Bell's palsy during pregnancy: Is it associated with adverse perinatal outcome?

Double echo steady-state free precession technique in MR neurography to evaluate extracranial facial nerve involvement in a case of Bell's palsy

Bell's palsy is the most common cause of facial weakness involving the facial nerve. While brain MRI is often acquired to evaluate for pathology along the intracranial course of the facial nerve, evaluation of inflammation affecting the extracranial segments of the facial nerve, particularly the intraparotid segments, is uncommon. We present a case report of acute Bell's palsy in a 35-year-old pregnant patient at 38 weeks' gestation. A double-echo steady state MR neurography technique, MENSA (Multi-Echo iN Steady-state Acquisition), acquired with a conformable prototype neck coil, was utilized to visualize abnormal enlargement and signal hyperintensity of the left intraparotid facial nerve. The case highlights a presentation of Bell's palsy affecting the extracranial segments of the facial nerve. This technique may be useful for longitudinal monitoring of Bell's palsy, planning of targeted treatments, and for evaluating other pathologies affecting the facial nerve.

Bell Palsy: Facts and Current Research Perspectives

Bell palsy is a non-progressive neurological condition characterized by the acute onset of ipsilateral seventh cranial nerve paralysis. People who suffer from this type of facial paralysis develop a droop on one side of their face, or sometimes both. This condition is distinguished by a sudden onset of facial paralysis accompanied by clinical features such as mild fever, postauricular pain, dysgeusia, hyperacusis, facial changes, and drooling or dry eyes. Epidemiological evidence suggests that 15 to 23 people per 100,000 are affected each year, with a recurrence rate of 12%. It could be caused by ischaemic compression of the seventh cranial nerve, which could be caused by viral inflammation. Pregnant women, people with diabetes, and people with respiratory infections are more likely to have facial paralysis than the general population. Immune, viral, and ischemic pathways are all thought to play a role in the development of Bell paralysis, but the exact cause is unknown. However, there is evidence that Bell's hereditary proclivity to cause paralysis is a public health issue that has a greater impact on patients and their families. Delay or untreated Bell paralysis may contribute to an increased risk of facial impairment, as well as a negative impact on the patient's quality of life. For management, antiviral agents such as acyclovir and valacyclovir, and steroid treatment are recommended. Thus, early diagnosis accompanied by treatment of the uncertain etiology of the disorder is crucial. This paper reviews mechanistic approaches, and emerging medical perspectives on recent developments that encounter Bell palsy disorder.

Bell's palsy in pregnancy: A scoping review of risk factors, treatment and outcomes

Objective

There are limited studies reporting on Bell's palsy and pregnancy. Our study aimed to evaluate risk factors, current treatment options and facial function outcomes in women who developed Bell's palsy in pregnancy. To our knowledge this is the first review analyzing these factors.

Data sources/review methods

A search of PubMed/MEDLINE, Embase, Web of Sciences and Scopus was carried out. Studies describing risk factors, treatment and/or facial function outcomes of Bell's palsy in pregnancy were included. PRISMA-Scr guidelines were followed.

Results

The search yielded 392 abstracts, of which 15 studies were included for analysis. It was not possible to perform a meta-analysis due to small numbers and quality of studies. There were 559 patients included from the 15 studies. The third trimester was the most common time for Bell's palsy to occur (n = 364, 65%). Pre-eclampsia was the most common co-morbidity reported. The most common treatment was corticosteroids and the majority of patients had a complete recovery of their palsy (58%, n = 192).

Conclusion

This analysis has evaluated all available data concerning risk factors, treatment and facial function outcomes of BP in pregnancy. The third trimester is the most common time for Bell's palsy to occur in pregnancy. There is currently a lack of high quality evidence into this condition in pregnancy.

Level of evidence

1.

A Study on Otorhinolaryngologist Perspective of Etiology and Outcomes in Lower Motor Neuron Facial Palsy: A Single Centre Experience Over a Year

To analyse the aetiology and outcomes of all patients attending otorhinolaryngology department for Lower Motor Neuron type facial palsy over one year. STUDY DESIGN-Retrospective study. SETTING-SRM medical college hospital and research institute, Chennai from Jan 2021 to December 2021. SUBJECTS-23 patients with LMN facial palsy in the ENT department were analysed. METHOD-Details about the onset of facial palsy, history of trauma, surgeries were collected. Facial palsy grading according to House Brackmann was done. Relevant investigations, neurological assessments, appropriate treatment, facial physiotherapy, eye protection and relevant surgical management were carried out.Outcomes were assessed by HB grading. Among 23 patients, mean age of presentation of LMN palsy is 40.39 ± 15.0 years. According to House Brackmann staging 21.73% had grade 5 facial palsy, 43.47% had grade 4,30.43% of patients had grade 3 and 4.34% had grade 2 facial palsy. 9 patients (39.13%) had facial palsy due to idiopathic cause, 6 (26.08%) had facial palsy due to otologic cause, 3(13.04%) due to Ramsay hunt syndrome and post traumatic in 8.69% of patients. Parotitis in 4.3% of patients and iatrogenic in 8.69% of patients. 18(78.26%) patients were treated medically alone and 5 (21.73%) patients required surgery.Mean duration of recovery is 28.52 ± 12.6 days. In follow up, 21.73% of patient had grade 2 facial palsy and 76 .26% of patients had recovered completely. Facial palsy in our study had very good recovery due to early diagnosis and early start of appropriate treatment.

