{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T06:44:35Z","timestamp":1792133075616,"version":"4.4.0"},"reference-count":22,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T00:00:00Z","timestamp":1792022400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T00:00:00Z","timestamp":1792022400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Laryngoscope"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To investigate the phase\u2010specific impact of cumulative nonselective electrical stimulation (ES) on long\u2010term functional sequelae and subsequent botulinum toxin (BoNT) therapeutic durability in patients with severe Bell's palsy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this retrospective cohort study, 317 patients with severe unilateral Bell's palsy (predominantly \u2265\u200990% ENoG degeneration, all \u2265\u200980%) who developed clinically confirmed facial synkinesis were analyzed. Patients were stratified based on ES onset timing (acute &lt;\u20091\u2009month, subacute 1\u20136\u2009months, and chronic &gt;\u20096\u2009months) and cumulative duration. Outcomes were assessed using the Sunnybrook Facial Grading System, Synkinesis Assessment Questionnaire (SAQ), and BoNT durability (duration of effect). Age\u2010adjusted analysis (ANCOVA) and machine\u2010learning\u2010based decision tree regression were employed to identify prognostic thresholds.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      ES exposure was significantly associated with increased synkinesis (9.32 vs. 8.27,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.007) and reduced BoNT durability (3.15 vs. 4.51\u2009months,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) compared to the non\u2010ES group. A critical safety threshold for cumulative ES was identified at 4.64\u2009h, beyond which synkinesis scores deteriorated by 35.7% and BoNT durability decreased by 23.8%. Notably, ES showed a strict phase\u2010dependent dichotomy: acute\u2010phase ES correlated with the highest synkinesis (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), whereas chronic\u2010phase ES was associated with significantly lower synkinesis (6.11\u2009\u00b1\u20092.05) and superior functional recovery compared to both acute\u2010phase and non\u2010ES cohorts (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.015).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The impact of ES on facial nerve recovery is highly phase\u2010specific. While chronic\u2010phase application offers therapeutic potential, excessive acute\u2010phase ES correlates with exacerbated synkinesis and reduced BoNT durability. Our data suggest a cumulative safety threshold of 4.64\u2009h, emphasizing the need for a judicious, time\u2010dependent approach to ES during the acute phase of nerve regeneration.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>3.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/lary.70991","type":"journal-article","created":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T05:47:39Z","timestamp":1792129659000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["For Patients With Sequelae From Bell's Palsy, Electrical Stimulation May Cause Increased Synkinesis When Aggressively Applied in the Acute Phase of Recovery"],"prefix":"10.1002","author":[{"given":"Soyeon","family":"Jung","sequence":"first","affiliation":[{"name":"Department of Plastic Surgery, Dong\u2010tan Sacred Heart Hospital Hallym University College of Medicine  Hwaseong\u2010si South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ji Hae","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology\u2014Head and Neck Surgery, Dong\u2010tan Sacred Heart Hospital Hallym University College of Medicine  Hwaseong\u2010si South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jun Sung","family":"Sur","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology\u2014Head and Neck Surgery, Dong\u2010tan Sacred Heart Hospital Hallym University College of Medicine  Hwaseong\u2010si South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Min Young","family":"Kwak","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology\u2014Head and Neck Surgery, Dong\u2010tan Sacred Heart Hospital Hallym University College of Medicine  Hwaseong\u2010si South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6634-7750","authenticated-orcid":false,"given":"Jin","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology\u2014Head and Neck Surgery, Dong\u2010tan Sacred Heart Hospital Hallym University College of Medicine  Hwaseong\u2010si South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,15]]},"reference":[{"issue":"3","key":"e_1_2_9_2_1","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1179\/108331903225002470","article-title":"The Efficacy of Electrotherapy for Bell's Palsy: A Systematic Review","volume":"8","author":"Quinn R.","year":"2003","journal-title":"Physical Therapy Review"},{"issue":"3","key":"e_1_2_9_3_1","first-page":"S1","article-title":"Clinical Practice Guideline: Bell's Palsy","volume":"149","author":"Baugh R. F.","year":"2013","journal-title":"Otolaryngology and Head and Neck Surgery"},{"issue":"8","key":"e_1_2_9_4_1","first-page":"e993","article-title":"A Systematic Review of Electrical Stimulation for Facial Nerve Disorders: Highlighting the Need for Standardized Outcome Measures","volume":"41","author":"Monsanto R. C.","year":"2020","journal-title":"Otology & Neurotology"},{"key":"e_1_2_9_5_1","article-title":"Physical Therapy for Bell's Palsy (Idiopathic Facial Paralysis)","volume":"12","author":"Teixeira L. J.","year":"2011","journal-title":"Cochrane Database of Systematic Reviews"},{"issue":"3","key":"e_1_2_9_6_1","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1002\/mus.26784","article-title":"Surface