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Zeng Z, Bai Y, Hao W, Zhang T, Yang J, Wu F, Li X. Elevated TRPV2 expression in the facial nerve of rats by cold stimulation: Implications for Bell's palsy. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024:101895. [PMID: 38685355 DOI: 10.1016/j.jormas.2024.101895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/27/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Bell's palsy, also referred to as clinical manifestations of unilateral facial nerve palsy, encompasses downward angling of the corners of the mouth, the absence of forehead creases, and unilateral incomplete eyelid closure. The incidence of Bell's palsy has increased progressively in recent years, but the underlying mechanism of its occurrence remains unknown; therefore, it is essential to investigate both the cause and treatment of Bell's palsy. Member 2 of the Subfamily V Transient Receptor Potential Cation Channel is a mechanically and thermally sensitive ion channel that plays a crucial role in neural growth and development. Using a novel modeling technique, we endeavored to develop an animal model of Bell's palsy and determine whether TRPV2 expression is altered throughout the course of a facial nerve injury. MATERIALS AND METHODS The rats were categorized into 3 groups, and their facial nerve function was assessed using RT-qPCR, WB, and pathologic testing, respectively, after undergoing unilateral cold air stimulation for 1, 3, and 7 days. TRPV2 expression was identified using these techniques. RESULTS In response to cold stimulation, rats exhibited facial nerve paralysis symptoms, demyelinating lesions in the facial nerve, and increased TRPV2 expression. CONCLUSIONS Extended cold stimulation of the facial nerve in rats may lead to an imbalance in facial nerve homeostasis and increased TRPV2 expression. These findings will contribute to the understanding of the potential mechanism by which cold stimulation affects the facial nerve. Moreover, this finding implies that TRPV2 could possibly function as an additional diagnostic marker or therapeutic target in the context of Bell's palsy.
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Affiliation(s)
- Ziqi Zeng
- Shanxi Medical University School and Hospital of Stomatology, Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, Shanxi, 030001, PR China
| | - Yulan Bai
- Shanxi Medical University School and Hospital of Stomatology, Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, Shanxi, 030001, PR China
| | - Weijiang Hao
- Huanzhong Dental Clinic, Taiyuan, Shanxi, 030001, PR China
| | - Tiefeng Zhang
- Chengxi Branch of Hangzhou Stomatology Hospital, Hangzhou, 310000, PR China
| | - Jing Yang
- Institute for Oral Science, Matsumoto Dental University, Shiojiri 399-0781, Japan
| | - Feng Wu
- Shanxi Medical University School and Hospital of Stomatology, Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, Shanxi, 030001, PR China.
| | - Xianqi Li
- Shanxi Medical University School and Hospital of Stomatology, Shanxi Province Key Laboratory of Oral Diseases Prevention and New Materials, Taiyuan, Shanxi, 030001, PR China; Institute for Oral Science, Matsumoto Dental University, Shiojiri 399-0781, Japan; Department of Oral and Maxillofacial Surgery, School of Dentistry, Matsumoto Dental University, Shiojiri 399-0781, Japan.
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Jeong J, Chung JH, Ryu S, Lee JD, Kim J, Lee HY, Song CI, Cho YS, Lee SA, Jun B. Monthly Variation in Bell's Palsy Based on Population Data of Korea. Audiol Neurootol 2024:1-7. [PMID: 38402865 DOI: 10.1159/000536365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/09/2024] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION Several studies have reported that the number of patients with Bell's palsy varied significantly by month and season. However, few studies have reported the monthly variation in Bell's palsy based on the whole population. We investigated the monthly variation in Bell's palsy in Korea during a long-term period based on whole population data. METHODS This retrospective study used the data of the National Health Insurance Service of Korea, which included the entire Korean population from 2008 to 2020. The monthly incidence of Bell's palsy per 100,000 was evaluated in total and according to sex, age, and residence. RESULTS The total average monthly incidence differed significantly by month, with the highest observed in January (9.1 per 100,000) and the lowest in June (7.7 per 100,000) (p < 0.001). The average monthly incidence according to sex, age, and residence also varied significantly by month, with most of the highest values noted in January and the lowest in June. CONCLUSION There was significant monthly variation in the incidence of Bell's palsy, with the highest in January during the winter and the lowest in June during the summer, based on whole population data over a long-term period in Korea.
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Affiliation(s)
- Junhui Jeong
- Department of Otorhinolaryngology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Jae Ho Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Soorack Ryu
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Republic of Korea
| | - Jong Dae Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Jin Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Ho Yun Lee
- Department of Otolaryngology-Head and Neck Surgery, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Chan Il Song
- Department of Otorhinolaryngology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sang Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se A Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Beomcho Jun
- Department of Otorhinolaryngology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
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Choi Y, Lee S, Yang C, Ahn E. The Impact of Early Acupuncture on Bell's Palsy Recurrence: Real-World Evidence from Korea. Healthcare (Basel) 2023; 11:3143. [PMID: 38132033 PMCID: PMC10743002 DOI: 10.3390/healthcare11243143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
Evidence-based treatment for Bell's palsy includes the administration of steroids within 3 days of symptom onset. Additionally, a few studies have suggested the importance of combining early acupuncture treatment in the acute phase of Bell's palsy with steroids. This study aimed to observe the impact of early acupuncture for Bell's palsy using real-world health insurance data in Korea. This retrospective study extracted data from 45,986 adult patients with Bell's palsy who received steroids between 2015 and 2017 with a follow-up period of at least 3 years until 2020 from the Korea National Health Insurance database. They were divided into the early acupuncture group (n = 28,267) and the comparison group (n = 17,719) based on the presence of an acupuncture treatment code within 7 days of diagnosis. The impact of early acupuncture on the likelihood of Bell's palsy recurrence was evaluated using multivariate logistic regression. The patients in the early acupuncture group had a lower likelihood of recurrence (odds ratio: 0.81, 95% confidence interval: 0.69-0.95). This study observed a beneficial impact of early acupuncture on Bell's palsy using real-world health insurance data in Korea. Further research is required to confirm these findings.
