Bell’s palsy: Treatment guidelines Adeline Jaclyn 2013.061.092
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