Bell's Palsy in Pregnancy and Postpartum: A Retrospective Case-Control Study of 182 Patients

OBJECTIVE

To assess the incidence of Bell's palsy in pregnant and postpartum women. Additionally, to compare facial outcomes in terms of Sunnybrook score following Bell's palsy with regard to corticosteroid treatment and other confounding factors.

STUDY DESIGN

Retrospective case-control study.

SETTING

University Hospital, Stockholm, Sweden.

METHODS

All women with Bell's palsy in pregnancy or postpartum (6 weeks after birth) with a computerized medical chart in the Stockholm Region 2005 to 2015 were included. The total number of births in the region during this period was retrieved from the Swedish Medical Birth Register. Nonpregnant age-matched women with Bell's palsy served as controls. Characteristics, medication, and Sunnybrook scores were collected. Risk factors for incomplete recovery (Sunnybrook score <96) at 3 months were calculated by logistic regression.

RESULTS

In total, 182 pregnant and postpartum women with Bell's palsy were identified. The estimated incidence among pregnant and postpartum women was 60.5/100,000 person-years. The mean Sunnybrook score at 3 months was 74 among pregnant and postpartum women and 83 for controls (p = .002). At 12 months, Sunnybrook score was 81 and 89, respectively (p = .017). Only one-third of the pregnant women received corticosteroid treatment.

CONCLUSION

The incidence of Bell's palsy in pregnancy and postpartum was 60.5 per 100,000 women and year in the Stockholm Region. Sunnybrook score was poorer in pregnant women compared with postpartum and nonpregnant women throughout. Corticosteroid treatment had little effect on any patients, however, only one-third of the pregnant women received this treatment.

Bell's palsy with preeclampsia in pregnancy

Bell's palsy in pregnancy is not frequently seen. The association of preeclampsia with Bell's palsy is reported in the research, however, the exact link between Bell's palsy and preeclampsia is unknown. The treatment of Bell's palsy during the pregnancy is difficult and controversial. We report two cases of Bell's palsy with preeclampsia diagnosed during the third trimester of the pregnancy. The first case was diagnosed with Bell's palsy with severe preeclampsia with placental abruption with fetal distress; the pregnancy was terminated by cesarean section. Another case was diagnosed with Bell's palsy with mild preeclampsia. She had a spontaneous vaginal delivery at term. Both the cases achieved complete recovery from Bell's palsy after treatment with corticosteroid and antiviral drugs. Every obstetrician should be able to recognize Bell's palsy in pregnancy and initiate early treatment with corticosteroid and mount surveillance for preeclampsia.

Gestational Bell's Palsy Is Associated with Higher Blood Pressure during Late Pregnancy and Lower Birth Weight: A Retrospective Case-Control Study

The associations between gestational Bell's palsy (GBP) and late obstetric complications (LOCs), i.e., preeclampsia (PE), eclampsia (EC), gestational hypertension (GHT), and gestational diabetes mellitus (GDM) remain unclear. This study aimed to evaluate these associations and the neonatal health of the newborns born from pregnant women with and without GBP. A retrospective 1:5 case-control study matching exact maternal age and gravidity between pregnant women with and without GBP in Songklanagarind Hospital from 2006 to 2016 was conducted. The associations between GBP and PE, EC, GHT, and GDM, as well as comparison of the newborns' health indices were analyzed by bivariate analysis (p < 0.05). Eight GBP cases out of 8,756 pregnant women were recruited. Six GBP cases were first or second gravid. GBP occurred during the third trimester in five cases. Except for higher median systolic blood pressure (125 (114.2, 127.5) vs. (110 (107.0, 116.0), p = 0.045) and diastolic blood pressures (77 (73.0, 80.8) vs. 70 (65.0, 73.2), p = 0.021) in the GBP cases, associations between GBP and all LOCs could not be concluded due to the lack of power. However, a significantly lower mean birth weight in the newborns of GBP mothers was found (2672.2 (744.0) vs. 3154.8 (464.7), p = 0.016) with statistically significant power. Except for the higher blood pressures and lower birth weights of the newborns of GBP mothers, an association between GBP and LOCs remains inconclusive.

