Acoustic reflex and House Brackmann rating scale as prognostic indicators of peripheral facial palsy in neuroborreliosis.

Lajmska borelioza je vektorom prenosiva infektivna bolest. Odlikuju je tri stadija bolesti, od kojih neuroborelioza predstavlja drugi tzv. rani diseminirani stadij. Kljenut ličnoga živca je u velikom broju slučajeva jedini simptom i znak neuroborelioze. U endemskim krajevima borelioze, svaka akutna kljenut ličnog živca indicira serološku obradu i implicira poseban pristup bolesti. Nekoliko je prognostičkih pokazatelja kljenuti ličnoga živca. Oni nam govore o mogućoj etiologiji, terapiji i prognozi kljenuti ličnog živca. Budući da se postavlja sumnja kako je izlječenje ličnoga živca u neuroboreliozi teže i duže traje, a sekvele su brojnije, cilj istraživanja je pronaći i potvrditi vrijednost kohleostapedijalnoga refleksa i House Brackmann ocjenske skale kao prognostičkih pokazatelja koji će pomoći da se lakše i preciznije odrede put terapije i rehabilitacije. U završnom dijelu studije, učinit će se i ispitivanje seropozitivnosti stanovnika Brodsko-posavske županije. Ispitanici i metode U istraživanje je uključeno 176 bolesnika s akutnom kljenuti ličnoga živca koji su nakon serološke obrade podijeljeni u tri osnovne skupine -boleriozu, Bellovu kljenut i kljenut ličnoga živca uzorkovanu virusom HSV1. Svakom bolesniku je učinjena preliminarna audiometrija s timpanometrijom i kohleostapedijalnim refleksima, a trenutno stanje kljenuti ličnoga živca ocijenilo prema House Brackmann ocjenskoj skali i fotodokumentiralo. Iste pretrage provedene su još u tri mjerenja - u 3., 6. i 12. tjednu od hospitalizacije. Ponovne ili kontrolne serologije nisu provođene. Poštivao se protokol kriterija za isključivanje iz studije. Svi bolesnici su dali svoj pristanak za sudjelovanje u istraživanju. U obradi podataka koristila se analiza preživljavanja (eng. survival analysis), jednosmjerna i dvosmjerna analiza varijance, Hi kvadrat test, Fisherovi egzaktni testovi, Kruskal Wallis test, Pearsonovi point- biserijalni koeficijenti korelacije i Spearmanov koeficijent korelacije. 90 Rezultati Od ukupno 176 ispitanika s kljenuti ličnoga živca, njih 35 (19,88%.) imalo je boreliozu. U ispitivanju prognostičke vrijednosti kohleostapedijalnoga refleksa, prikazani su rezultati usporedbe lokacije lezije za 4 točke mjerenja prema dijagnozi. U svakoj vremenskoj točki pacijenti s dijagnozom borelije imali su statistički značajno najveći postotak suprastapedijalnih lezija, pogotovo u trećem tjednu od hospitalizacije (uglavnom i nastanka kljenuti) (p<0,001), također i u kasnijim mjerenjima, sve do završetka studije u 12. tjednu od nastanka kljenuti (p=0,001). U odnosu na vrijeme oporavka, rezultat analize pokazuje kako se skupina bolesnika s boreliozom najsporije oporavljala (p<0,001). Kod bolesnika s boreliozom, malo preko polovine se oporavilo do šestoga tjedna, većina bolesnika s Bellovom kljenuti oporavila se već do trećega tjedna a većina bolesnika s HSV1 niti u prvom mjerenju nije niti imala suprastapedijalnu leziju. Čak 47% bolesnika s boreliozom oporavilo se tek u dvanaestom tjednu ili se uopće nije oporavilo u usporedbi s Bellovom kljenuti i bolesnika s HSV1. U ispitivanju prognostičke vrijednosti House Brackmann ocjenske skale, bolesnici sve tri skupine su u prvom i zadnjem mjerenju imali slične prosječne rezultate na HB skali. No, rezultat na skali je sporije opadao za bolesnike s boreliozom. Usporedbom brzine oporavka pokazalo se kako postoje značajne razlike u vremenu do kojeg se bolesnik oporavio, odnosno imao rezultat 1 na HB skali ovisno o bolesti (p<0,001). Pacijenti s dijagnozom borelioze sporije su se oporavljali u odnosu na Bellovu kljenut i HSV1: preko polovice bolesnika s boreliozom nije se oporavilo sve do 12. tjedna ili se uopće nije oporavilo tijekom trajanja istraživanja dok se većina bolesnika s Bellovom kljenuti i HSV1 oporavilo već u 3. tjednu od nastanka kljenuti. U dodatnim analizama potvrđeno je da su bolesnici s HSV1 koji su u prvom mjerenju imali suprastapedijalnu leziju svi (100%) su bili izloženi pothlađenosti, što potvrđuje sumnju na etiologiju vazospazma ili reaktivacije virusa. Usporedbom kohleostapoedijalnoga refleksa i House Brackmann ocjenske skale, najveće razlike u klasifikaciji bolesnika bile su u tome što House Brackmann skala u odnosu na kohleostapedijalni refleks pokazuje postupniji i kasniji oporavak. U ispitivanju osjeta kao prodromalnog znaka u kljenuti ličnoga živca u neuroboreliozi, bolesnici s boreliozom u većem broju su imali glavobolje u odnosu na druge dvije bolesti. Na brzinu oporavka kohleostapedijalnog refleksa i brzinu oporavka prema House Brackmann skali nisu postojale statistički značajne razlike u brzini oporavka ovisno o terapiji. Na koncu, izvršena je procjena seropozitivnosti stanovnika Brodsko-posavske županije i dokazana prokuženost boreliozom od 22%, što regiju pretvara u moguće endemsko područje. Zaključak Ovim istraživanjem dokazano je da su kohleostapedijalni refleks i House Brackmann ocjenska skala vrijedni prognostički pokazatelji kljenuti ličnoga živca u bolesnika s neuroboreliozom.Introduction and aim Lyme borreliosis is the most common tick-transmitted disease. It is characterized by three stages, which makes neuroborreliosis second so-called early