Bell’s Palsy
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Transcript of Bell’s Palsy
Bell's PalsyAMRESH Ku MAR. B. P. R. BHATIA, M. K. MALIK.
Thirty four patients of Bell's
Palsy have been studied over a
period of one and half years.
Various aetiological factors,
diagnostic tests and therapy
have been reviewed.
Inspite of the great advancement
in the field of medical science, Bell's
Palsy still remains a dilemma to the
treating otolaryngologists. Several
factors have been held responsible
to affect the severity and the out-
come of the disease (Adourt and
Wingerd 1974). Nerve excitability
test has been found useful in predic-
ting the prognosis of the disease
(Camp Bell 1962). Decreased or
loss of response on paralysed side by
Nerve excitability test is supposed to
indicate poor prognosis (Mark May
1978). Electrogustometry has been
used to determine the site of injury
and the prognosis of the patient.
Decreased lacrimal flow on the para-
lysed side by Schirmer's test also
indicates bad prognosis (Mark May
1978). Controversy exists about
the effect of diabetes mellitus on the
severity and prognosis of the disease,
(Korczyn 1971 and Boddie 1972),
(Sardana et. al', 1978).
In the present study, various as-
pects of this disease have been
studied and discussed.
Material and Method
Thirty four patients of Bell's Palsy
have been examined and followed up
Amresh Kumar, Lecturer; B. P. R. Bhatia,Reader & Head; M. K. Malik, Lecturer,Department of E. N. T., L. L. R. M. MedicalCollege, Meerut
over a period of one and half years
to study the various aspects of the
disease. The diagnosis of the Bell's
Palsy was made on the following
criteria :
(1) Sudden onset of partial or
complete paralysis of the mus-
cles of expression on one side
of face.
(2) The absence of history of
erruptions or vesicles over the
face or in the ear.
(3) The absence of any disease of
middle ear which could have
involved the facial nerve.
(4) The absence of any symptom
or sign of the disease of the
central nervous system.
After establishing the diagnosis of
Bell's Palsy, the detail history of the
patient was taken. Special emphasis
was laid on the following points :
(1) Any history of pain in or around
the ear preceding palsy.
(2) History of exposure to cold
preceding palsy.
Detail clinical examination of the
facial nerve was done to determine
whether the patient had clinically
complete paralysis or the partial
paralysis.
(1) Nerve Excitability Test : It
was done with the help of a
nerve stimulator to find any
evidence of partial or complete
denervation.
(2) Electrogustometry Test :
It was done with the help of
electrogustometer based on the
circuit of Krarup's modification.
(3) Schirmer's Test : Lacrimal
flow was compared on the
healthy and paralysed side.
Certicosteroids were not given to
any patient and the patients either
showed spontaneous recovery or the
surgical decompression of the nerve
was done.
Incidence of Diabetes Mellitus was
determined in these patients and its
effect on the severity and the
prognosis of the palsy was observed.
Observations and Results
These are based on the study of
thirty four patients.
Table-1 shows the age and sex of
these patients. The table-1 shows
TABLE I
Showing Age and Sex distributionof the patients
Male Female Total
3 2 51 4 58 7 151 3 41 3 43 2 5
Nil Nil Nil
16 18 34
(3) History of change in taste after Age in yearsdeveloping palsy.—
0-1011-2021-3031-4031-4041-5051-60
Total
Address for reprints Assessment of the function ofDr. Amresh Kumar facial nerve was done by the follow-D-5, Medical College CampusMeerut. ing tests
that the males and females were
about equally affected. Maximum
number of patients were encountered
Indian Journal of Otoloryngology, Volume 36, No. 3, September, 1984 105
BELL'S PALSY—KUMAR, et at.
in the age group of 21-30 years. The
youngest patient sutfering from the
disease was a two years old female
child.
Involvement of right side was seen
in 19 (55.9%) cases while left side
was affected in 15 (44.1%) cases.
Table-II shows presentation of
Bell's Palsy and its relation to prog-
nosis.
The table-II indicates that pain and
change in taste do not affect the
prognosis of the disease. It also in-
dicates that history of exposure to
cold was found only in 6 (17.6%)
cases.
TABLE 1.1
Showing presentation of Bell's Palsyand its relation to Prognosis
Number Per- Prog-Presentation of cases centage nosis
History of painin ear 23 67.6% Good
History ofexpsoure to cold 6 17.6% Good
History of changein taste 10 29.4% Good
Out of these 34 patients, 22 were
studied in a period of one year from
January to December and the other
twelve (12) were studied in next
six months.
Table-III indicates the seasonal
distribution of the 22 patients studied
between January to December.
It is clearly evident from the table-III
that the maximum number of cases
(22.7%) were encountered in the
month of April which is fairly hot.
History of exposure to cold was also
present only in (17.6%) cases. It is
therefore apparent from the present
analysis that cold is not an important
factor in the causation of the disease.
Clinically complete paralysis was
found in 26 (76.5%) patients while 8
(23.5%) had partial paralysis.
TABLE Ill
Showing seasonal distributionof the patients
MonthNumberof cases Percentage
January Nil —
February 4 18.2%March 1 4.5%April 5 22.7%May 2 9.0%June 1 4.5%July 1 4.5%August 1 4.5%September 3 13.7%October 1 4.5%November 2 9.0%December 1 4.5%
Tota 1 22
Nerve Excitability test showed
partial denervation in 4 patients. Out
of these 4 patients, only one could
recover.
Electrogustometry showed maxi-
mum difference of 48 microamperes
on paralysed and healthy side.
Lacrimal flow by Schirmer's test
was equal on both the sides in all
the cases and did not prove of much
value.
Table-IV shows the recovery of the
disease.
TABLE IV
Showing recovery of the Palsy
Number Per-Outcome of cases centage
Overall complete recovery 27 79.4%Spontaneous recovery 25 73.5%Recovery after facial nerve
decompression (out of 4) 2 50.0%
The table-IV indicates that the
overall recovery of the disease was
79.4% and 73.5% cases recovered
spontaneously.
Out of 4 patients who underwent
surgical decompression of the nerve,
two were those patients who initially
showed partial denervation. These
patients did not recover even after
the surgical decompression of the
nerve.
The incidence of diabetes mellitus
was found to be 14.7% among these
patients and diabetes mellitus was
not found to have any effect either
on the severity of the palsy or on
the prognosis of the palsy.
Discussion
Adour et. aL, (1978) studied 1048
patients of Bell's Palsy and found
highest incidence of the disease in
the third decade of life. In our
analysis also, the maximum number
of patients are encountered between
the age of 21-30 years. This indicates
that the disease is more common in
young persons.
The females and males are equally
involved in both the series which
indicates that the incidence is not
higher in any sex. However Adour
et. al., (1978) reported higher inci-
dence in women during first fourteen
days of menstrual cycle. The analysis
of both the studies also indicates that
history of pain and change in taste
do not affect the outcome of the
disease.
In our analysis, maximum number
of patients were encountered in the
month of April. Adour et. a/., (1978)
also reported that cold has no impor-
tance in the causation of the disease.
Nerve excitability test proved helpful
in predicting the prognosis of these
patients and those showing evidence
of denervation had poor prognosis,
of these patients and those showing
evidence of denervation had poor
prognosis. Mark May (1978) also
reported that decreased response by
nerve excitability test is an un-
favourable factor in the prognosis
of the disease. Electrogustometry
showed maximum difference of 48
microamperes on two sides. However,
a critical difference of 10 micro-
amperes which is supposed to indi-
cate bad prognosis was not found in
any patient. Decreased lacrimal flow
on the paralysed side indicates bad
106 Indian Journal of Otolaryngology, Volume 36, No. 3, September, 1984
BELL'S PALSY—KU MAR, et al.
prognosis (Mark May (1978, Adour
et. aL, 1978), but it did not prove
of much value in our study and
lacrimal flow was equal on both the
sides in all the cases.
Diabetes mellitus was not found
to have any effect on the severity of
the palsy and the outcome of the
disease as also reported by Boddie
(1972) and Sardana et. al., (1978) in
the earlier study.
References
1. Amos, D. Korczyn : Bell's Palsy andDiabetes Mellitus. Lancetl : 108,1971.
2. Adour, K. K., M. D., John Wingerd, M. A. :"Idiopathic facial paralysis (Bell's Palsy),factors affecting severity and outcome in446 patients" Neurology (Minneap)24 (12) : 1112, 1974.
3. Boddie, H. G. : Recurrent Bell's Palsy.Journal of Laryngology and Otology.86 : 1117-20, 1972.
4. Camp Bell, E. D. R., ETAL : 'value ofNerve excitability, measurement in pro-gnosis of facial palsy. British MedicalJournal. 2 : 7-10, 1962.
5. Krarups, B. : Electrogustometry, Amethod for clinical taste examination.Acta Otology. 49 : 294, 1958.
6. Kedar K. Adour, M.D., Frederick M.Bly, M.D., Raymond L. Hilsingar, Jr.M. D. Z. M. Khan, M.D. and M. I.Sheldon, M.D. : The true nature of Bell'sPalsy. Analysis of 1,000 consecutivepatients. Laryngoscope. 88 : 787, 1978.
7. Mark May, M.D. : Bell's Palsy : Pro-gressive ascending paralysis, therapeLticimplications. Laryngoscope. 88 : 61,1978.
8. Sardana D. S., Gupta Om. K., Kumar A.Role of diabetes mellitus in the aetiologyof Bell's Palsy. Indian Journal ofOtolaryngology: 30 (2) : 61, 1978.
Indian Journal of Otolaryngology, Volume 36, No. 3, September, 1984 107