Bell's palsy during pregnancy and the post-partum period: A contemporary management approach

Bell's palsy during pregnancy and the immediate post-partum period represents a unique clinical entity requiring an individualised management approach. Whilst the exact link between Bell's palsy and pregnancy is still unclear, the majority of cases occur in the third trimester and immediate post-partum period. These patients have been demonstrated to experience worse long term outcomes and are less likely to receive early corticosteroid therapy. This review suggests a contemporary management algorithm to ensure that these patients receive early therapy that is safe for the patient and foetus and meets the unique physical needs of the expecting or new mother.

Kinesitherapy for idiopathic facial palsy: A protocol of systematic review and meta-analysis

BACKGROUND

Idiopathic facial nerve palsy (Bells palsy) is the most common acute mono-neuropathy which lack of effective treatments. Kinesitherapy as an alternative therapeutic approach was widely used in clinical. But the effects on Bells palsy outcome are still debated.

METHODS

The aim of this study is to systematically review the therapeutic efficacy of kinesitherapy for Bells palsy. Database including PubMed, EMBASE, Cochrane Library, Chinese Biomedical database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical database (VIP) and WangFang database will be searched to collect randomized controlled trails (RCTs) on kinesitherapy for Bells palsy from inception to Nov 2020. The therapeutic effects based on recovery rate, House-Brackmann (H-B) facial classification system, Sunny brook face grading system and adverse events after the treatment will be marked as the primary outcomes. RevMan V.5.3 software will be used to calculate the data synthesis as well as to perform meta-analysis if the results are appropriate.

RESULTS

The literature will provide a high-quality synthesis of current evidence of kinesitherapy for Bells palsy from various comprehensive assessment, including the recovery rate, H-B facial classification, Sunny brook face scores, adverse events rate, Facial disability index (FDI), residual symptoms 6 months after onset, incomplete recovery rate after 1 year.

CONCLUSION

The systematic review will provide up-to-date evidence to assess kinesitherapy for Bells palsy.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020215109.

Bell's Palsy in Pregnancy: A Case Series

The association between pregnancy-associated Bell's palsy (PABP) and gestational hypertension (GHT), preeclampsia (PE), and eclampsia (EC) remains inconclusive. We aimed to study the characteristics of PABP cases and the neonatal outcomes at our institution. All cases diagnosed with PABP from 2006 to 2016 were identified. Demographic and clinical characteristics including maternal age, previous medical and obstetric illnesses, gestational age at the onset of PABP, the development of PE/EC, GHT, gestational diabetes mellitus (GDM), treatment and outcomes, as well as neonatal health indices and anomalies were described. Eight patients with PABP were identified. Most of the cases were first- or second-gravidity pregnancies. PABP occurred during the third trimester except for one case in whom PABP developed 2 days postpartum. No PABP case associated with EC was found. PE was found in only one case in whom GHT occurred in a previous pregnancy. Moreover, GHT combined with GDM was found in a case with previous GHT. The recovery of PABP was satisfactory. Previous obstetric complications are associated with the current PE, GHT and GDM. Facial weakness recovers favorably regardless of treatment and the neonatal outcomes are overall satisfactory.

Neuropathy and pregnancy: An overview

Peripheral nerve injuries are rare in pregnant women. Nevertheless, physiological changes linked to pregnancy may induce nerve lesion. In this review we propose to focus on peripheral nerve disorders the most frequently encountered in pregnant patients. Focal neuropathy or polyneuropathy may appear during pregnancy or at delivery. In other cases, pre-existing neuropathies may deteriorate during pregnancy. In addition to clinical description, we summarised management proposed in the literature.

Bell's Palsy in Pregnancy

Importance

The incidence and severity of Bell's palsy are increased in pregnancy, with most cases arising in the third trimester or postpartum period. It has been indicated that pregnancy-related Bell's palsy has worse long-term outcomes, such as complete facial paralysis, compared with nonpregnant women and males.

Objective

This article outlines the existing literature diagnosis, treatment, and prognosis of Bell's palsy, specifically looking at the implications during pregnancy. The aim is to provide a reference for physicians treating Bell's palsy in pregnant patients.

Evidence Acquisition

Existing literature on neuropathies during pregnancy, clinical presentation, and treatment of Bell's palsy was reviewed through a MEDLINE and PubMed search. Referenced articles were reviewed and used as primary source materials as appropriate.

Results

Multiple clinical tests of motor function are used to establish the diagnosis of Bell's palsy including Wartenberg's lid vibration test, an abnormal eyelash occlusion test, and asymmetry with voluntary and spontaneous smiling. Optimal treatment for Bell's palsy remains controversial. While early treatment with corticosteroids for 10 days is highly recommended, the simultaneous use of antiviral therapy is frequently performed but has less supporting evidence. Pregnancy itself and delay in treatment initiation are associated with persistent nerve palsy, whereas treatment started within 3 days of symptom onset is usually associated with full recovery. Recurrence of Bell's palsy in pregnancy is rare.