disseminated stage. In numerous cases peripheral facial palsy is the only symptom and sign of neuroborreliosis. In endemic areas of borreliosis, every acute peripheral facial palsy indicates serological processing and implies a special approach to disease. There is a several predictors of peripheral facial palsy. They are showing us a possible etiology, therapy and prognosis of peripheral facial palsy. Whereas, there is a suspision that the treatment of peripheral facial palsy is more difficult and takes longer, including numerous sequaelae, purpose of research is finding and confirming the value of acoustic reflex and House Brackmann rating skale as prognostic indicators that will make therapy direction and rehab easier and more precise. In the final part of the study, testing to seropositivity will be done on population of Brodsko- Posavska county. Patients and methods Research included 176 patients with acute peripheral facial palsy who were after serological processing divided in three basic groups - borreliosis, Bell's palsy and peripheral facial palsy caused by HSV1 virus. Preliminary audiometry with timpanometry and acoustic reflexes was done on each patient, and a current condition of peripheral facial palsy was rated according to House Brackmann rating scale and photographed. The same testing was implemented in three other measurements - in 3., 6. and 12. week since hospitalization. Repeated serology was not implemented. Protocol criteria was in accordance with exclusion from the study. Every patient had given their consent to be included in research. Survival analysis will be used for data processing, one-way and two-way, analysis of variance, Chi- Square test, Fisher exact test, Kruskal Wallis test, Pearson Point-biserial correlation coefficient and Spearman's rank correlation coefficient. 93 Results In this research acoustic reflex and House Brackmann rating skale are being observed as predictors of peripheral facial palsy in neuroborreliosis. 35 out 176 patients with peripheral facial palsy had borreliosis, which makes incidence of peripheral facial palsy in borreliosis 19,88 %. The research of predictor function of acoustic reflex shows results of comparison of leason location for 4 measurement spots according to diagnosis. In each timepoint patients with diagnosis of Lyme disease had statistically significantly the biggest percentage of suprastapedial lesions, especially in the third week since hospitalization (mostly occurance of paralysis as well) (p < 0,001), as well as in measuring that occured later, all the way to the end of study in the 12. week since paralysis occurance (p = 0,001). Comparing to the time needed to recover, result of analysis shows how group of patients with Lyme disease took the longest to recover (p < 0,001). Among the patients with borreliosis, a bit more than half of them had recovered until the sixth week, while the most patients with Bell's paralysis had already recovered until the third week, and most of the patients with HSV1 did not even have suprastapedijalnu lesion in the first measurement whatsoever. 47% of patients with borreliosis recovered only in the 12. week comparing to Bell's paralysis and patients with HSV1. Testing predictor function of House Brakmann rating scale, patients from all three groups had similar average results on HB scale in the first and the last measurement. However, result on the scale was falling much slower for patients with borreliosis. Comparing the speed of recovery it was shown that there are significant differences in time before until the patient had recovered, or in other words the patient had result 1 on HB scale depending on diagnosis (p < 0,001). Patients with Lyme disease diagnosis took longer to recover than patients with Bell's paralysis and HSV1: more than half of patients with borreliosis had not recovered until the 12. week or did not recover at all during the research while most of the patients with Bell's paralysis and HSV1 had already recovered in the 3. week since occurance of palsy. In additional analysis there was confirmed that all of the patients (100 %) with HSV1 who had suprastapedial lesion in the first measurement were exposed to hypothermia, which confirms the suspision related to etiology, vasospasm or reactivation of the virus. In comparison to acoustic reflex and House Brackmann rating scale, the biggest difference in the classification of the patients was that House Brackmann scale comparing to acoustic reflex shows gradual subsequent recovery. Testing feeling as prodromal sign of peripheral facial palsy in neuroborrealiosis, bigger number of the patients with Lyme disease had headache comparing to other two diagnosis. There were not found any statistically significant differences in recovery cochleostapedial reflex and recovery of facial nerve according to House Breckamm skale that was related to the therapy. At the end, conducting evaluation of seropositivity of the population of Brodsko- posavska county, it was confirmed seroprevalence with borreliosis of 22%, which makes this region a possible endemic area. Conclusion Conducting this research it was proven that cochlostapedial reflex and House Brackmann scale are valuable prognostic indicators of peripheral facial palsy in patients with neuroborreliosis