The Pennsylvania Academy of
Otolaryngology - Head and Neck Surgery
Cosmetic and Reconstructive
​Skin Cancer Reconstruction After Mohs Surgery
Author: Michael Ondik, MD (Montgomery County ENT)
Overview:
Skin cancer is a very prevalent problem. The two most common forms of skin cancer are basal cell carcinoma and squamous cell carcinoma. These cancers are typically treated by excising the area containing the skin cancer. In certain areas such as the face, hands and feet, it is essential to remove the skin cancer while removing as little normal skin as possible. Mohs surgery is a technique performed by specially trained dermatologists which can help preserve normal tissue while removing the cancer. The resulting defect from the Mohs surgery may be repaired by an Ear, Nose & Throat Surgeon (ENT) using specialized Facial Plastics techniques to produce the most cosmetic scar possible.
Symptoms:
Skin cancer can present in a variety of manners. In general, squamous cell may appear as rough or red scaly patches and basal cell carcinomas will appear as a pearly or waxy bump or a scar-like flat, firm, pale area. Both types of cancers can appear as a non-healing ulcer or scab.
Melanoma, the third most common form of skin cancer, usually appears a dark mole-like lesion that may bleed or itch. One technique to help identify melanomas versus a benign (or non-cancerous) mole is known as the ABCDE rule:
A – Asymmetry: Benign moles tend to be symmetrical
B – Border: Benign moles tend to have smooth, regular borders
C – Color: Benign moles tend to have a uniform color
D – Diameter: Benign moles tend be have a diameter of less than 6mm
E – Evolving: Benign moles tend to look the same over time and not change
What to Expect at Your Otolaryngologist Office Visit:
If you have a lesion on your face or neck suspicious for a skin cancer, your ENT will first have to biopsy the area to determine if it is a cancer. A biopsy is a short procedure to remove either all or a portion of the lesion so it can be sent to the lab for examination. Your doctor with inject a local anesthetic into the area and either cut out or shave off the lesion. Depending on the size of the lesion a biopsy may be sufficient to remove the entire lesion, but often another procedure will be required to remove any remaining lesion (see next section below).
Treatment:
If the biopsy proves to be a skin cancer then the remaining lesion and surrounding area will need to be excised to ensure that no skin cancer remains. Your ENT may excise the cancer and close the defect or you may have the cancer treated by a Mohs surgeon in which case your ENT may be involved repairing the defect. There are several methods to close skin cancer defects. Small defects can usually be closed by slightly lengthening the defect into an elliptical shape and then stitching the edges together. Other defects may require additional incisions next to the defect to move adjacent skin in a technique known as a local flap. Depending the on the size, depth and location of the defect, a skin graft may be used. A graft is skin that is taken from another area (perhaps from behind the ear) and used to fill the defect. Particularly large or complex defects may require a regional flap in which skin is borrowed from another area of face (for example, cheek skin can be transferred to the nose). This is typically a two-stage procedure in which the patient will come back in a couple of weeks for a second final procedure. Finally, some cancer defects areas can be left to heal on their own without any suturing.
Bleph Brow​
Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center)
Overview:
Aging typically results in decreased elasticity of the skin and soft tissues of the face. This often results in the formation of lines across the forehead and between the eyes. As this soft tissue loses elasticity, the distance between the eyebrows and eyelashes also shortens, resulting in the perception of a lower brow. 1,2. This malpositioning of the brow, in addition to deepening of wrinkle may make one appear tired or angry. A brow lift can soften facial lines, raise the eyebrows and restore a softer, more pleasing appearance. A blepharoplasty is a surgical procedure that repairs droopy eyelids and may involve removal of excess soft tissues.
Symptoms:
You may be an appropriate candidate for a brow lift if you have:
Creases across your forehead or high on the bridge of your nose, between your eyes.
Vertical creases between your eyebrows.
A low or sagging brow that's contributing to sagging upper eyelids.
You may be an appropriate candidate for blepharoplasty if you have:
Baggy or droopy upper eyelids
Excess skin of the upper eyelids that interferes with your vision
Excess skin on of the lower eyelids
Bags under your eyes
Severe sagging of skin around your eyes and eyelids may, in addition to being unsightly, have a functional impact on your vision. It may in fact reduce your peripheral vision, particularly in the upper and lower field of vision. Blepharoplasty may be helpful in reducing or eliminating vision problems that are attributable to excess skin while making you appear younger and less fatigued.
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What to Expect at Your Otolaryngologist Office Visit:
Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications.
To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed.
Prior to undergoing any procedures, your doctor will ask you to stop smoking. This is due to the fact that smoking decreases blood flow to areas and increases your risk of vascular disease. This results in considerable impairment to your healing process following surgery. Patients are instructed to avoid the use of anticoagulants (Warfarin, Eliquis) prior to surgery. The physician that manages your anticoagulants will need to determine how long prior to surgery you need to stop taking these medicines. Aspirin and nonsteroidal anti-inflammatory drugs should also be discontinued for at least 2 weeks before surgery.
Smoking must be discontinued for at least 4 weeks before surgery. All herbal preparations, vitamins, and homeopathic treatments should also be avoided for 2 weeks before surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications. Additionally, if you have chronic medical conditions, close communication will be required with your primary care physician, and any specialists involved in your care, to determine suitability for elective surgery and obtain medical clearance.
Herbal supplements to avoid prior to surgery include: Ginkgo biloba , St. John’s wort, Echinacea, ginseng, valerian, glucosamine, vitamin C (>2000 mg daily) fever few, golden seal, vitamin E (>400 mg daily), Fish oils (omega-3 fatty acids), garlic, licorice, Kava, or Licorice. 3
Treatment:
Both browlift and blepharoplasty are performed either in a hospital or outpatient surgical facility. During these procedures, you will be placed under general anesthesia –rendering you unconscious. These procedures vary on a case by case basis depending on desired results and an individual’s anatomy. The specific techniques used by your plastic surgeon for brow lifts may be one of the following.4, 5
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Endoscopic Brow Lift: Incisions will be placed behind your hairline. An endoscope (a long telescope with a light source and camera) will be placed through the incisions to view the underlying tissue and aid in surgery. Using a different “port” or incision site, your surgeon will lift forehead tissues and anchor them in place using sutures. This technique reduces the number of incisions needed.
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Coronal Brow lift: Incisions are placed behind the hairline, across the top of your head, from one ear to the other. Your forehead will be lifted, with the scalp in front of the incision now overlapping the scalp which was behind it. This area of overlap is then removed and the remaining scalp is sutured in place. It should be noted that this technique is not performed in patients with high hairlines, thinning hair, or those likely to experience either, as this may lead to poor outcomes.
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Hairline brow lift: Your surgeon will make an incision at the border of the top of your forehead and the beginning of your hairline. Excess skin and soft tissue from your forehead will be removed. The scalp tissue is left unaltered and as a result your hairline will not be moved back. This technique in particularly is effective in addressing forehead wrinkles and is often used in patients with receding hairlines. However, due to the fact that the incision is not placed within the scalp, a scar may be visible although it will be well camouflaged along the hairline.
Following blow lift surgery, your forehead may be taped and your head might be wrapped loosely to decrease swelling. A small plastic tube, a drain, may be placed along the incision line to drain any excess blood or fluid that may accumulate under the skin and soft tissue.
Blepharoplasty is also performed in an outpatient setting. This procedure is often done in combination with a brow lift or may be done independently. A cut is made along the fold of the upper eyelid, and any excess soft tissue is removed. The incision is then closed and camouflaged within the eyelid crease. The lower lid incision is performed either below the eyelashes, within the natural crease, or inside the lower lid. Excess tissue is again removed and the incision closed.
After your procedure you will likely spend sometime in the recovery room, where you are monitored. You then leave later the same day to recuperate at home. Your surgeon will discuss specifics regarding wound care with your following your procedure on the day of surgery.
Further Reading:
https://www.aafprs.org/patient/procedures/blepharoplasty.html
https://www.mayoclinic.org/tests-procedures/brow-lift/basics/definition/prc-20087441
https://www.plasticsurgery.org/cosmetic-procedures/brow-lift/procedure
​References:
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Angelos P.C., Stallworth C.L., and Wang T.D.: Forehead lifting: state of the art. Facial Plast Surg 2011; 27: pp. 050-057
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Knize D.M.: Anatomic concepts for brow lift procedures. Plast Reconstr Surg 2009; 124: pp. 2118-2126
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Lighthall, J.G. and Wang, T.D., Complications of Forehead Lift. Facial plastic surgery clinics of North America 2013., 21(4),619-624.
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Chand M, Perkins SW. Comparison of surgical approaches for upper facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg 2000;8(4):326–31
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Shadfar S, Perkins SW. Surgical treatment of the brow and upper eyelid. Facial Plastic Surgery Clinics. 2015 May 1;23(2):167-83.
Botox Filler
Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center)
Overview
Aging typically results in decreased elasticity of the skin and soft tissues of the face. This often results in the formation of lines across the glabella (wrinkles between your eyebrows) and crow’s feet. Since it’s initial approval by the Food and Drug Administration (FDA) in 2002, cosmetic use of Botulinum toxin has allowed surgeons to noninvasively treat facial aging. These treatments are widely popular due to their efficacy and noninvasive nature. Patient’s may receive in-office treatments without prolonged recovery time. Botox Cosmetic is currently FDA approved for treatment of glabellar lines, crow’s feet, and forehead lines. Off-label uses in various other areas of the face are common however. These injections use various forms of botulinum toxin to temporarily paralyze muscles activity. There are several brands of Botulinum Toxin-A used for aesthetic purposes. Botox (also known under the commercial names BOTOX Cosmetic, Vistabel, Vistabex; Allergan, Inc. Irvine, CA) is the most well-known brand. Other products include Dyport, Myobloc, and Xeomin. Botox works by blocking acetylcholine, a chemical that is responsible for transmitting electrical signals that result in muscle contraction. This results in temporary muscle paralysis, weakening overactive muscles that may be contributing to increased facial rhytids (wrinkles). When injected into these muscles, it results in a more relaxed and smoother appearance. Botulinum toxin is also used to treat other conditions including cervical dystonia (involuntary contraction of neck muscles), hyperhidrosis (excessive sweating), chronic migraines, muscle contractures, sialorrhea (excessive production of saliva), and various other conditions.
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Injectable fillers play a prominent role in facial rejuvenation, with more than 1.9 million treatments a year in the United States.1 Correcting facial volume loss with aging is the most common application. The immediacy, predictability, and safety of these procedures with no recovery time makes them a particularly useful therapy, much like Botox. Injectable fillers add volume, allowing for shape restoration, to the aging face and can be used in combination with various other treatments (laser therapy, Botox, brow lifts, etc.) allowing for a more complete approach to the aging face. Dermal fillers may be biocompatible or synthetic. Biocompatible fillers are typically resorbable and have a period of duration lasting approximately 6-12 months. Synthetic fillers are permanent but have previously been associated with migration, granuloma formation, and eliciting an immune response. There are few indications currently for use of synthetic fillers to correct age-related changes. Your doctor can discuss further questions regarding filler type.
Symptoms:
Botulinum Toxin can be used for: smoothening of crow’s feet, forehead furrows, frown lines, lip lines, and ‘bunny lines (wrinkles adjacent to the nose). It can also be used to diminish neck bands, improve dimpling of the chin, improve a gummy smile, lift the corners of the mouth for improvement in smiling, or soften a square jaw line.
Dermal Fillers may be used to: plump thin lips, enhance shallow facial contours, soften facial creases and wrinkles, improve appearance of depressed scars, augment contour deformities of the face, decrease shadows due to lower eyelids.
However, in certain patients, surgery such as facelift, brow lift, or blepharoplasty may be a more appropriate approach for facial rejuvenation. This may vary on your anatomy and your doctor will counsel you regarding the most appropriate approach for your specific concerns on initial consultation.
What to Expect at Your Otolaryngologist Office Visit:
Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications.
To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed.
Tell your doctor if you have received any type of botulinum treatment within the past four months. Also, inform your physician if you are taking any muscle relaxants, sleeping aids, or allergy medications. In certain circumstances, if you are taking blood thinners, you may have to discontinue them for several days prior to your injection. This is in order to reduce your risk of bleeding or excessive bruising. You will be asked to discuss this with the physician that manages your blood thinning medication prior to cessation of this medication.
Treatment:
Most individuals tolerate injections without significant discomfort. Your doctor may use one or more of several methods to numb the area prior to injection. These include: topical anesthesia, or ice and vibration anesthesia, using massage to reduce discomfort. These injections are performed in the office and do not require general anesthesia. A thin needle will then be used to inject aliquots of botulinum toxin into your muscles. The number and dosage of injections will vary depending on many factors, including the extent of the area being treated. Following, the procedure you can expect to resume your normal daily activities.
Initially, you should attempt to refrain from rubbing or massaging the injected areas as this may cause the Botox to migrate to adjacent areas. Botox will typically take effect in 24-72 hours after injection. Its maximum effect is seen in about 1-2 weeks following injection. The aesthetic effects of Botox typically last three to four months. As the treated muscles regain movement, lines and wrinkles may begin to reappear prompting patients to return for further treatments. Over time, these lines and wrinkles may appear to be less noticeable due to retraining of the muscles to relax and a decreased reliance on them for expression.
Treatment with dermal fillers is similar to that of Botox. Anticipated injection sites will be cleansed with antibacterial agent. Injections are typically well tolerated with minor discomfort as above. Depending on the extent of treatment, the entire process may take 15 minutes or as long as an hour. An ice pack will be used following treatment to decrease swelling and alleviate minor discomfort. You are then able to resume your normal activities.
Further Reading:
https://www.aafprs.org/media/media_resources/fact_botox.html
https://www.aafprs.org/media/press-release/20160822.html
https://www.plasticsurgery.org/cosmetic-procedures/botulinum-toxin
https://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers
https://www.aafprs.org/patient/procedures/wrinkles.html
References:
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Bass, L.S., 2015. Injectable filler techniques for facial rejuvenation, volumization, and augmentation. Facial Plastic Surgery Clinics, 23(4), pp.479-488.
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Dayan, S.H. and Maas, C.S., 2007. Botulinum toxins for facial wrinkles: beyond glabellar lines. Facial Plastic Surgery Clinics, 15(1), pp.41-49.
Facial Scarring​
Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center)
Overview:
Scarring may result following injury sustained to the skin and soft tissues after surgery or trauma. The amount of overlying skin loss affects not only the appearance of scars but the degree with which surrounding areas are distorted as well. The degree of scar deformity is influenced by extent of soft tissue loss, scar orientation, position with respect to certain facial landmarks, patient age, and genetic factors which may influence the healing process and scar formation. Scar revision involves optimization of the appearance of the scar. Ideally, scars are thin, flat, and match the color of the surrounding skin with orientation along relaxed skin tension lines or wrinkles. Scar revision procedures aim to change the characteristics of scars in such a way that they become more ideal. Of course, there are limitations imposed by the extent of the scar, shape, neighboring landmarks, and variable healing. It is important to note that the goal of this procedure is to alter a poor scar into a better appearing, less noticeable, scar.
Symptoms:
Different types of scars include:
-Discolored scars/surface irregularities
-Hypertrophic scars (thick clusters of scarred tissue; often raised with changes to pigmentation)
-Keloids (typically larger than hypertrophic scars, maybe painful or itchy, and extend beyond edges of the original wound)
Contracture: restrict functional movement due to scarring and resultant tethering of underlying tissue.
The type of scar you have, in addition to its extent and distribution, will determine the appropriate techniques your plastic surgeon will use in revising it.
What to Expect at Your Otolaryngologist Office Visit:
Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications.
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To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals in terms of your appearance after your procedure. The risks, benefits, and realistic goals will be discussed.
Prior to undergoing any procedures, your doctor will ask you to stop smoking. This is due to the fact that smoking decreases blood flow to areas and increases your risk of vascular disease. This results in considerable impairment to your healing process following surgery. Patients are instructed to avoid the use of anticoagulants (Warfarin, Eliquis) prior to surgery. The physician that manages your anticoagulants will need to determine how long prior to surgery you need to stop taking these medicines. Aspirin and nonsteroidal anti-inflammatory drugs should also be discontinued for at least 2 weeks before surgery.
Smoking must be discontinued for at least 4 weeks before surgery. All herbal preparations, vitamins, and homeopathic treatments should also be avoided for 2 weeks before surgery because of the risk of postoperative bleeding and intraoperative anesthetic complications. Additionally, if you have chronic medical conditions, close communication will be required with your primary care physician, and any specialists involved in your care, to determine suitability for elective surgery and obtain medical clearance.
Herbal supplements to avoid prior to surgery include: Ginkgo Biloba, St. John’s wort, Echinacea, ginseng, valerian, glucosamine, vitamin C (>2000 mg daily) fever few, golden seal, vitamin E (>400 mg daily), Fish oils (omega-3 fatty acids), garlic, licorice, Kava, or Licorice
Scar revision minimizes scars, making them less conspicuous allowing them to blend in with surrounding skin. Your physician will remind you that scars are unavoidable results of injury and their progression may be unpredictable. Although scar revision can decrease scarring in a controlled manner, the scar cannot be completely erased. Your doctor will recommend the best choice for you.
Treatment:
You will be kept comfortable during your procedure through the administration of medications including local or general anesthesia, or intravenous sedation. Your procedure may be performed either in the operating room or in the office depending on the extent of the surgery and your general health.
The specific type of scar revision procedure you undergo will be dependent on the severity of your scarring. The type, location, and size of your scar will be taken into consideration. A combination of techniques may be recommended by your surgeon to achieve optimal results.
Topical treatments including silicone gels, tapes, or external compressive dressings may help wound closure and healing. These products may be used to aid in the healing process following your procedures. Injectable treatments, such as Dermal fillers, may be used to augment depressed or concave scars. These treatments are typically repeated to maintain results. Injection of steroid-based compounds may reduce scar formation and can help alter the texture, size, and appearance of your scar.
Surface treatments such as dermabrasion, laser therapy, chemical peels, or skin bleaching agents may be recommended as well. Advanced techniques in scar revision may be required including excision of your scar with complex closure patterns such as W-plasty or Z-plasty techniques aimed at better hiding the scar with irregular patterns. Local tissue rearrangements may be performed to reposition a scar so that it is less conspicuous.
Further Reading:
https://www.plasticsurgery.org/reconstructive-procedures/scar-revision
References:
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Garg, S., Dahiya, N. and Gupta, S., 2014. Surgical scar revision: an overview. Journal of cutaneous and aesthetic surgery, 7(1), p.3.
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Shockley, W.W., 2011. Scar revision techniques: z-plasty, w-plasty, and geometric broken line closure. Facial plastic surgery clinics of North America, 19(3), pp.455-463
Facial Paralysis​
Author(s): Tom Shokri, MD (Penn State Hershey Medical Center): Jessyka G Lighthall, MD (Penn State Hershey Medical Center)
Overview:
The seventh cranial nerve (also known as the Facial Nerve) primarily serves a motor function (some fibers control a sensory component in the external auditory canal, salivation, or taste along the anterior tongue). Injury to the nerve, anywhere along its distribution from the facial nerve nucleus within the brainstem to its final innervation of the muscles of facial expression, may cause weakness or complete paralysis of the face.
Symptoms:
Facial paralysis can result in one side of the face being partially or completely paralyzed.
This may cause: eyebrow sagging, drooping of the eye, and corner of the mouth, incomplete closure of the eye, nasal obstruction, epiphora (overflow of tears in the eye), or minor changes to hearing.
What to Expect at Your Otolaryngologist Office Visit:
Initially, your evaluation will begin with a review of your medical history. Be prepared to answer questions regarding your current and prior medical conditions. Your current medications will be reviewed as well as any surgical procedures you’ve had performed in the past. Tell your provider if you are allergic to any medications.
To best determine your treatment options, the physician will then perform a physical exam. The provider may also take photographs for your medical record. It is important to have a frank discussion regarding your expectations during your initial visit. Explain your main concerns and your goals with respect to your appearance. The risks, benefits, and realistic goals will be discussed.
If specific risk factors for a particular etiology are identified during your examination, then laboratory testing as well as imaging will be directed toward supporting or excluding a particular cause. Your doctor will order blood work to rule out any underlying infectious cause for your facial paralysis (Lyme disease, Herpes Zoster, etc.) or autoimmune condition. A CT scan with contrast of the face/neck and temporal bone or an MRI with contrast may be ordered to visualize possible sites of injury along the course of the facial nerve. Additionally, if a stroke or neural injury is suspected imaging may be recommended to rule this out.
For patients with complete facial paralysis, a electrophysiological test will likely be ordered 3-5 days following injury. Electroneuronography (ENoG) involves placement of electrodes that stimulate the facial nerve and measure muscle activity. If this test demonstrates greater than 90% degeneration, surgical decompression may be considered. This involves removal of the bony surroundings of the nerve. The need for surgery is addressed on case by case basis and is not recommended universally to all patients.
Treatment:
Steroids are effective in the treatment of facial nerve palsy. A steroid taper will be prescribed by your surgeon and should optimally be given within 72 hours of presentation of your symptoms. There is a moderate amount of evidence suggesting that adding antiviral medications to your steroid regimen may improve outcomes. This remains controversial although there are no significant adverse side effects to the medication. You will likely be referred to a Facial Nerve Center for reassessment of your facial paralysis and monitoring of your response to therapy. If you are unable to close your eye completely, lubricating eye drops and ointment will be recommended in addition to an eye moisture chamber which will allow for adequate moisturization of the globe and prevent injury to the cornea. If there is suspicion of injury to your eye, you may be referred to an ophthalmologist for further assessment. This is important in preventing irreversible blindness from corneal exposure and injury.
If it is suspected that your paralysis is due to Lyme Disease, you will be given an antibiotic, this may be in addition to steroid treatment. Your provider will reassess your response to therapy within several weeks. The late phase of treatment of facial paralysis is directed toward any residual facial movement deficits. Your surgeon will discuss any specific surgical interventions or long term therapies based on your symptoms. A number of medical and surgical options are available to treat patients who have long-term sequelae.
Further Reading:
References:
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Sajadi MM, Sajadi MR, Tabatabaie SM. The history of facial palsy and spasm: Hippocrates to Razi. Neurology 2011;77:174–8.
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Adour KK, Byl FM, Hilsinger RL Jr, et al. The true nature of Bell’s palsy: analysis of 1,000 consecutive patients. Laryngoscope 1978;88:787–801.
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Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002;(549):4–30. 4. De Diego JI, Prim MP, Madero R, et al. Seasonal patterns of idiopathic facial paralysis: a 16-year study. Otolaryngol Head Neck Surg 1999;120:269–71. 5. Marson AG, Salinas R. Bell’s palsy. West J Med 2000;173:266–8. 6. Peitersen E. The natural history of Bell’s palsy. Am J Otol 1982;4:107–11. 7. Greco A, Gallo A, Fusconi M, et al. Bell’s palsy and autoimmunity. Autoimmun Rev 2012;12:323–8. 8. Eviston TJ, Croxson GR, Kennedy PG, et al. Bell’s palsy: aetiology, clinical features and multidisciplinary care. J Neurol Neurosurg Psychiatry 2015. [Epub ahead of print]. 9. Murakami S, Mizobuchi M, Nakashiro Y, et al. Bell palsy and herpes simplex virus: identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med 1996;124:27–30. 10. Furuta Y, Ohtani F, Sawa H, et al. Quantitation of varicella-zoster virus DNA in patients with Ramsay Hunt syndrome and zoster sine herpete. J Clin Microbiol 2001;39:2856–9. 11. Michaels L. Histopathological changes in the temporal bone in Bell’s palsy. Acta Otolaryngol Suppl 1990;470:114–7 [discussion: 118]. 12. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149:S1–27. 13. Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg 1996;114:380–6. 14. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: 146–7. 15. Nowak DA, Linder S, Topka H. Diagnostic relevance of transcranial magnetic and electric stimulation of