Conclusions and Relevance

To date, there is limited literature in the diagnosis and treatment of Bell's palsy during pregnancy. The prognosis of Bell's palsy in pregnancy is worse than in nonpregnant individuals. Early treatment with steroids is recommended, but not without risk.

Epidemiology of neurologic disease in pregnancy

Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.

[Blocked Nose, Nosebleeds, Ringing in the Ear: ENT Diseases During Pregnancy]

Blocked Nose, Nosebleeds, Ringing in the Ear: ENT Diseases During Pregnancy Abstract. In this overview the clinical pictures of ear, nose and throat diseases and their symptoms, which occur frequently but also particularly during pregnancy, are presented. In addition, the respective therapy options in this partially vulnerable phase of mother and child are discussed. The primary principle is 'as much as necessary, but as little as possible'. Even if the complaints often disappear with the birth of the child, there may be considerable suffering of the pregnant woman and therapy may be necessary. Moreover, an adequate therapy should be applied with all ENT diseases, even for those not specifically associated with pregnancy.

Bell's Palsy

PURPOSE OF REVIEW

Bell's palsy is a common outpatient problem, and while the diagnosis is usually straightforward, a number of diagnostic pitfalls can occur, and a lengthy differential diagnosis exists. Recognition and management of Bell's palsy relies on knowledge of the anatomy and function of the various motor and nonmotor components of the facial nerve. Avoiding diagnostic pitfalls relies on recognizing red flags or features atypical for Bell's palsy, suggesting an alternative cause of peripheral facial palsy.

RECENT FINDINGS

The first American Academy of Neurology (AAN) evidence-based review on the treatment of Bell's palsy in 2001 concluded that corticosteroids were probably effective and that the antiviral acyclovir was possibly effective in increasing the likelihood of a complete recovery from Bell's palsy. Subsequent studies led to a revision of these recommendations in the 2012 evidence-based review, concluding that corticosteroids, when used shortly after the onset of Bell's palsy, were "highly likely" to increase the probability of recovery of facial weakness and should be offered; the addition of an antiviral to steroids may increase the likelihood of recovery but, if so, only by a very modest effect.

SUMMARY

Bell's palsy is characterized by the spontaneous acute onset of unilateral peripheral facial paresis or palsy in isolation, meaning that no features from the history, neurologic examination, or head and neck examination suggest a specific or alternative cause. In this setting, no further testing is necessary. Even without treatment, the outcome of Bell's palsy is favorable, but treatment with corticosteroids significantly increases the likelihood of improvement.

Bell's facial nerve palsy in pregnancy: a clinical review

Bell's facial nerve palsy (FNP) during pregnancy and the puerperium can present significant challenges for the patient and clinician. Presentation and prognosis can be worse in this group of patients. This article reviews the background, manifestation and management options of FNP. In particular, it focuses on the controversies that exist regarding corticosteroid use during pregnancy and outlines approaches to diagnosis and treatment. Based on this review, we recommend an early evidence-based approach using guidelines derived from non-pregnant populations. This includes assessment for atypical causes, a multidisciplinary input and early introduction of corticosteroids to limit progression and improve prognosis.

Bilateral Bell palsy as a presenting sign of preeclampsia

BACKGROUND

Bell palsy is a facial nerve neuropathy that is a rare disorder but occurs at higher frequency in pregnancy. Almost 30% of cases are associated with preeclampsia or gestational hypertension. Bilateral Bell palsy occurs in only 0.3%-2.0% of cases of facial paralysis, has a poorer prognosis for recovery, and may be associated with a systemic disorder.

CASE

We describe a case of a 24-year-old primigravid woman with a twin gestation at 35 weeks diagnosed initially with bilateral facial palsy and subsequently with preeclampsia. She then developed partial hemolysis, elevated liver enzymes, and low platelet count syndrome, prompting the diagnosis of severe preeclampsia, and was delivered.

CONCLUSION

Bilateral facial palsy is a rare entity in pregnancy that may be the first sign of preeclampsia and suggests increased severity of disease, warranting close monitoring.

Clinical practice guideline: Bell's Palsy executive summary

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Bell's Palsy. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations developed encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

Clinical practice guideline: Bell's palsy

OBJECTIVE

Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

PURPOSE

The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

Bell's palsy in pregnancy: underlying HELLP syndrome or pre-eclampsia?

Bell's palsy is not uncommon during pregnancy. An association with pre-eclampsia (PE) has been reported previously. Furthermore, it has even been suggested that Bell's palsy could be a predictor of PE. We report three cases illustrating various possible aspects of this association, one of them including the features of HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome.