Bell's palsy

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Bell's palsy is an idiopathic lower motor neurone disease of the facial nerve (cranial nerve VII) causing a facial nerve palsy. Called also BP, Bell palsy, Bell's phenomenon, facial palsy, and idiopathic facial paralysis.

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  • Sir Charles Bell described it around 1824.
  • Nicolaus Friedrich, an 18th century professor of medicine at Wurzburg, published a case report of a facial nerve paralysis of unknown origin in 1798.[1]
  • There is not general agreement on whether other cranial nerves may be affected.
  • Herpes simplex virus has been believed to be the most likely cause.
  • Not to be confused with Bell's phenomenon

Contents

Prognosis

The prognosis of the unmodified disease is quite good with recovery likely in a month but sometimes taking three months or even 9 months - sustaining doubt about whether treatments with significant likely side-effects should be used. The question continues to attract debate and a study designed to have adequate power (double blind RCT of 400 patients) was done in 2004-6 in Scotland[2]. Best treatment in those who present late after 72 hours is unknown. Recurrence rate of Bell’s palsy is about 12%.

Complications

  • Aberrant regeneration of nerve fibres:
    • Connection to the lacrimal ducts instead of the salivary glands - lacrimation while eating, or "crocodile tears"
    • Connection to the wrong muscles - facial synkinesis
  • An association is an increase the risk of non-hemorrhagic stroke in those of chinese extraction[3]
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  • If within 72 hours of onset use prednisolone 25mg bd for 10 days
  • Both the Bolitho and Bolam tests can be satisfied for treatment or for not treating, outside 72 hours.
  • Reevaluate all patients at 3 months - if improved its Bells, if no improvement MRI to exclude small tumour[1].

Evidence

While earlier meta-analysis had suggested that corticosteroids plus antiviral treatment was likely to be beneficial[4] it is now known that the combination of aciclovir and prednisolone has no advantage over prednisolone alone administered early. Three more recent meta-analysis found no benefit from antivirals[5][6][7]. These took in the data from the Scottish Bell's Palsy Study which concluded "In patients with Bell's palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of aciclovir given alone or an additional benefit of acyclovir in combination with prednisolone."[8]. At 9 months double placebo had 85 % full recovery compared to 94% recovery with steroids, a number needed to treat of 6. Acyclovir had a complete recovery rate only of 71%.

Treatments

In summary:

  • Prednisolone 25mg bd for 10 days from within 72 hours of onset is beneficial[9]. Short term side effects are minimal and minor.
  • Antiviral treatment is unlikely to be benefical[10]
  • Facial nerve decompression surgery is of unknown effectiveness[11]
    • If offered electrodiagnostic testing must be done in a timely manner because decompression of the facial nerve later than 14 days definitely does not alter outcome[1]
  • Combination aciclovir and steroid treatment commenced within 72 hours for 10 days is unlikely to be benefical over steroids alone[12]
  • Valciclovir plus prednisolone may be better than prednisolone alone (RCT, n=221).[13]
  • Facial neuromuscular re-education may be useful in the few with persistent nerve damage.[14]

External Links

References

  1. a b c Zandian A, Osiro S, Hudson R, Ali IM, Matusz P, Tubbs SR, Loukas M. The neurologist's dilemma: A comprehensive clinical review of Bell's palsy, with emphasis on current management trends. Medical science monitor : international medical journal of experimental and clinical research. 2014; 20:83-90.(Epub) (Link to article – subscription may be required.)
  2. http://www.dundee.ac.uk/bells/ Scottish Bell's Palsy Study (SBPS)
  3. Chiu YN, Yen MF, Chen LS, Pan SL. Increased risk of stroke after Bell's palsy: a population-based longitudinal follow-up study. Journal of neurology, neurosurgery, and psychiatry. 2012 Mar; 83(3):341-3.(Link to article – subscription may be required.)
  4. Clinical Evidence on Bell’s Palsy
  5. de Almeida JR, Al Khabori M, Guyatt GH, Witterick IJ, Lin VY, Nedzelski JM, Chen JM. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA : the journal of the American Medical Association. 2009 Sep 2; 302(9):985-93.(Link to article – subscription may be required.)
  6. Goudakos JK, Markou KD. Corticosteroids vs corticosteroids plus antiviral agents in the treatment of Bell palsy: a systematic review and meta-analysis. Archives of otolaryngology--head & neck surgery. 2009 Jun; 135(6):558-64.(Link to article – subscription may be required.)
  7. Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis. BMJ (Clinical research ed.). 2009; 339:b3354.(Epub)
  8. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD, Clarkson JE, Hammersley V, Hayavi S, McAteer A, Stewart K, Daly F. Early treatment with prednisolone or acyclovir in Bell's palsy. The New England journal of medicine. 2007 Oct 18; 357(16):1598-607.(Link to article – subscription may be required.)
  9. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD, Clarkson JE, Hammersley V, Hayavi S, McAteer A, Stewart K, Daly F. Early treatment with prednisolone or acyclovir in Bell's palsy. The New England journal of medicine. 2007 Oct 18; 357(16):1598-607.(Link to article – subscription may be required.)
  10. Clinical Evidence on Bell’s Palsy
  11. Clinical Evidence on Bell’s Palsy
  12. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD, Clarkson JE, Hammersley V, Hayavi S, McAteer A, Stewart K, Daly F. Early treatment with prednisolone or acyclovir in Bell's palsy. The New England journal of medicine. 2007 Oct 18; 357(16):1598-607.(Link to article – subscription may be required.)
  13. Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K, Fukuda S, Furuta Y, Ohtani F, Aizawa H, Aoyagi M, Inamura H, Nakashima T, Nakata S, Murakami S, Kiguchi J, Yamano K, Takeda T, Hamada M, Yamakawa K. Valacyclovir and prednisolone treatment for Bell's palsy: a multicenter, randomized, placebo-controlled study. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society and. European Academy of Otology and Neurotology. 2007 Apr; 28(3):408-13.(Link to article – subscription may be required.)
  14. Manikandan N. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. Clinical rehabilitation. 2007 Apr; 21(4):338-43.(Link to article – subscription may be required.)
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