Bell Palsy Update The Brow Lift brow liner

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many high-frequency consonants. In the past,                           The route of viral entry is thought by some in-
these patients were considered poor or impossible                   vestigators to be the oral cavity and submandibular
candidates for hearing aids. Now, however, with                     gland, proximally via the chorda tympanic nerve,
more sophisticated design, compression circuitry,                   with subsequent involvement of the main trunk of
open mold and CROS-BI-CROS fittings (CROS                           the facial nerve. Clinically, this route is mani-
stands for contralateral routing of signals) and                    fested by an early diminution in the submandibu-
greater understanding of the effects of tubing                      lar gland's salivary flow rates, or by an erythema-
size on attenuation of the low and middle fre-                      tous chorda tympani as seen through the tympanic
quencies, many patients with high-frequency loss                    membrane. These changes frequently precede al-
can be fitted comfortably and necessary amplifi-                    terations in facial nerve function.
cation achieved.                                                       Therapeutically, controversy still rages over the
   A patient with a unilateral loss was not, in the                 efficacy of surgical decompression. Reports of
past, considered a candidate for amplification.                     immediate return of function following the oper-
However, because such a patient is unable to                        ation tend to support the use of surgical pro-
locate the origin of sounds, unable to hear some-                   cedures in selected cases Recently, a well-con-
one on his "bad side" and finds communication                       trolled prospective study has challenged the
in noise exceptionally difficult, he should benefit                 rationale for steroid treatment in idiopathic pa-
from binaural hearing. Therefore, depending on                      ralysis.
the needs, goals and motivation of these patients,                                                         ROGER CRUMLEY, MD
a hearing aid may be of great value.                                                          REFERENCES
   A child with a minimal hearing loss, even as                       Adour K: Cranial polyneuritis and Bell palsy. Arch Otolaryngol
                                                                    102:262-264, May 1976
little as 15 to 20 decibels, should not be over-                      May M: Bell's palsy and the chorda tympani nerve: A clinical
                                                                    and electron microscopic study. Laryngoscope 85:1957-1974, Dec
looked as a possible candidate for amplification.                   1975
                                                                      May M: Red chorda tympani nerve and Bell's palsy. Laryn-
The auditory channel is so important to the ac-                     goscope 84:1507-1513, Sep 1974
quisition of communication skills that no child                       May M, Hawkins CD: Bell's palsy: Results of surgery; saliva-
                                                                    tion test versus nerve excitability test as a basis of treatment.
should be without adequate hearing for any period                   Laryngoscope 82:1337-1348, Jul 1972
during his formative and educational years. A
hearing aid should be worn on a trial basis and
consultation among parents, physician, teacher
 and audiologist is essential before a decision is                  The Brow Lift
                                   JAMES A. CRABTREE, MD            A LOCAL BROW LIFT is a useful adjunctive pro-
                          REFERENCES                                cedure in cosmetic surgical procedures on the
  Northern JL, Downs MP: Development of auditory behavior,
In Hearing in Children. Baltimore, The Williams & Wilkins Co.,
                                                                    eyelids. Particularly benefical in elderly patients
1974, pp 61-75                                                      with brow ptosis, this procedure involves excis-
  Northern JL, Downs MP: Hearing aids for children, In Hearing      ing an ellipse of skin immediately above the hair
in Children. Baltimore, The Williams & Wilkins Co., 1974, pp
226-227                                                             of the brow. After primary closure the resulting
  Courtois J, Berland 0: Changing concepts in hearing aid use.
First Oticongress, Copenhagen 1971                                  upward and lateral slant of the eye yields a more
  Thorne ABC: Noise Induced Hearing Loss and the Physician.
Audiotone Division/Royal Industries, Phoenix, 1972                  alert and pleasing facial appearance. In addition,
   Staab WJ: CROS and/or Open Canal Fittings. Telex Com-            excess upper lid skin occasionally becomes func-
munications-Hearing Aids Division, Minneapolis, 1974
   Courtois J, Berland 0: Ipsi-lateral no-mold fitting of hearing
aids. 2nd Oticongress, Copenhagen 1972
                                                                    tionally and cosmetically less disturbing.
                                                                        A relatively simple operation, the local brow
                                                                    lift requires minimal undermining of skin mar-
                                                                    gins and can be done readily under local anes-
Bell Palsy-Update                                                   thesia with little patient risk. The design of the
THE PATHOGENESIS of idiopathic facial paralysis                     surgical ellipse is dependent upon the location
has been poorly understood for decades. Recent                      and extent of brow elevation desired. The resec-
work indicates that a viral infection of the facial                 tion is usually at the lateral aspect of the brow
nerve is responsible. In many cases, a polyneu-                     to maximize the upward lateral slant. A double
ritis occurs, with viral involvement of the phrenic,                layered closure with eversion of the skin edges
hypoglossal, trigeminal, glossopharyngeal or other                  is essential to minimize widening of the post-
nerves. There is evidence that the responsible                      operative scar. "Tacking" sutures from the lower
virus is herpes simplex.                                            incision line to forehead periosteum has been ad-

