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Original Research
Key Messages
• There are several opinions that type 2 diabetes mellitus has a bad influence on the prognosis of Bell’s palsy. The present study
investigated effect of type 2 diabetes mellitus on Bell’s palsy healing process.
• Type 2 diabetes had no effect on Bell’s palsy prognosis.
a r t i c l e i n f o a b s t r a c t
Article history: Objectives: Bell’s palsy (BP) is defined as an acute facial weakness of unknown cause. Many factors affect-
Received 23 September 2016
ing the healing of BP have been identified; 1 factor commonly considered relevant is the presence of type 2
Received in revised form
diabetes mellitus. Our aim was to investigate the effects of diabetes on the healing of BP.
2 October 2017
Accepted 17 October 2017 Methods: Sixty patients with BP were followed up for 1 to 3 years and were divided into 2 groups, those
with and those without type 2 diabetes. All were prescribed prednisone (initially 1 mg/kg per day, with
a tapered dose reduction) and acyclovir (200 mg orally every 4 h, 5 times daily, for 5 days). Their recov-
Keywords:
Bell’s palsy ery times were compared.
diabetes mellitus Results: The healing times of the patients with and without diabetes did not differ.
facial paralysis Conclusions: Diabetes does not affect the severity, recovery rate from or healing of BP.
prognosis © 2017 Canadian Diabetes Association
healing time
r é s u m é
Mots clés :
Objectifs : La paralysie de Bell (PB) se caractérise par une faiblesse faciale soudaine dont la cause est inconnue.
paralysie de Bell
diabète sucré
Parmi les nombreux facteurs qui nuisent à la guérison de la PB, le facteur généralement jugé pertinent
paralysie faciale est la présence du diabète sucré de type 2. Notre objectif était d’examiner les répercussions du diabète
pronostic sur la guérison de la PB.
vitesse de guérison Méthodes : Nous avons suivi 60 patients atteints de PB durant 1 à 3 ans et les avons répartis en 2 groupes
: les patients atteints du diabète de type 2 et les patients non atteints. Tous se sont fait prescrire de la
prednisone (ordonnance initiale de 1 mg/kg par jour, suivie d’une réduction progressive de la dose) et
de l’acyclovir (200 mg par voie orale toutes les 4 heures, 5 fois par jour, durant 5 jours). Nous avons comparé
leur vitesse de guérison.
Résultats : La vitesse de guérison des patients diabétiques ou non diabétiques ne différait pas.
Conclusions : Le diabète n’a pas de répercussions sur la gravité, le taux de rétablissement ou la guérison
de la PB.
© 2017 Canadian Diabetes Association
Introduction
Methods
who were taking oral antidiabetic drugs were switched to insulin.
This was a retrospective case-control study approved by our ethics
A dose adjustment was made for patients using insulin. Then patients
committee (#2015-107-04/11). The study was conducted in an oto-
were placed on steroid therapy (initially, 1 mg/kg/day, reduced by
laryngology clinic between October 2012 and October 2014. We
half every day) and acyclovir (200 mg orally every 4 h, 5 times a
enrolled 60 patients who complained of facial paralysis and were
day, for 5 days). Patients without diabetes were given the same treat-
diagnosed with BP; they visited our clinic regularly during the first
ment and were also monitored for blood pressure. The groups were
week after diagnosis. Each patient underwent a complete ear, nose
compared in terms of recovery time and the severity of facial
and throat examination, a neurologic examination, routine blood
paralysis.
testing (including blood sugar and glycated hemoglobin [A1C] levels),
The effect of A1C serum levels on the severity of BP, the recov-
vital findings (including blood pressure), audiologic testing, sero-
ery rates and the durations of BP in patients with diabetes were
logic testing and magnetic resonance imaging with gadolinium
explored. The recovery times of patients with and without com-
enhancement. All patients were divided into 2 groups: those with
plications of diabetes were compared.
type 2 diabetes and and those without diabetes.
We enrolled 30 patients who were diagnosed as having type 2
Statistical analyses
diabetes according to American Diabetes Association Expert Com-
mittee criteria. Their serum A1C levels and diabetes-associated com-
Statistical analyses were performed with the aid of SPSS v. 19.0
plications were recorded. The other 30 patients had no additional
software (SPSS, Chicago, Illinois, United States). Data distributions
disease other than hypertension (HT).
were examined using the Shapiro-Wilk test. Continuous variables
Patients were routinely examined for facial-nerve motor func-
are expressed as means ± standard deviations and categorical vari-
tions: wrinkling the forehead, raising the eyebrows, closing the eyes,
ables as frequencies with percentages. Continuous variables were
opening the mouth, difference in nasolabial folds, showing the teeth,
compared using the independent samples t test or the Mann-
baring the teeth and opening the mouth, pursuing the lips, blowing
Whitney U test. Categorical variables were compared using the chi-
out the cheeks. All patients were graded using the House-Brackmann
squared test. A p value <0.05 was considered to reflect statistical
system (Table 1) (5). The pretreatment degree of facial paralysis,
significance.
according to the House-Brackmann system, are shown in Table 2.
