Electroneuronography

Electroneuronography
Electroneuronography
Synonyms	Electroneurography
Purpose	used to study the facial nerve (Bell's palsy)

Last updated April 10, 2024

Electroneuronography or electroneurography (ENoG) is a neurological non-invasive test used to study the facial nerve in cases of muscle weakness in one side of the face (Bell's palsy). The technique of electroneuronography was first used by Esslen and Fisch in 1979 to describe a technique that examines the integrity and conductivity of peripheral nerves. In modern use, ENoG is used to describe study of the facial nerve, while the term nerve conduction study is employed for other nerves.

It consists of a brief electrical stimulation of the nerve in one point underneath the skin, and at the same time recording the electrical activity (compound action potentials) at another point of the nerve's trajectory in the body. The response is displayed in a cathode ray tube (CRT) or through the video monitor of a computer. The stimulation as well as the recording are carried out by disc electrodes taped to the skin, and the technician may use electrically conducting gel or paste to bolster the signals being input and output. Alternatively, the recording electrodes may also be used to pick up the electrical activity of a muscle innervated by that nerve. In such instances electroneuronography is closely related to electromyography.

It is performed by an audiologist, who carries out tests to compare the two sides of the face. The stimulation electrode is located at the stylomastoid foramen and the recording electrode is located near the nasolabial fold. The ENoG test is the only objective measure of facial nerve integrity.

Background

In the human body there are twelve pairs of cranial nerves. Electroneuronography is typically concerned with the amount of degradation in the facial nerves, each of which consists of thousands of fibers. Motor and sensory fibers are typically found in a 2:1 ratio, and it has been proposed that only half of the motor units need to be functional for normal nerve conduction to take place. The facial nerves originate in the brainstem, cross through the auditory canal, exit the skull at the stylomastoid foramen, and terminate face in 2 main branches on each side of the face. These control muscle contractions and facial expressions.^{[ citation needed ]}

Facial nerve paralysis can impact several aspects of a person's life, ranging from emotional or psychological effects to the actual physical limitations themselves. People who have been affected by such conditions often have difficulty speaking, drinking, eating, and showing the simplest of facial expressions. All of these combine to limit socialization and active involvement in the public domain. The proper assessment of facial nerve integrity is, therefore, vital to the detection and treatment of such disorders. Electroneuronography is used as a basis for a physician's course of action in managing disease. A doctor may opt for continued observation of the patient following initial testing, or they may recommend surgery to deal with the damage.^{[ citation needed ]}

Facial nerve disorders may stem from a myriad of contributing factors: Bell's palsy, injury resulting from surgical error, trauma to the temporal bone, otitis media, multiple sclerosis, mumps, chicken pox, and other conditions.^{[ citation needed ]}

Testing/Mechanism of Operation

Recording Techniques

Electroneuronography tests are performed by audiologists. Typically, the system calculates the difference between compound muscle action potentials generated near the nose (nasolabial fold) in response to supramaximal electrical stimulation near the ear (stylomastoid foramen). Thus, the electrical stimulus travels along the facial nerve, allowing it to be specifically pinpointed. Increasing sensitivity and specificity of the recordings has been a constant goal, and it is believed that variability arises from the location and pressure of the electrodes, the stimulating current, and skin resistance. Esslen and Fisch placed the electrodes on the nasolabial fold, and this has become the standard, but May and Hughes experimented with electrodes placed on the nasal ala, citing better waveforms. The two positions were compared with respect to supramaximal threshold, waveform shape/amplitude, and repeatability. With regard to the supramaximal threshold, the nasal alae demonstrated a superior biphasic waveform while requiring less input stimulation to yield adequate results. In all other categories, however, there was no statistical difference between taking measurements at the nasolabial fold compared to the nasal alae.^{[ citation needed ]}

It is common for a general feeling of discomfort to accompany the electrical stimulation of the nerve, but nearly all patients prefer to undergo the procedure in order to effect a treatment for their condition. Measurements are generally taken on the normal, unaffected side of the face first, and then on the abnormal side. Bipolar stimulation is generated at the stylomastoid foramen, while the recording electrodes are attached at the terminal ends of the nerve near the nose. A ground electrode is placed in the center of the patient's forehead, sufficiently far from the facial nerve as to not give an output reading. A variety of stimulation locations may also be employed, to get the best possible results. Audiologists aim to get the most efficient readings possible by optimizing results with a minimal input stimulus. The amount of damage is calculated as a ratio of how much nerve conduction has been retained by the affected side compared to the healthy value. Massive amounts of clinical experience may be required to accurately interpret the data received from testing, and misreading the results may put the patient at serious risk of developing further damage or creating a problem with otherwise healthy facial nerves.^{[ citation needed ]}

Analyzing the Results

Amplitude is the key component in the interpretation of electroneuronography tests. The resulting waveforms are analyzed and reported as a percentage using the following formula:^{[ citation needed ]}

Dysfunctional Side (volts) / Healthy Side (volts) = Percentage of Response

Other forms of recording the output include using a percentage of fibers that are no longer active. This is essentially the same as subtracting the percentage of response from 100%. Either method is clinically accepted, provided the terminology is consistent and not interchanged.

