her symptoms completely resolved.
Hemifacial spasm is characterized by unilateral clonic twitching, although our patient presented with more unusual symptoms of pain and swelling. Onset of symptoms is mostly in middle age and women are more commonly affected. Differential diagnoses include trigeminal neuralgia, temporomandibular joint dysfunction, salivary gland pathology and migrainous headache. Botulinum toxin injection is recognized as an effective treatment option for primary hemifacial spasm. Microvascular decompression is a relatively safe procedure with a high success rate. Although a rare pathology, posterior inferior cerebellar artery compression causing facial pain, swelling and hearing loss should be considered as a differential diagnosis in similar cases.
PMCID: PMC4018959  PMID: 24661509
Facial pain; Hemifacial spasm; Facial pain; Vascular compression; Posterior inferior cerebellar artery; Vascular compression
12.  Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia–A computer tomography based navigated surgical intervention: Case report and review 
Annals of Maxillofacial Surgery  2014;4(1):110-114.
Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated.
PMCID: PMC4073452  PMID: 24987612
Abscess; complication; computed tomography-based navigated surgical intervention; inferior alveolar nerve block anesthesia
13.  Comparative Analysis of the Anesthetic Efficacy of 0.5 and 0.75 % Ropivacaine for Inferior Alveolar Nerve Block in Surgical Removal of Impacted Mandibular Third Molars 
Ropivacaine belongs to pipecoloxylidide group of local anesthetics. There are reports supporting the use of ropivacaine as a long acting local anesthetic in oral and maxillofacial surgical procedures, with variable data on the concentration that is clinically suitable.
Materials and Methods
A prospective randomized double-blind study protocol was undertaken to assess the efficacy of 0.5 and 0.75 % ropivacaine for inferior alveolar nerve block in surgical extraction of impacted mandibular third molars. A total of 60 procedures were performed, of which thirty patients received 0.5 % and thirty received 0.75 % concentration of the study drug.
All the patients in both the study groups reported subjective numbness of lip and tongue. The time of onset was longer for 0.5 % ropivacaine when compared to 0.75 % solution. 90 % of the study patients in 0.5 % ropivacaine group reported pain corresponding to VAS ≥3 during bone guttering and 93.3 % patients reported pain corresponding to VAS >4 during tooth elevation. None of the patients in 0.75 % ropivacaine group reported VAS >3 at any stage of the surgical procedure. The duration of soft tissue anesthesia recorded with 0.75 % ropivacaine was average 287.57 ± 42.0 min.
0.75 % ropivacaine was found suitable for inferior alveolar nerve blocks in surgical extraction of impacted mandibular third molars.
PMCID: PMC4518782  PMID: 26225007
Ropivacaine; Local anesthesia; Oral surgery; Dental; Inferior alveolar nerve block
14.  Efficacy of 4 % Articaine and 2 % Lidocaine: A clinical study 
This study was undertaken to compare the anesthetic properties of 4 % Articaine hydrochloride and 2 % Lidocaine both with 1:100,000 epinephrine for mandibular inferior alveolar nerve anesthesia.
Materials and Methods
Thirty healthy patients were included in this randomized double-blind clinical cross over study. Each subject received each test solution at different times. Inferior alveolar nerve block anesthesia was used for extraction of bilateral impacted mandibular third molar on different occassions. The time of onset of action, duration of anesthesia, efficacy of anesthesia, hemodynamic parameters and oxygen saturation were monitored during the procedure. A visual analog scale was used to assess pain during surgery, and thus subjectively evaluate the anesthetic efficacy of the two solutions.
No statistically significant differences were seen in the onset and duration of anesthesia between the Articaine and Lidocaine solutions.
4 % Articaine offers better clinical performance than 2 % Lidocaine, particularly in terms of latency and duration of the anesthetic effect. However, no statistically significant differences in anesthetic efficacy were recorded between the two solutions.
PMCID: PMC3589513  PMID: 24431806
Efficacy; Articaine; Lidocaine; Impacted mandibular third molar; Randomized; Clinical study
15.  The Incidence of Intravascular Needle Entrance during Inferior Alveolar Nerve Block Injection 
Background and aims
Dentists administer thousands of local anesthetic injections every day. Injection to a highly vascular area such as pterygomandibular space during an inferior alveolar nerve block has a high risk of intravascular needle entrance. Accidental intravascular injection of local anesthetic agent with vasoconstrictor may result in cardiovascular and central nervous system toxicity, as well as tachycardia and hypertension. There are reports that indicate aspiration is not performed in every injection. The aim of the present study was to assess the incidence of intravascular needle entrance in inferior alveolar nerve block injections.
Materials and methods
Three experienced oral and maxillofacial surgeons performed 359 inferior alveolar nerve block injections using direct or indirect techniques, and reported the results of aspiration. Aspirable syringes and 27 gauge long needles were used, and the method of aspiration was similar in all cases. Data were analyzed using t-test.
15.3% of inferior alveolar nerve block injections were aspiration positive. Intravascular needle entrance was seen in 14.2% of cases using direct and 23.3% of cases using indirect block injection techniques. Of all injections, 15.8% were intravascular on the right side and 14.8% were intravascular on the left. There were no statistically significant differences between direct or indirect block injection techniques (P = 0.127) and between right and left injection sites (P = 0.778).
According to our findings, the incidence of intravascular needle entrance during inferior alveolar nerve block injection was relatively high. It seems that technique and maneuver of injection have no considerable effect in incidence of intravascular needle entrance.
PMCID: PMC3533637  PMID: 23285329
Inferior alveolar nerve; injection; local anesthesia
16.  Anterior and middle superior alveolar nerve block for anesthesia of maxillary teeth using conventional syringe 
Dental Research Journal  2012;9(5):535-540.
Dental procedures in the maxilla typically require multiple injections and may inadvertently anesthetize facial structures and affect the smile line. To minimize these inconveniences and reduce the number of total injections, a relatively new injection technique has been proposed for maxillary procedures, the anterior and middle superior alveolar (AMSA) nerve block, which achieves pulpal anesthesia from the central incisor to second premolar through palatal approach with a single injection. The purpose of this article is to provide background information on the anterior and middle superior alveolar nerve block and demonstrate its success rates of pulpal anesthesia using the conventional syringe.
Materials and Methods:
Thirty Caucasian patients (16 men and 14 women) with an average age of 22 years-old, belonging to the School of Dentistry of Los Andes University, were selected. All the patients received an AMSA nerve block on one side of the maxilla using the conventional syringe, 1 ml of lidocaine 2% with epinephrine 1:100.000 was injected to all the patients.
The AMSA nerve block obtained a 66% anesthetic success in the second premolar, 40% in the first premolar, 60% in the canine, 23.3% in the lateral incisor, and 16.7% in the central incisor.
Because of the unpredictable anesthetic success of the experimental teeth and variable anesthesia duration, the technique is disadvantageous for clinical application as the first choice, counting with other techniques that have greater efficacy in the maxilla. Although, anesthetizing the teeth without numbing the facial muscles may be useful in restorative dentistry.
PMCID: PMC3612188  PMID: 23559916
AMSA nerve block; dental anesthesia; local anesthesia; maxillary nerve
17.  Two Cases of Heerfordt's Syndrome: A Rare Manifestation of Sarcoidosis 
Case Reports in Otolaryngology  2016;2016:3642735.
Heerfordt's syndrome is a rare manifestation of sarcoidosis characterized by the presence of facial nerve palsy, parotid gland enlargement, anterior uveitis, and low grade fever. Two cases of Heerfordt's syndrome and a literature review are presented. Case  1. A 53-year-old man presented with swelling of his right eyelid, right facial nerve palsy, and swelling of his right parotid gland. A biopsy specimen from the swollen eyelid indicated sarcoidosis and he was diagnosed with incomplete Heerfordt's syndrome based on the absence of uveitis. His symptoms were improved by corticosteroid therapy. Case  2. A 55-year-old woman presented with left facial nerve palsy, bilateral hearing loss, and swelling of her bilateral parotid glands. She had been previously diagnosed with uveitis and bilateral hilar lymphadenopathy. Although no histological confirmation was performed, she was diagnosed with complete Heerfordt's syndrome on the basis of her clinical symptoms. Swelling of the bilateral parotid glands and left facial nerve palsy were improved immediately by corticosteroid therapy. Sarcoidosis is a relatively uncommon disease for the otolaryngologist. However, the otolaryngologist may encounter Heerfordt's syndrome as this syndrome presents with facial nerve palsy and swelling of the parotid gland. Therefore, we otolaryngologists should diagnose and treat Heerfordt's syndrome appropriately in cooperation with pneumologists and ophthalmologists.