After treatment, those of House-Brackmann grade I were regarded
as having recovered satisfactorily; House-Brackmann grades II
Results
through VI reflected unsatisfactory recovery. Patients with diabe-
tes were hospitalized and monitored for vital parameters and blood
The patients with diabetes were between 47 and 76 years of age
sugar levels. At the beginning of treatment, patients with diabetes
(mean, 62.8±8.79 years). The patients without diabetes were 25 to
70 years of age (mean, 47.5±13.11 years); the mean age differed sig-
nificantly in the 2 groups (p<0.001). The group with diabetes con-
Table 1 tained 12 (40%) women and 18 (60%) men; the group without
House-Brackmann grading system diabetes included 16 (53.3%) men and 14 (46.6%) women. The recov-
Grade Description Characteristic ery times did not differ in the 2 groups (p=0.438). We found no rela-
tionship between age and recovery time (p=0.876). The 2 groups
I Normal Normal symmetrical function
II Mild Slight weakness noticeable only on close inspection did not differ significantly in terms of the extent of facial paralysis
dysfunction Complete eye closure with minimal effort (p=0.611).
Slight asymmetry of smile with maximal effort The 2 groups were compared in terms of recovery rates. No sig-
Synkinesis barely noticeable, contracture or spasm nificant between-group differences were evident (p=0.947). The
absent
III Moderate Obvious weakness, but not disfiguring
average recovery time was 98.27±213.76 days in the group with dia-
dysfunction May not be able to lift eyebrow betes and 95.13±137.51 days in the group without diabetes. The
Complete eye closure and strong but asymmetrical median recovery time was 30 days in both groups (p>0.05).
mouth movement All patients were evaluated in terms of concomitant HT. In the
Obvious, but not disfiguring synkinesis, mass
group with diabetes, 14 patients (46.6%) had HT, as did 6 (20%) in
movement or spasm
IV Moderately Obvious disfiguring weakness the group without diabetes. The proportions did not differ between
severe Inability to lift brow the groups (p=0.055).
dysfunction Incomplete eye closure and asymmetry of mouth The A1C levels of patients with diabetes were measured to assess
with maximal effort the efficacy of long-term glucose control. The healing times were
Severe synkinesis, mass movement, spasm
V Severe Motion barely perceptible
not significantly influenced by these levels (p=0.666).
dysfunction Incomplete eye closure, slight movement corner The complications in patients with diabetes are shown in Table 3;
mouth 10 patients had 1 complication, and 6 patients had more than 1.
Synkinesis, contracture and spasm usually absent We asked whether these complications affected the healing times.
VI Total paralysis No movement
Neuropathy did not affect the healing times (p=0.666); neither did
ARTICLE IN PRESS
S. Şevik Eliçora, D. Erdem / Can J Diabetes xxx (2017) 1–4 3
Discussion Diabetes did not significantly affect the severity or healing rate
of BP or the recovery rate. A possible influence of steroid therapy
A number of factors supposedly affecting the prognosis of BP have on BP development in patients with diabetes should be consid-
been studied; they include age, sex, the side affected, hypertension, ered; such patients should be closely monitored.
hypercholesterolemia and diabetes. The most controversial of these
factors is diabetes. Takemoto et al found an association between dia-
betes and lack of recovery (6). Kanazawa et al found that although Author Disclosures
the healing process of patients with diabetes was similar to that
of those without diabetes for the first month, healing was notably Conflicts of interest: None.
slower in patients with diabetes at months 3 and 6 (7). We found
no difference in lack of recovery rates between patients with and
without diabetes, in agreement with other reports (8–10). We also References
found that age did not affect recovery time, and others have come
to the same conclusion (8–11). Recent studies have found no rela- 1. Gilden DH. Clinical practice: Bell’s palsy. N Engl J Med 2004;351:1323–31.
2. Morris AM, Deeks SL, Hill MD, et al. Annualized incidence and spectrum of illness
tionship between age and the severity of facial paralysis (7,8). from an outbreak investigation of Bell’s palsy. Neuroepidemiology 2002;21:255–
Some studies have explored the combination of HT and BP. Kudoh 61.
et al found that diabetes was not associated with the extent of 3. Peitersen E. Bell’s palsy: The spontaneous course of 2500 peripheral facial nerve
palsies of different etiologies. Acta Otolaryngol Suppl 2002;549:4–30.
paralysis, but that both HT and diabetes slowed healing (12). In con-
4. Salinas RA, Alvarez G, Daly F, Ferreira J. Corticosteroids for Bell’s palsy (idio-
trast, when we studied 13 patients with diabetes and HT and pathic facial paralysis). Cochrane Database Syst Rev 2010;(3):CD001942.