Any responsive level above 10% is regarded as being able to spontaneously recover and does not typically require surgical intervention. Anything beneath the threshold usually requires active and invasive means to correct. To ensure accurate results, and consequently an appropriate course of action, readings may need to be taken every few days until fairly constant values are recorded.

Diagnostic Uses

Alternative Tests

Several alternative procedures exist for testing facial nerve integrity. Electromyography, Acoustic reflex testing (formerly the gold standard), MRI, CT scanning, transcranial magnetic stimulation, blink reflex tests, and maximal/minimal stimulation tests may also be used to assess the viability of the nerves. Currently, however, electroneuronography serves as the only objective test compared to these options, and the test is preferentially performed before the others.

House-Brackmann Facial Grading Scale

The House-Brackmann (HB) scale is the standard used by medical professionals to evaluate facial nerve function. It is a measure of the range of intentional motion the patient's facial muscles have, and is based largely on the observations of the physician. Because of the subjective nature of the scale, there may be discrepancies between assessments by different doctors, but the overall reliability and ease of use has made this scale the most commonly employed by medical professionals.

The scale itself consists of six levels of facial nerve function, ranging from healthy (level 1) to a total lack of movement (level 6). When performing a visual examination, the level at which the patient's facial nerves are functioning is reported as a fraction of the 6 levels. Therefore, someone with normal facial nerve integrity would be reported as "1/6," or "level 1 of 6." Grade two is associated with mild weakening of the facial nerve, and grades three and four have moderate damage, varying only on the basis of the ability to close the eye. The next two levels include severe impairment and total paralysis, respectively. Electroneuronography may only be employed in the most severe instances (5/6 or 6/6) because in the other cases there is clear evidence that the nerve is mostly intact. Even so, it may be helpful to chart a patient's progress beginning at the lowest levels of damage.

Common Causes of Weakness

Perhaps the most common cause of damage to the facial nerve is Bell's palsy (BP). It has a reported incidence of about 0.00015% within the world population each year, and in up to approximately 10% of those cases, the disorder will recur. The etiology of this disease is currently unknown, but hypotheses include infections, genetic predisposition, environmental factors, and neuropathy. Among those who develop the disorder, unilateral paralysis of the facial muscles occurs in a day or two, but it is common for the patient to recover on their own over the span of a few weeks. Even if the condition is resolved, the patient still stands a 20% chance of having lifelong weakness in their facial muscles, and 5% of these people will have permanent damage equivalent to a level of 4 or higher on the House-Brackmann scale.

Another possible effect of Bell's palsy is Wallerian degeneration (WD), which may take days to become evident. Because of the slow-acting nature of this pathology, a patient may present healthy electroneuronography results despite a lack of volitional control of the facial muscles immediately following the onset of Bell's palsy. This is because the degeneration has not yet reached completion, and some fibers are still intact. Therefore, it is standard procedure to wait at least three days after symptoms present themselves to perform an electroneuronography test, in order to prevent false negatives. At the other end of the spectrum, tests are generally not recommended after a period of twenty-one days. Typically, electroneuronography recordings are taken on the third day of symptoms and repeated every four days until a plateau is reached.

Facial Nerve Injury

Seddon classified facial nerve injuries into three broad categories: neuropraxia, neurotmesis, and axonotmesis. Neuropraxia is the most common form of injury associated with Bell's palsy, and it is characterized by paralysis without a degeneration of the peripheral nerve. Electroneuronography would yield a normal or mildly impaired response, as the nerve fibers are still whole but unresponsive to conscious control. Neurotmesis is regarded as the worst possible outcome, with electroneuronography readings equivalent to a flat line, or no response to stimulation. This represents total degradation of the facial nerve. Lastly, axonotmesis consists of damage to the inner nerve fibers while the outer covering remains whole, and also yields a flat line in response to stimulation. Because of their similar recordings, electroneuronography cannot, by itself, distinguish between the latter two forms of nerve injury.^{[ citation needed ]}

Related Research Articles

Ramsay Hunt syndrome type 2, commonly referred to simply as Ramsay Hunt syndrome (RHS) and also known as herpes zoster oticus, is inflammation of the geniculate ganglion of the facial nerve as a late consequence of varicella zoster virus (VZV). In regard to the frequency, less than 1% of varicella zoster infections involve the facial nerve and result in RHS. It is traditionally defined as a triad of ipsilateral facial paralysis, otalgia, and vesicles close to the ear and auditory canal. Due to its proximity to the vestibulocochlear nerve, the virus can spread and cause hearing loss, tinnitus, and vertigo. It is common for diagnoses to be overlooked or delayed, which can raise the likelihood of long-term consequences. It is more complicated than Bell's palsy. Therapy aims to shorten its overall length, while also providing pain relief and averting any consequences.

