Bells Palsy:

To Treat or Not to Treat

K. Kevin Ho, M.D.

Shawn D. Newlands, M.D., Ph.D., M.B.A.
University of Texas Medical Branch at Galveston
Grand Rounds Presentation February 14, 2007

Historical Perspectives

Sir Charles Bell (1774-1842)

Studied facial anatomy
extensively during Battle of
Waterloo
Concluded that facial nerve
controlled facial expression
Respiratory nerve of the Face

Anatomy

Bells Palsy

Idiopathic facial paralysis

Diagnosis of Exclusion
Most common diagnosis
(> 60%) for acute facial palsy
30 per 100,000
Peripheral neuropathy
Generally unilateral
Rapid onset < 48 hours

Age Distribution
2002

Peitersen E. Acta Otolaryngol 2002;549:430.

Peitersen E. Am. J. Otology. 1982

Complete Remission & Age

90

84
75
64

36

0-14

15-29

30-44 Age 45-59

> 60

Peitersen E. Acta Otolaryngol 2002;549:430.

Return of Muscular function

85 %

Months
Peitersen E. Acta Otolaryngol 2002;549:430.

Time of beginning remission &

Sequelae

Peitersen E. Am. J. Otology. 1982

Complete Recovery
71

Peitersen E. Acta Otolaryngol 2002;549:430.

Incomplete vs. Complete

Peitersen E. Acta Otolaryngol 2002;549:430.

Symptomatology

Reduced Stapedial reflex

Complete palsy @ presentation
Tear flow
Post-auricular pain
Dysgeusia
Hyperacusis
Peitersen E. Acta Otolaryngol 2002;549:430.

71%
69%
67%
52%
34%
14%

Predicting Muscular Sequelae

91

91
83

% Muscular
Sequelae

Abnormal
63

Normal

27

5
Taste

Stapedial

Lacrimation

Peitersen E. Acta Otolaryngol 2002;549:430.

Favorable prognosis for

full recovery

Incomplete palsy
Early recovery
Young patients
Normal taste, stapedial reflex, lacrimation
Lack of post-auricular pain
Peitersen E. Acta Otolaryngol 2002;549:430.

Pathophysiology

Exact etiology unknown

Viral infection
Herpes Simplex

Vascular ischemia
Autoimmune disorder
Hereditary

Role of HSV-1

Murakami: Ann Intern Med, Volume 124(1).January 1, 1996.27-30

Diabetes Mellitus

Bells patients with DM

14 % (Korczyn AD 71)
21 % (Alford BR 71)
38 % (Yasuda K 75)

66% demonstrate glucose intolerance

Functional recovery poorer in diabetics

Pregnancy

Incidence of Bells palsy 3-4 x higher

(Hilsinger, Cohen et al.)

Third trimester with highest risk

Higher risk of complete palsy
Lower chance of complete recovery
(Gillman et al.)

Preeclampsia 6 x prevalence in pregnant

women with facial palsy

Differential Diagnosis
Acute facial palsy

Infection
Herpes Zoster Oticus
(Ramsey Hunt Syndrome)
Lyme disease
Acute Otitis media +/- mastoiditis
Congenital
Treacher Collins syndrome
Mobius syndrome
Trauma
Temporal Bone fracture
Barotrauma
Metabolic
Diabetes
Hypothyroidism
Vascular
Benign intracranial hypertension
Neoplasm
Facial neuroma
Acoustic neuroma
Toxic
Thalidoide
Iatrogenic

Early Grading System

Peitersen E. Am. J. Otology. 1982

House-Brackman Grading System

MRI

Post-GAD
Pre-GAD
Kinoshita T et al. Clin. Radiology 2001; 56: 926-32

Contrast Enhancement:
Bells Palsy vs. Control
Bells Palsy

Control

Kinoshita T et al. Clin. Radiology 2001; 56: 926-32

Topognostic Test

Lacrimal
Schirmers Test

Stapedial reflex
Taste
Salivary flow

Electrical Test

Nerve Excitation test

Maximal Stimulation test
Electroneurography
Electromyography

(NET)
(MST)
(ENoG)
(EMG)

Sunderland classification of
peripheral nerve injury
Neurapraxia

Axonotmesis

Neurotmesis

Electroneurography (ENoG)

Transcutaneous stimulation (Evoked EMG)

Compound muscle action potential (CMAP)
Most useful in acute phase within
3 days 3 weeks of palsy
But no info on class of injury
(axonotmesis vs. neurotmesis)

Time course of Degeneration

Gantz: Laryngoscope,
Fisch U. Am
Volume
J. Otology.
109(8).August
1984
1999.1177-1188

Fisch 1984

Fisch U. Am J. Otology. 1984

Electromyography (EMG)

Recording of voluntary muscle

action potentials by needles
electrodes
Does not differentiate
axonotmesis & neurotmesis
More useful 2-3 weeks after
onset of complete paralysis
Perform EMG if ENoG > 95%
degeneration

EMG Interpretation

Active voluntary motor units (MU)

Myogenic fibrillation potention &

Absent voluntary MU

Complete nerve degeneration

Fibrillation + MU

Intact motor axon

Partial degeneration

Polyphasic MU

Regenerating nerve

Management of Bells Palsy

Observation
Medical Treatment

Surgery

Steroid
Anti-viral agents
Decompression
Dynamic vs. static reanimation

Facial Rehabilitation

Cochrane review on Efficacy of

steroids

4 trials of 179 patients

Trial 1: Cortisone vs. placebo
Trial 2: Prednisone + vitamins vs. vitamins
Trial 3: High dose prednisone vs. saline
Trial 4: Methylprednisolone
Primary endpoint: VII recovery @ 6 mos
Conclusions: NO significant benefit for giving steroids to Bells palsy patients
Drawbacks: Individual studies underpowered. Steroid regimens differ.

Efficacy of Steroid treatment

Prospective RCT
56 patients
Arm I: Steroids
Arm II: Placebo
Success = HB I or II
F/u @ 3 and 6 weeks
No significant difference in response in the
2 groups
Turk-Boru U et al. Kulak Burun Bogaz Ihtis Derg. 2005;14(3-4):62-6.

Steroids in Complete paralysis

Meta-analysis of 3 prospective trials

230 patients with HB VI

Treatment within 7 days of onset

Total prednisone dose > 400 mg
(405-425 mg)
Complete Recovery: HB VI I
Steroid group has 17% higher rate of CR
than control (placebo/ no treatment)
Ramsey MJ et al. Laryngoscope 2000; 110: 335-341

Steroid vs. Steroid + Acyclovir

Double-blind RCT
99 Bells palsy patients
53 treated with acyclovir- prednisone
46 with placebo prednisone
Prednisone dose 400 mg five times daily x 10 days
Combined therapy is better in terms of:
Return of muscle motion
Prevention of partial nerve degeneration

Adour KK 1996 Ann Otol Rhinol Laryngol. 1996 May;105(5):371-8

Steroid vs. Steroid + Acyclovir

Prednisolone

Prednisolone +
Valacyclovir

Prospective RCT of
150 patients
Prednisolone (20 tid x
5d, 10 tid x 3 d, 10 qD
x 2 d)
Predisolone +
Valacyclovir (500 bid x
5 d)
No significant
difference in recovery

Kawaguchi: Laryngoscope, Volume 117(1).January 2007.147-156

Timing of Medical Treatment

Hato N. Otol & Neurotol: 24(6) 2003

Sample Treatment

Corticosteroids

Anti-viral

Prednisone 60 mg PO daily x 5 days, taper

Valacyclovir 1000 mg PO TID

Eye care

Glasses/ Sunglasses/ avoid contact lens

Artificial tears, lacrilube
Taping
Gold weight to upper eyelid
Opthalmologic consultation

Pensak ML. Assessment and Management of the Paralyzed face. Otol. & Neurotol. Update. Nov 2006

Surgical Decompression

Middle Fossa
Transmastoid
Translabyrinthine
Retrolabyrinthine
Retrosigmoid

History of Surgical Decompression

Adour KK. 2002 Jan;259(1):40-7

Anatomy of Facial Canal

Tympanic
1.53 mm

Mastoid
1.48 mm

Labyrinthine
1.02 mm
0.68 mm

Coker NJ. Atlas of Otologic Surgery p.339

Controversy over
Surgical Decompression

In favor of:

Gantz BJ 99
Sillman JS 92
Huges GB 88
Goin DW 82
Fisch U 81
Brackmann DE 80
Giancarlo HR 70

Against:

Adour KK 01
Aoyagi M 88
May M 84
Gacek RR 81
McNeill R 74
Adour KK 71
Mechelse K 71

Results of Middle Fossa Approach

Grade

Iowa

Michigan

Baylor

Total

II

15

III

IV

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Michigan Study:
MCF vs. Steroids

Grade
Glasscock M, Shambaugh G: Facial nerve surgery. In Surgery of the ear, 1990:434-465.

Early MCF

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Timing of Decompression

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Algorithm

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Factors to consider for Surgical

Decompression

Age
Comorbidities
ENoG
Endpoint
Progression / velocity of degeneration

Days from onset of paralysis

Return of muscle function

Thank you