6 patients without diabetes but with HT, we found no significant 5. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck
Surg 1985;93:146–7.
differences in recovery times of BP. The frequency of HT was higher
6. Takemoto N, Horii A, Sakata Y, Inohara H. Prognostic factors of peripheral facial
among patients with diabetes because they were older than the palsy: Multivariate analysis followed by receiver operating characteristic and
patients without diabetes. Kaplan-Meier analyses. Otol Neurotol 2011;32:1031–6.
Viral infections play an important role in the pathogenesis of BP. 7. Kanazawa A, Haginomori S, Takamaki A, et al. Prognosis for Bell’s palsy: A com-
parison of diabetic and nondiabetic patients. Acta Otolaryngol 2007;127:888–
Esaki et al showed, in an animal model of drug-related diabetes, 91.
that herpes simplex virus type 1 caused severe facial paralysis (13). 8. Kiziltan ME, Uluduz D, Yaman M, Uzun N. Electrophysiological findings of acute
Herpes zoster (shingles) is the second most common viral infec- peripheral facial palsy in diabetic and non-diabetic patients. Neurosci Lett
2007;418:222–6.
tion associated with facial palsy. A study analyzing 1,701 cases of 9. Bibas T, Jiang D, Gleeson J. Disorders of the facial nerve. In: Gleeson M, ed. Scott-
BP identified the herpes simplex virus as a causative factor in 7% Brown’s otorhinolaryngology head and neck surgery. 7th edn. London: Edward
of the cases (3). In our study, 1 patient who did not recover from Arnold, 2008, pg. 3883–6.
10. Murakami S, Mizobuchi M, Nakashiro Y, et al. Bell palsy and herpes simplex virus:
facial palsy had both diabetes and shingles. Identification of viral DNA in endoneurial fluid and muscle. Ann Intern Med
We investigated the effects of long-term diabetes control on the 1996;124:27–30.
severity and healing times of facial paralysis. We found no corre- 11. Lee HY, Byun JY, Park MS, Yeo SG. Effect of aging on the prognosis of Bell’s palsy.
Otol Neurotol 2013;34:766–70.
lation between serum A1C levels and either parameter. One study
12. Kudoh A, Ebina E, Kudo H, Matsuki A. Delayed recovery of patients with Bell’s
found a correlation between serum A1C levels and severity of BP palsy complicated by non-insulin-dependent diabetes mellitus and hyperten-
(14); another reported that there is no relationship between serum sion. Eur Arch Otorhinolaryngol 1998;255:166–7.
13. Esaki S, Yamano K, Kiguchi J, et al. Diabetic mice show an aggravated course
A1C levels and severity of BP (7).
of herpes simplex virus-induced facial nerve paralysis. Otol Neurotol
Kiziltan et al found no relationship between the severity of facial 2012;33:1452–7.
paralysis and the duration of diabetes (8). The longer the duration 14. Riga M, Kefalidis G, Danielides V. The role of diabetes mellitus in the clinical
of diabetes, and the poorer the control of blood glucose levels, the presentation and prognosis of Bell palsy. J Am Board Fam Med 2012;25:819–
26.
greater the risk for complications, but we found no difference in the 15. Takahashi A, Sobue I. Concurrence of facial paralysis and diabetes mellitus: Preva-
healing times of patients with diabetes and without complications. lence, clinical features and prednisolone treatment. In: Goto Y, Horiuchi A, Kogure
ARTICLE IN PRESS
4 S. Şevik Eliçora, D. Erdem / Can J Diabetes xxx (2017) 1–4
K, eds. Diabetic neuropathy. Amsterdam, The Netherlands: Experta Medica, 1982, 18. Martinez A. Diabetic neuropathy: Topography, general electrophysiologic fea-
pg. 173. tures, effect of ischemia on nerve evoked potential and frequency of the entrap-
16. Thomas PK, Tomlinson D. Diabetic and hypoglycemic neuropathy. In: Dyck P, ment neuropathy. Electromyogr Clin Neurophysiol 1986;26:283–95.
Thomas PK, Asbury A, et al., eds. Diabetic neuropathy. 3rd edn. Philadelphia: 19. Bosco D, Plastino M, Bosco F, et al. Bell’s palsy: A manifestation of prediabe-
WB Saunders, 1993, pg. 1219–50. tes? Acta Neurol Scand 2011;123:68–72.
17. Stamboulis E, Vassilopoulos D, Kalfakis N. Symptomatic focal mononeuropathies 20. Kiziltan ME, Akalin MA, Sahin R, Uluduz D. Peripheral neuropathy in patients
in diabetic patients: Increased or not? J Neurol 2005;252:448–52. with diabetes mellitus presenting as Bell’s palsy. Neurosci Lett 2007;427:138–41.