Cranial nerves are the nerves that emerge directly from the brain, of which there are conventionally considered twelve pairs. Cranial nerves relay information between the brain and parts of the body, primarily to and from regions of the head and neck, including the special senses of vision, taste, smell, and hearing.

<span class="mw-page-title-main">Bell's palsy</span> Facial paralysis resulting from dysfunction in the cranial nerve VII (facial nerve)

Bell's palsy is a type of facial paralysis that results in a temporary inability to control the facial muscles on the affected side of the face. In most cases, the weakness is temporary and significantly improves over weeks. Symptoms can vary from mild to severe. They may include muscle twitching, weakness, or total loss of the ability to move one or, in rare cases, both sides of the face. Other symptoms include drooping of the eyebrow, a change in taste, and pain around the ear. Typically symptoms come on over 48 hours. Bell's palsy can trigger an increased sensitivity to sound known as hyperacusis.

The facial nerve, also known as the seventh cranial nerve, cranial nerve VII, or simply CN VII, is a cranial nerve that emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. The nerve typically travels from the pons through the facial canal in the temporal bone and exits the skull at the stylomastoid foramen. It arises from the brainstem from an area posterior to the cranial nerve VI and anterior to cranial nerve VIII.

<span class="mw-page-title-main">Hypoglossal nerve</span> Cranial nerve XII, for the tongue

The hypoglossal nerve, also known as the twelfth cranial nerve, cranial nerve XII, or simply CN XII, is a cranial nerve that innervates all the extrinsic and intrinsic muscles of the tongue except for the palatoglossus, which is innervated by the vagus nerve. CN XII is a nerve with a sole motor function. The nerve arises from the hypoglossal nucleus in the medulla as a number of small rootlets, pass through the hypoglossal canal and down through the neck, and eventually passes up again over the tongue muscles it supplies into the tongue.

Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles. EMG is performed using an instrument called an electromyograph to produce a record called an electromyogram. An electromyograph detects the electric potential generated by muscle cells when these cells are electrically or neurologically activated. The signals can be analyzed to detect abnormalities, activation level, or recruitment order, or to analyze the biomechanics of human or animal movement. Needle EMG is an electrodiagnostic medicine technique commonly used by neurologists. Surface EMG is a non-medical procedure used to assess muscle activation by several professionals, including physiotherapists, kinesiologists and biomedical engineers. In computer science, EMG is also used as middleware in gesture recognition towards allowing the input of physical action to a computer as a form of human-computer interaction.

Neurotmesis is part of Seddon's classification scheme used to classify nerve damage. It is the most serious nerve injury in the scheme. In this type of injury, both the nerve and the nerve sheath are disrupted. While partial recovery may occur, complete recovery is impossible.

Axonotmesis is an injury to the peripheral nerve of one of the extremities of the body. The axons and their myelin sheath are damaged in this kind of injury, but the endoneurium, perineurium and epineurium remain intact. Motor and sensory functions distal to the point of injury are completely lost over time leading to Wallerian degeneration due to ischemia, or loss of blood supply. Axonotmesis is usually the result of a more severe crush or contusion than neurapraxia.

A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. These tests may be performed by medical specialists such as clinical neurophysiologists, physical therapists, physiatrists, and neurologists who subspecialize in electrodiagnostic medicine. In the United States, neurologists and physiatrists receive training in electrodiagnostic medicine as part of residency training and in some cases acquire additional expertise during a fellowship in clinical neurophysiology, electrodiagnostic medicine, or neuromuscular medicine. Outside the US, clinical neurophysiologists learn needle EMG and NCS testing.

In neuroscience, nerve conduction velocity (CV) is the speed at which an electrochemical impulse propagates down a neural pathway. Conduction velocities are affected by a wide array of factors, which include age, sex, and various medical conditions. Studies allow for better diagnoses of various neuropathies, especially demyelinating diseases as these conditions result in reduced or non-existent conduction velocities. CV is an important aspect of nerve conduction studies.

The stylomastoid foramen is a foramen between the styloid and mastoid processes of the temporal bone of the skull. It is the termination of the facial canal, and transmits the facial nerve, and stylomastoid artery. Facial nerve inflammation in the stylomastoid foramen may cause Bell's palsy.

Central facial palsy is a symptom or finding characterized by paralysis or paresis of the lower half of one side of the face. It usually results from damage to upper motor neurons of the facial nerve.

Nerve injury is an injury to a nerve. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve fiber injury and whether there is continuity of the nerve. Usually, however, nerve injuries are classified in five stages, based on the extent of damage to both the nerve and the surrounding connective tissue, since supporting glial cells may be involved.

Synkinesis is a neurological symptom in which a voluntary muscle movement causes the simultaneous involuntary contraction of other muscles. An example might be smiling inducing an involuntary contraction of the eye muscles, causing a person to squint when smiling. Facial and extraocular muscles are affected most often; in rare cases, a person's hands might perform mirror movements.

Cranial nerve disease is an impaired functioning of one of the twelve cranial nerves. Although it could theoretically be considered a mononeuropathy, it is not considered as such under MeSH.

Repetitive nerve stimulation is a variant of the nerve conduction study where electrical stimulation is delivered to a motor nerve repeatedly several times per second. By observing the change in the muscle electrical response (CMAP) after several stimulations, a physician can assess for the presence of a neuromuscular junction disease, and differentiate between presynaptic and postsynaptic conditions. The test was first described by German neurologist Friedrich Jolly in 1895, and is also known as Jolly's test.

Somatosensory evoked potential is the electrical activity of the brain that results from the stimulation of touch. SEP tests measure that activity and are a useful, noninvasive means of assessing somatosensory system functioning. By combining SEP recordings at different levels of the somatosensory pathways, it is possible to assess the transmission of the afferent volley from the periphery up to the cortex. SEP components include a series of positive and negative deflections that can be elicited by virtually any sensory stimuli. For example, SEPs can be obtained in response to a brief mechanical impact on the fingertip or to air puffs. However, SEPs are most commonly elicited by bipolar transcutaneous electrical stimulation applied on the skin over the trajectory of peripheral nerves of the upper limb or lower limb, and then recorded from the scalp. In general, somatosensory stimuli evoke early cortical components, generated in the contralateral primary somatosensory cortex (S1), related to the processing of the physical stimulus attributes. About 100 ms after stimulus application, additional cortical regions are activated, such as the secondary somatosensory cortex (S2), and the posterior parietal and frontal cortices, marked by a parietal P100 and bilateral frontal N140. SEPs are routinely used in neurology today to confirm and localize sensory abnormalities, to identify silent lesions and to monitor changes during surgical procedures.

Smile surgery or smile reconstruction is a surgical procedure that restores the smile for people with facial nerve paralysis. Facial nerve paralysis is a relatively common condition with a yearly incidence of 0.25% leading to function loss of the mimic muscles. The facial nerve gives off several branches in the face. If one or more facial nerve branches are paralysed, the corresponding mimetic muscles lose their ability to contract. This may lead to several symptoms such as incomplete eye closure with or without exposure keratitis, oral incompetence, poor articulation, dental caries, drooling, and a low self-esteem. This is because the different branches innervate the frontalis muscle, orbicularis oculi and oris muscles, lip elevators and depressors, and the platysma. The elevators of the upper lip and corner of the mouth are innervated by the zygomatic and buccal branches. When these branches are paralysed, there is an inability to create a symmetric smile.

Electromyoneurography (EMNG) is the combined use of electromyography and electroneurography This technique allows for the measurement of a peripheral nerve's conduction velocity upon stimulation (electroneurography) alongside electrical recording of muscular activity (electromyography). Their combined use proves to be clinically relevant by allowing for both the source and location of a particular neuromuscular disease to be known, and for more accurate diagnoses.

Facial nerve decompression is a type of nerve decompression surgery where abnormal compression on the facial nerve is relieved.

References

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Choi, Seung-Ho; Yoon, Tae Hyun; Lee, Kwang-Sun; Ahn, Joong Ho; Chung, Jong Woo. (2007). Blepharokymographic analysis of eyelid motion in Bell's palsy. Laryngoscope, 117(2), 308–312.
Haig, A.J.; Tong, H.C.; Yamakawa, K.; Quint, D.J.; Hoff, J.T.; Chiodo, A.; Miner, J.A.; Choksi, V.R.; Geisser, M.E. (2005). The sensitivity and specificity of electrodiagnostic testing for the clinical syndrome of lumbar spinal stenosis. Spine, 30(23), 2667–2676.
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External links

http://www.dundee.ac.uk/bells/index_files/hbscale.htm (House-Brackmann Facial Grading Scale)

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