Electrical Stimulation for Facial Paralysis Is Not Harmful","volume":"61","author":"Puls W. C.","year":"2020","journal-title":"Muscle & Nerve"},{"issue":"5","key":"e_1_2_9_7_1","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1177\/1545968315604399","article-title":"Electrical Stimulation to Promote Peripheral Nerve Regeneration","volume":"30","author":"Willand M. P.","year":"2016","journal-title":"Neurorehabilitation and Neural Repair"},{"issue":"14","key":"e_1_2_9_8_1","first-page":"3817","article-title":"Electrical Stimulation for Nerve Regeneration: Towards a New Generation of Neural Implants?","volume":"594","author":"Gordon T.","year":"2016","journal-title":"Journal of Physiology"},{"key":"e_1_2_9_9_1","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1080\/000164802760370736","article-title":"Bell's Palsy: The Spontaneous Course of 2,500 Peripheral Facial Nerve Palsies of Different Etiologies","volume":"549","author":"Peitersen E.","year":"2002","journal-title":"Acta Oto\u2010Laryngologica. Supplementum"},{"issue":"2","key":"e_1_2_9_10_1","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1055\/s-2008-1075840","article-title":"Management of Synkinesis","volume":"24","author":"Husseman J.","year":"2008","journal-title":"Facial Plastic Surgery"},{"issue":"7","key":"e_1_2_9_11_1","doi-asserted-by":"crossref","first-page":"2602","DOI":"10.1523\/JNEUROSCI.20-07-02602.2000","article-title":"Brief Electrical Stimulation Promotes the Speed and Accuracy of Motor Axonal Regeneration","volume":"20","author":"Al\u2010Majed A. A.","year":"2000","journal-title":"Journal of Neuroscience"},{"key":"e_1_2_9_12_1","first-page":"285","volume-title":"Facial Nerve Surgery","author":"Sunderland S.","year":"1977"},{"issue":"1","key":"e_1_2_9_13_1","first-page":"43","article-title":"Significance of Electromyographic Feedback in the Therapy of Facial Palsy","volume":"55","author":"Grosheva M.","year":"2007","journal-title":"HNO"},{"issue":"2","key":"e_1_2_9_14_1","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1055\/s-0040-1715189","article-title":"The Treatment of Facial Asymmetry With Botulinum Toxin: Current Concepts, Guidelines, and Future Trends","volume":"53","author":"Heydenrych I.","year":"2020","journal-title":"Indian Journal of Plastic Surgery"},{"issue":"4","key":"e_1_2_9_15_1","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1016\/j.aanat.2009.03.004","article-title":"Electrical Stimulation of Paralyzed Vibrissal Muscles Reduces Endplate Reinnervation and Does Not Promote Motor Recovery After Facial Nerve Repair in Rats","volume":"191","author":"Sinis N.","year":"2009","journal-title":"Annals of Anatomy"},{"issue":"4","key":"e_1_2_9_16_1","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1055\/s-2000-15546","article-title":"Facial Paralysis: Is There a Role for a Therapist?","volume":"16","author":"Diels H. J.","year":"2000","journal-title":"Facial Plastic Surgery"},{"issue":"2","key":"e_1_2_9_17_1","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1002\/lary.22404","article-title":"Botulinum Toxin in the Treatment of Facial Synkinesis and Hyperkinesis","volume":"122","author":"Filipo R.","year":"2012","journal-title":"Laryngoscope"},{"issue":"12","key":"e_1_2_9_18_1","first-page":"1851","article-title":"Electrical Stimulation for Facial Nerve Paralysis: A Review of Clinical Evidence","volume":"22","author":"Al\u2010Talib H.","year":"2015","journal-title":"Journal of Clinical Neuroscience"},{"issue":"4","key":"e_1_2_9_19_1","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1177\/0269215507070790","article-title":"Effect of Facial Neuromuscular Re\u2010Education on Facial Symmetry in Patients With Bell's Palsy: A Randomized Controlled Trial","volume":"21","author":"Manikandan N.","year":"2007","journal-title":"Clinical Rehabilitation"},{"issue":"2","key":"e_1_2_9_20_1","first-page":"87","article-title":"Botulinum Toxin in the Treatment of Facial Synkinesis","volume":"3","author":"Pascual\u2010Pascual S. I.","year":"2005","journal-title":"Journal of Pediatric Neurology"},{"issue":"6","key":"e_1_2_9_21_1","first-page":"762","article-title":"Botulinum Toxin Treatment of Synkinesis and Hypertonia After Facial Palsy","volume":"28","author":"Frasson E.","year":"2003","journal-title":"Muscle & Nerve"},{"issue":"3","key":"e_1_2_9_22_1","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1097\/PHM.0000000000000171","article-title":"Role of Electrical Stimulation Added to Conventional Therapy in Patients With Idiopathic Facial (Bell) Palsy","volume":"94","author":"Tuncay F.","year":"2015","journal-title":"American Journal of Physical Medicine & Rehabilitation"},{"key":"e_1_2_9_23_1","doi-asserted-by":"publisher","DOI":"10.1177\/26893614251385556"}],"container-title":["The Laryngoscope"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/lary.70991","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/lary.70991","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/lary.70991","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T05:47:43Z","timestamp":1792129663000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/lary.70991"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,15]]},"references-count":22,"alternative-id":["10.1002\/lary.70991"],"URL":"https:\/\/doi.org\/10.1002\/lary.70991","archive":["Portico"],"relation":{},"ISSN":["0023-852X","1531-4995"],"issn-type":[{"value":"0023-852X","type":"print"},{"value":"1531-4995","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,15]]},"assertion":[{"value":"2026-02-19","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-09-30","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-10-15","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"lary.70991"}}