PMCID: PMC4739221  PMID: 26885424
18.  Recurrences of Bell's palsy  
Journal of Medicine and Life  2014;7(Spec Iss 3):68-77.
Introduction. Bell’s palsy in known as the most common cause of facial paralysis, determined by the acute onset of lower motor neuron weakness of the facial nerve with no detectable cause. With a lifetime risk of 1 in 60 and an annual incidence of 11-40/100,000 population, the condition resolves completely in around 71% of the untreated cases. Clinical trials performed for Bell’s palsy have reported some recurrences, ipsilateral or contralateral to the side affected in the primary episode of facial palsy. Only few data are found in the literature. Melkersson-Rosenthal is a rare neuromucocutaneous syndrome characterized by recurrent facial paralysis, fissured tongue (lingua plicata), orofacial edema.
Purpose. We attempted to analyze some clinical and epidemiologic aspects of recurrent idiopathic palsy, and to develop relevant correlations between the existing data in literature and those obtained in this study.
Methods & Materials. This is a retrospective study carried out on a 10-years period for adults and a five-year period for children.
Results. A number of 185 patients aged between 4 and 70 years old were analyzed. 136 of them were adults and 49 were children. 22 of 185 patients with Bell’s palsy (12%) had a recurrent partial or complete facial paralysis with one to six episodes of palsy. From this group of 22 cases, 5 patients were diagnosed with Melkersson-Rosenthal syndrome. The patients’ age was between 4 and 70 years old, with a medium age of 27,6 years. In the group studied, fifteen patients, meaning 68%, were women and seven were men. The majority of patients in our group with more than two facial palsy episodes had at least one episode on the contralateral side.
Conclusions. Our study found a significant incidence of recurrences of idiopathic facial palsy.
Recurrent idiopathic facial palsy and Melkersson-Rosenthal syndrome is diagnosed more often in young females.
Recurrence is more likely to occur in the first two years from the onset, which leads to the conclusion that we should have a follow up of patients diagnosed with Bell’s palsy for at least two years from the onset, especially in children’ case.
The frequency of recurrent facial palsy in children was similar to that in adults. Recurrent idiopathic facial palsy is not known enough and needs further controlled studies.
PMCID: PMC4391412  PMID: 25870699
Bell’s palsy; recurrent facial palsy; Melkerson-Rosenthal syndrome
19.  Complications in Brief: Quadriceps and Patellar Tendon Tears 
Effective treatment of knee extensor mechanism disruptions requires prompt diagnosis and thoughtful decision-making with surgical and nonsurgical approaches. When surgery is chosen, excellent surgical technique can result in excellent outcomes. Complications and failures arise from missed or delayed diagnoses and from technical problems in the operating room. In particular, inappropriate surgical timing (especially late surgery), misplaced patellar drill holes, and failure to address concomitant injuries can result in complications seen when repairing a patellar or quadriceps tendon tear. We review the complications that can occur during treatment of these injuries (Table 1).Table 1Errors and complications in the treatment of quadriceps and patellar tendon tearsError/complicationClinical effectPreventionDetectionRemedyJudgment errors Missed diagnosis: patella tendon tearPatient seen in the emergency room, presumed to have a patella dislocation; sent home; delay in treatment leads to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Infrapatellar pain Infrapatellar gap Inability to maintain full active extension Unable to perform straight leg raise Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (alta)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: quadriceps tendon tearVery common, especially in obese patients; delay in treatment leading to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Suprapatellar pain Suprapatellar gapInability to maintain full active extension Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (baja)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: intact retinaculum but torn quadriceps tendonPatient able to perform weak straight leg raise as a result of intact retinaculum, but quadriceps tendon actually completely torn; lack of power leading to altered gait and joint kinematics, joint breakdown and potential subsequent traumatic injuries(1) Careful physical examination: check for extensor lag(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI(1) Palpable defect in soft tissues proximal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion Missed diagnosis: multiligament knee injury, failure to recognize extensor mechanism disruptionWith severe traumatic knee injuries, clinicians may focus on ligament/bony injury and may miss extensor mechanism disruption, leading to incomplete care of injuries and significant disability(1) Careful review of imaging, particularly sagittal views(2) Thorough physical examination(1) Palpable defect in soft tissues proximal/distal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination; careful review all imaging Delayed diagnosis: delayed surgeryOperating too late after injury; tendon becomes scarred down and retracted; may be difficult to perform primary repair; may require tissue grafting and multiple surgeriesPerforming surgery as soon as possible, preferably within first weekProper detection and early management; if noted too late, consider V-Y or Scuderi technique Incorrect diagnosis: partial tendon tearTendon only partially disrupted (< 10 mm separation of the tendon from bone); will heal without surgery; in one study, nonsurgical management resulted in 93% success rate [5](1) MRI(2) Ultrasound(3) Physical examination(1) Patient should be able to maintain full active extension(2) Radiographs: normal patellar heightThis individual can be treated nonoperatively with immobilization until the tendon has healed Incorrect diagnosis: retinaculum torn, but quadriceps tendon intactAs long as the tendon is intact, the retinaculum should heal nonoperatively(1) Careful physical examination(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI or ultrasound Incorrect diagnosis: inability to extend knee or perform straight leg raise, but extensor mechanism is intactMultiple reasons:(1) Femoral nerve palsy(2) Pain(3) Intraarticular pathology: locked knee (loose body, bucket handle meniscal tear, etc)(1) Thorough history and careful physical examination(2) Additional imaging: MRIConsider aspiration/injection of local anesthetic and reexaminationPotential judgment errors Performing definitive surgery in open injuryConsider staged procedure if contaminated wound(1) Irrigation and debridement(2) Definitive fixationThorough history and careful physical examinationSingle stage management of contaminated or chronically open injuries potentially leads to infection and repair failure Failure to account for diabetesPoor tissue quality that should be accounted for. Delayed wound and tendon healingThorough history and careful physical examination. Tight perioperative glycemic controlLaboratory studies. Patient’s glycemic historyConsultation with patient’s primary care provider/internal medicineAdequate diseased tendon debridement.Delayed postoperative motion to account for expected delayed healingTechnical errors Positioning and preparing(1) Supine, bump under ipsilateral hip to internally rotate lower extremity(2) Consider full muscle paralysis to aid in reduction Inadequate exposureGenerous midline incision needed to see extent of injury (retinacular injury) and define injury pattern (midsubstance tear versus avulsion from patella) Failure to identify correct injury pattern: patellar tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from inferior pole patella(2) Midsubstance rupture(3) Distal avulsion from tibial tubercle(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate fixation method Failure to identify correct injury pattern: quadriceps tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from superior pole patella(2) Midsubstance rupture(3) Mixed(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate preoperative planning and fixation method Failure to débride patella/quadriceps tendon stumpFailure to débride scar or devascularized tissue may predispose to failure of the repair and/or chronic weaknessRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Failure to débride/prepare patella bone bedFailure to débride patella bone bed may predispose to poor healingRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Tendon repair: inadequate tissue for repair of midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsConsider augmentation with contralateral hamstring autograft or allograft; role for other biologics (dermal patches, etc)? Tendon repair: appropriate tension for midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsLateral radiograph of contralateral leg can help determine appropriate tension Transosseous tendon repair: divergent tunnelsDivergent tunnels lead to asymmetric reduction of tendon to bone; may lead to poor contact and therefore poor healing or maltracking(1) Adequate exposure of entire patella(2) Parallel pin drill guide(3) Consider use of fluoroscopy Transosseous tendon repair: tunnel penetration into articular surfaceIatrogenic articular cartilage injury(1) Adequate exposure of entire patella(2) Parallel pin drill guide Transosseous tendon repair: drill breakageBroken drill bit in tunnel(1) Careful drilling technique(2) Do not attempt to change direction of drill hole once started drilling(3) Do not torque drill(4) Use stout drill bit Transosseous tendon repair: anterior placement of tunnelsMay lead to downward tilting of the patella and increase patellofemoral contact forces and pain(1) Place drill holes in center of patella (with respect to AP)(2) If have to cheat, cheat toward articular surface Transosseous tendon repair: overtightening repairMay lead to patella alta or baja(1) Prepare opposite leg to assist with tensioning(2) Obtain intraoperative radiograph and compare with contralateral side Transosseous tendon repair: undertightening repair(1) May lead to patella alta or baja(2) Poor tendon to bone contact may interfere with healing(1) When tying knots, make sure to remove all the slack and that the tendon is pulled snuggly into patella bone trough(2) Adequate retinacular repair Transosseous tendon repair: prominent proximal suture knotsMay lead to skin irritationAttempt to bury knots and cover with surrounding soft tissue Suture anchor tendon repairAdvantages:(1) Less dissection(2) Decreased surgical time(3) More accurate suture placement(4) Low profile Suture anchor tendon repair: anchor pulloutCauses:(1) Poorly placed anchors(2) Poor bone quality(3) Weak anchors(1) Anchors should be placed in center of patella [2](2) Not to be used in osteoporotic bone(3) Two 5.0-mm corkscrew titanium anchors (equivalent pullout to transosseous tunnels) [1] Suture anchor tendon repair: proud anchorsProud anchors will not allow the tendon edge to be pulled into the bone trough in the patella, possibly leading to a gap at the bone-tendon junction and poor healingAnchors should be slightly countersunk to pull tendon firmly into bone trough in patella Failure to repair retinacular tissueMay lead to increased stress on central repair(1) Adequate exposure(2) Suture medial and lateral retinaculumAdditional complications Infection(1) Open injury(2) Comorbidities  Diabetes  Smoking  Chronic disease(1) Irrigation and debridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Wound complications(1) Open injury(2) Comorbidities  Diabetes  Smoking  Chronic disease(3) Prominent sutures(1) Irrigation and débridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Nerve injuryExtremely rareRehabilitation complications Prolonged immobilizationLeads to stiffness and decreased ROMIntraoperative assessment of maximum flexion before gapping between bone and tendon is observedEarly ROM (10–14 days): active flexion, passive extension to limits determined intraoperatively Inadequate immobilization(1) Wound complications(2) Failure of repairROM bracing locked in extension Overly aggressive physical therapyNeed time for tendon-to-bone healing to occurNo forced flexion or active extension in first 6 weeks
PMCID: PMC3916631  PMID: 24338040
20.  Comparative study between manual injection intraosseous anesthesia and conventional oral anesthesia 
Objective: To compare intraosseous anesthesia (IA) with the conventional oral anesthesia techniques. Materials and methods: A simple-blind, prospective clinical study was carried out. Each patient underwent two anesthetic techniques: conventional (local infiltration and locoregional anesthetic block) and intraosseous, for res-pective dental operations. In order to allow comparison of IA versus conventional anesthesia, the two operations were similar and affected the same two teeth in opposite quadrants. Results: A total of 200 oral anesthetic procedures were carried out in 100 patients. The mean patient age was 28.6±9.92 years. Fifty-five vestibular infiltrations and 45 mandibular blocks were performed. All patients were also subjected to IA. The type of intervention (conservative or endodontic) exerted no significant influence (p=0.58 and p=0.62, respectively). The latency period was 8.52±2.44 minutes for the conventional techniques and 0.89±0.73 minutes for IA – the difference being statistically significant (p<0.05). Regarding patient anesthesia sensation, the infiltrative techniques lasted a maximum of one hour, the inferior alveolar nerve blocks lasted between 1-3 hours, and IA lasted only 2.5 minutes – the differences being statistically significant (p≤0.0000, Φ=0.29). Anesthetic success was recorded in 89% of the conventional procedures and in 78% of the IA. Most patients preferred IA (61%) (p=0.0032). Conclusions: The two anesthetic procedures have been compared for latency, duration of anesthetic effect, anesthetic success rate and patient preference. Intraosseous anesthesia has been shown to be a technique to be taken into account when planning conservative and endodontic treatments.
Key words: Anesthesia, intraosseous, oral anesthesia, Stabident®, infiltrative, mandibular block.
PMCID: PMC3448326  PMID: 22143700
21.  Melkersson-Rosenthal Syndrome with Orofacial Swelling and Recurrent Lower Motor Neuron Facial Nerve Palsy: A Case Report and Review of the Literature 
Case Reports in Otolaryngology  2015;2015:214946.
Melkersson-Rosenthal Syndrome (MRS) is a rare otoneurologic condition, which is poorly understood and often underdiagnosed. Etiology and incidence are unclear, although infectious, inflammatory, and genetic causes have been implicated. Recurrent facial nerve palsy, facial swelling, and fissured tongue are the symptoms and signs of this condition. However, this triad is not typical in all patients as patients may present with one or more of the symptoms, which makes management of this condition difficult. Steroids may prove to be useful especially in patients who have facial nerve palsy. In this case report, we have described a 46 year-old Caucasian male who presented to the clinic for the evaluation of orofacial swelling and left facial deviation with a history of multiple treatments for recurrent lower motor neuron type facial nerve palsy.
PMCID: PMC4655274  PMID: 26635986
22.  Comparison of anesthetic efficacy of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine for inferior alveolar nerve block in patients with irreversible pulpitis 
Objectives: This study was done to compare the anesthetic efficacy of 4% articaine with 1:100,000 epinephrine with that of 2% lidocaine with 1:80,000 epinephrine during pulpectomy in patients with irreversible pulpitis for inferior alveolar nerve block in mandibular posterior teeth. Material and Methods: Patients with irreversible pulpitis referred to the Department of Conservative Dentistry and Endodontics, K.D. Dental College, randomly received a conventional inferior alveolar nerve block containing 1.8 mL of either 4% articaine with 1:100,000 epinephrine or 2% lidocaine with 1:80,000 epinephrine. After the patient’s subjective assessment of lip anesthesia, the absence/presence of pulpal anesthesia through electric pulp stimulation was recorded and the absence/presence of pain was recorded through visual analogue scale. Results: The pulpal anesthesia success for articaine (76%) was slightly more than with lidocaine (58%) as measured with pulp tester as well as for the pain reported during the procedure the success rate of articaine (88%) was slightly more than that of lidocaine (82%) although the difference between the two solutions was not statistically significant. Conclusions: Both the local anesthetic solutions had similar effects on patients with irreversible pulpitis when used for inferior alveolar nerve block.
Key words:Anesthesia, articaine, lignocaine, pulpitis.
PMCID: PMC4312679  PMID: 25674319
23.  Acute Cranial Neuropathies Heralding Neurosyphilis in a Human Immunodeficiency Virus-Infected Patient 
Patient: Male, 31
Final Diagnosis: Neurosyphilis
Symptoms: Diplopia •facial droop • facial nerve palsy • headache
Medication: —
Clinical Procedure: —
Specialty: Infectious Diseases
Unusual clinical course
Symptomatic early neurosyphilis with isolated acute multiple cranial nerves palsy as initial manifestation of HIV infection is very rare. It is caused by direct invasion of the central nervous system by the spirochete Treponema pallidum.
Case Report:
A 31-year-old African-American homosexual man presented with bilateral hearing loss, constant vertigo, intermittent horizontal diplopia, and bilateral facial droop, which was associated with occipital headache without fever. Neurological examination revealed bilateral vestibulocochlear and facial nerve palsy. On brain magnetic resonance imaging (MRI) before and after administration of gadolinium, he was found to have extensive isolated basilar meningeal enhancement involving the midbrain, pons along the seven and eight nerves complex bilaterally, consistent with basal meningoencephalitis.