       36      JULY 1977 * 127 * 1

vised by some authors and may be useful in pre-                   Recurrent Laryngeal Nerve
venting postoperative sagging.                                    Section for Spastic Dysphonia
   An alternate approach to the local brow lift
is an elliptical excision in the temporal hair line               SPASTIC DYSPHONIA is a severe vocal disability in
with undermining and elevation of forehead skin.                  which a person speaks with excessively adducted
This technique requires more dissection and is                    vocal cords. The resulting weak phonation sounds
less accurate in the final brow positioning than is               tight, as if the patient were being strangled, and
the local resection. One obvious disadvantage of                  has also been described as laryngeal stutter. It
a local brow lift is the visible scar that results.               is often accompanied by face and neck grimaces.
With proper suture technique and satisfactory                     In the past spastic dysphonia has been regarded
use of cosmetics and eyebrow pencil for cover-up,                 as psychoneurotic in origin and has been treated
however, this drawback is minimal.                                with speech therapy and psychotherapy with dis-
                                  JAMES N. THOMPSON, MD           appointing results.
                          REFERENCES                                 Because of laboratory and clinical observation
  Rafaty FM, Goode RL, Fee WE: The brow-lift operation. Arch      that recurrent nerve paralysis retracts the involved
Otolaryngol 101:467-468, Aug 1975
  Rees TD, Wood-Smith D: Cosmetic facial surgery. Philadelphia,
WB Saunders Co, 1973, p 180
                                                                  vocal cord from the midline, it was proposed that
                                                                  deliberate section of the recurrent nerve would
                                                                  improve the vocal quality of patients with spastic

Local Anesthesia of the Ear                                       dysphonia. In 72 patients the recurrent nerve has
                                                                  been sectioned after lidocaine (XylocaineO)-in-
by lontophoresis                                                  duced temporary paralysis showed significant im-
LOCAL ANESTHESIA of the ear canal and tympanic                    provement in vocal quality. With nerve section in
membrane by iontophoresis is an effective and                     addition to postoperative speech therapy, approxi-
painless procedure. In the past, the application of               mately half of the patients have close to a normal
topical solutions to obtain anesthesia has been                   but soft phonatory voice. In the rest there were
disappointing. Injections of local anesthetics have               varying degrees of improvement, but all, so far,
been painful, particuarly in children. Comeau                     have been pleased with the improvement in ease
and co-workers have revised Albrecht's method                     and quality of phonation and in reduction or elimi-
of iontophoresis so that it is an efficient means of              nation of face and neck grimaces. Two men have
anesthetizing the tympanic membrane for myrin-                    a breathy component in their phonatory voices,
gotomies and can be used for procedures involving                 and one woman has variable pitch. In three pa-
the ear canal.                                                    tients spasticity has redeveloped 4 to 7 months
   lontophoresis is a process utilizing direct elec-              postoperatively. In one of these the situation has
trical current by which chemical agents such as                   been corrected by superior laryngeal nerve section.
epinephrine and lidocaine can be caused to mi-                                                       HERBERT H. DEDO, MD
grate through intact skin. The ions in the anesthe-                                       REFERENCES
tic are positively charged and driven through the                   Dedo HH: Recurrent laryngeal nerve section for spastic dys-
                                                                  phonia. Ann Otol Rhinol Laryngol 85:451-459, Aug 1976
skin by the repelling action of the positive                        Brodnitz FS: Spastic dysphonia. Ann Otol Rhinol Laryngol
electrode (direct current). A fresh solution of 2                 85:210-214, Aug 1976
percent lidocaine (XylocaineB) and 1:2000 epine-
phrine is used. Anesthesia of the tympanic mem-
brane occurs in ten minutes.                                      Daytime Sleepiness Caused by
   The principal advantages of this technique are                 Nighttime Airway Obstruction
that the procedure is painless and much less bleed-
ing occurs. The vertigo that occasionally occurs                  EXCESSIVE DAYTIME SLEEPINESS, especially in
after Xylocaine® injection is avoided. This                       overweight men, can be caused by an intermittent
method of anesthesia is especially beneficial in                  airway obstruction during sleep. This sleep apnea
myringotomies and in inserting collar-button tubes                syndrome has parallels with the better known
in children.                                                      but much less common pickwickian syndrome,
                               W. HUGH POWERS, MD
                                                                  and also can occur in children. The most im-
  Comeau M, Brummettr VJ: Local anesthesia of the ear by
                                                                  portant feature of this syndrome is that all of the
iontophoresis. Arch Otolaryngol 98:114-120, Aug 1973              patients we have encountered so far, and most of
  Albrecht W: Neue Versuche zur lokalen Anasthesierung des
Trommelfells. Arch F Ohrenh 85:198-215, May 1911                  their physicians too, are completely unaware that

                                                                  THE WESTERN JOURNAL OF MEDICINE                    37

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