Bell’s palsy: Treatment guidelines

Adeline Jaclyn2013.061.092

The most acute onset unilateral peripheral facial weakness

20-30 cases for 100.000 60-70% unilateral peripheral facial palsy Sex equally Any age, median 40 years Lowest under 10 years, highest over 70 years Left and right sides equally

Clinical characteristics

Onset sudden Symptom typically peak

within a few days Additional symptom

› Pain in or behind ear› Numbness or tingling in the affected side usually

without any objective deficit on neurological examination

› Hyperacusis› Disturbed taste on the ipsilateral anterior tongue

Bilateral idiopathic facial palsy less 7 % recurrence The mean interval 9.8 years after first episode

Diagnosis First determine central or peripheral Peripheral : all facial muscles ipsilateral Central : lower facial muscles contralateral

DD/ : DM HIV Lyme disease Ramsay Hunt syndrome Sarcoidosis Sjogren’s syndrome Parotid-nerve tumors Leprosy Polyarteritis nodosa Amyloidosis

Diagnosis workup Nerve excitability test (produce visible muscle

contraction) : difference > 3.5 mA between affected and

unafected side (poorer outcome) Measuring the peak-to-peak amplitude of the

evoked compound action potential (compared) : ≥ 90% reduction affected side (poor)

Trigeminal blink reflex only test to measure intracranial pathway of the

facial nerve To study various postparalysis sequelae (ex.

synkinesis and hemifacial spasms) With recovery of facial function the ipsilateral R1

latency becomes less prolonged The amount of initial prolongation of this response

correlates with greater loss of facial motor function

MRI : enhancement of internal acoustic meatal segment

on the affected side (not specific) Should not be done routinely To look for other possible causes

Treatment To speed recovery and to prevent corneal

complications Eye care : eye patching and lubrication

Lubrication drops : frequently during the day Eye ointment : at night

Physical therapy Corticosteroids Antiviral agents

Prednisolone › Corticosteroid (potent anti-inflammatory)› Minimise nerve damage (improve the outcome)› Randomized, double-blind, placebo-controlled

trials : improves outcome and shortens the time to complete recovery

› Less than 72 h duration› Dose : 60 mg per day for 5 days then reduced

by 10 mg per day (total 10 days) and 50 mg per day ( in two divided doses) for 10 days

› Cost-effective

Antiviral agents Related to HSV Autopsy study : latent HSV-1 has been isolated

from the majority of the geniculate ganglia samples

HSV-1 genome : 79% of facial nerve endoneurial fluid (not in the controls)

The benefit has not been definitively established

Physical therapy Exercise, biofeedback, laser, electrotherapy,

massage and thermotherapy : hasten recovery The evidence for the efficacy is lacking Cochrane systemic review : no significant Limited evidence : improvement began earlier Reduces time to recover (possible)

Prognosis 71% motor function recovery completely

within 6 months without treatment Poor prognostic factors : old age,

hypertension, DM, impairment of taste and complete facial weakness.

1/3 patients incomplete recovery and residual effect

Residual effect : post-paralytic hemifacial spasm, co-contracting muscles, synkinesis, sweating while eating or during physical exertion

Most common abnormal regeneration patterns : Crocodile tears (lacrimation of the ipsilateral eye

during chewing) Jaw-winking (closure of the ipsilateral eyelid when

jaw opens)

Thank you