Neurosyphilis can present as initial manifestation of HIV infection with early involvement of basal meninges and cranial nerves. It is important to understand that neurosyphilis is still a significant disease with complex neurological presentation. Early diagnosis and treatment of neurosyphilis is crucial due to potential persistent disabilities that can be easily treated or even prevented.
PMCID: PMC4181462  PMID: 25265092
Cranial Nerve Diseases; HIV; Magnetic Resonance Imaging; Meningoencephalitis; Neurosyphilis
24.  Ramsay Hunt syndrome 
The strict definition of the Ramsay Hunt syndrome is peripheral facial nerve palsy accompanied by an erythematous vesicular rash on the ear (zoster oticus) or in the mouth. J Ramsay Hunt, who described various clinical presentations of facial paralysis and rash, also recognised other frequent symptoms and signs such as tinnitus, hearing loss, nausea, vomiting, vertigo, and nystagmus. He explained these eighth nerve features by the close proximity of the geniculate ganglion to the vestibulocochlear nerve within the bony facial canal. Hunt's analysis of clinical variations of the syndrome now bearing his name led to his recognition of the general somatic sensory function of the facial nerve and his defining of the geniculate zone of the ear. It is now known that varicella zoster virus (VZV) causes Ramsay Hunt syndrome.
 Compared with Bell's palsy (facial paralysis without rash), patients with Ramsay Hunt syndrome often have more severe paralysis at onset and are less likely to recover completely. Studies suggest that treatment with prednisone and acyclovir may improve outcome, although a prospective randomised treatment trial remains to be undertaken. In the only prospective study of patients with Ramsay Hunt syndrome, 14% developed vesicles after the onset of facial weakness. Thus, Ramsay Hunt syndrome may initially be indistinguishable from Bell's palsy. Further, Bell's palsy is significantly associated with herpes simplex virus (HSV) infection. In the light of the known safety and effectiveness of antiviral drugs against VZV or HSV, consideration should be given to early treatment of all patients with Ramsay Hunt syndrome or Bell's palsy with a 7-10 day course of famciclovir (500 mg, three times daily) or acyclovir (800 mg, five times daily), as well as oral prednisone (60 mg daily for 3-5 days).
 Finally, some patients develop peripheral facial paralysis without ear or mouth rash, associated with either a fourfold rise in antibody to VZV or the presence of VZV DNA in auricular skin, blood mononuclear cells, middle ear fluid, or saliva. This indicates that a proportion of patients with "Bell's palsy" have Ramsay Hunt syndrome zoster sine herpete. Treatment of these patients with acyclovir and prednisone within 7 days of onset has been shown to improve the outcome of recovery from facial palsy.

PMCID: PMC1737523  PMID: 11459884
25.  Cerebellopontine angle facial schwannoma relapsing towards middle cranial fossa 
Clinics and Practice  2011;1(2):e32.
Facial nerve schwannomas involving posterior and middle fossas are quite rare. Here, we report an unusual case of cerebellopontine angle facial schwannoma that involved the middle cranial fossa, two years after the first operation. A 53-year-old woman presented with a 3-year history of a progressive left side hearing loss and 6-month history of a left facial spasm and palsy. Magnetic resonance imaging (MRI) revealed 4.5 cm diameter of left cerebellopontine angle and small middle fossa tumor. The tumor was subtotally removed via a suboccipital retrosigmoid approach. The tumor relapsed towards middle cranial fossa within a two-year period. By subtemporal approach with zygomatic arch osteotomy, the tumor was subtotally removed except that in the petrous bone involving the facial nerve. In both surgical procedures, intraoperative monitoring identified the facial nerve, resulting in preserved facial function. The tumor in the present case arose from broad segment of facial nerve encompassing cerebellopontine angle, meatus, geniculate/labyrinthine and possibly great petrosal nerve, in view of variable symptoms. Preservation of anatomic continuity of the facial nerve should be attempted, and the staged operation via retrosigmoid and middle fossa approaches using intraoperative facial monitoring, may result in preservation of the facial nerve.
PMCID: PMC3981252  PMID: 24765294
facial schwannoma; cerebellopontine angle; middle cranial fossa; facial nerve preservation.

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