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Affiliation(s)
- Yujin Choi
- KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon 34054, Republic of Korea; (Y.C.); (C.Y.)
| | - Suji Lee
- Department of Acupuncture and Moxibustion, Kyung Hee University Medical Center, Seoul 02447, Republic of Korea;
| | - Changsop Yang
- KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon 34054, Republic of Korea; (Y.C.); (C.Y.)
| | - Eunkyoung Ahn
- KM Data Division, Korea Institute of Oriental Medicine, Daejeon 34054, Republic of Korea
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Woo M, Yuk D, Choi SW, Lee J, Lee HH. Prognostic Value of Electroneuronography in Severe Cases of Facial Palsy. Ann Rehabil Med 2023; 47:511-518. [PMID: 37990500 PMCID: PMC10767212 DOI: 10.5535/arm.23082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/05/2023] [Accepted: 09/20/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVE To examine the prognostic value of electroneuronography (ENoG) in predicting functional recovery in severe cases of acute facial palsy. METHODS Patients with severe degrees of facial palsy (initial House-Brackmann [HB] grades IV to VI) with available electrodiagnostic studies conducted 2-4 weeks after symptom onset were reviewed retrospectively. The patients were categorized into "good recovery" and "poor recovery" groups, with the former showing mild to no dysfunction (HB I to III) and the latter exhibiting moderate to severe dysfunction (HB IV to VI) on follow-up evaluation, 2 months after onset. ENoG amplitudes in four facial muscles (frontalis, nasalis, orbicularis oculi, and orbicularis oris), as well as age, sex, affected side, disease etiology, comorbidities, and laboratory findings, were compared between the two groups. RESULTS Thirty-seven patients were included. Twenty-nine of the patients showed "good recovery," and eight showed "poor recovery" at 2 months after symptom onset. Univariate analysis yielded no significant difference in age, sex, affected side, disease etiology, comorbidities, and laboratory findings between the two groups. Preserved ENoG amplitudes (individual, average, and trimmed means) were significantly higher in the good recovery group than in the poor recovery group (p<0.005). Sex (p=0.038) and the ENoG of the nasalis muscle, acquired 2-4 weeks from symptom onset (p=0.004), showed significant differences in multivariate regression analysis. CONCLUSION This study suggests that the female sex and lower ENoG of the nasalis muscle, acquired 2-4 weeks from symptom onset, have negative prognostic value for the 2-month functional outcome of severe facial palsy cases.
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Affiliation(s)
- Minwoo Woo
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Konkuk University, Seoul, Korea
| | - Doyoung Yuk
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Konkuk University, Seoul, Korea
| | - Seo Won Choi
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Konkuk University, Seoul, Korea
| | - Jongmin Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Konkuk University, Seoul, Korea
| | - Hyun Haeng Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University School of Medicine, Konkuk University, Seoul, Korea
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Varga E, Battamir U, Szegedi I, Hudák L, Kovács N, Nagy AC. Seasonal patterns in the epidemiology of Bell's palsy in Hungary. Front Neurol 2023; 14:1188137. [PMID: 37409014 PMCID: PMC10318583 DOI: 10.3389/fneur.2023.1188137] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023] Open
Abstract
Introduction Epidemiological data on Bell's palsy are vital for elucidating disease prevalence and enhancing therapeutic options. Our objective was to explore the prevalence and possible risk factors associated with Bell's palsy recurrence in the Clinical Center of the University of Debrecen service area. Secondary data analysis was performed using hospital discharge data, including patient information and comorbidities. Methods Data was obtained from the Clinical Center of the University of Debrecen, on Bell's palsy patients who were treated at the hospital between January 1, 2015 and December 31, 2021. Multiple logistic regression analysis was used to examine the factors associated with Bell's palsy recurrence. Results Of the 613 patients analyzed, 5.87% had recurrent paralysis, and the median time interval between episodes was 315 days. Hypertension was significantly associated with Bell's palsy recurrence. Moreover, seasonal distribution analysis revealed that the number of Bell's palsy episodes was higher in colder seasons, with spring and winter having a significantly higher number of episodes than summer and autumn. Discussion This study provides insights into the prevalence and associated risk factors of Bell's palsy recurrence, which could aid in its management and help reduce the long-term consequences of the disease. Further research is necessary to determine the precise mechanisms underlying these findings.
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Affiliation(s)
- Eszter Varga
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ulambayar Battamir
- Department of Health Informatics, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - István Szegedi
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Lilla Hudák
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nóra Kovács
- Department of Public Health and Epidemiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Attila Csaba Nagy
- Department of Health Informatics, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
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Nurminen P, Marjamaa J, Niemelä M, Sairanen T. Incidence and prevalence of Hemifacial Spasm in Finland's largest hospital district. J Neurol Sci 2023; 446:120587. [PMID: 36804510 DOI: 10.1016/j.jns.2023.120587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/04/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Hemifacial spasm (HFS) is a movement disorder of facial muscles innervated by the facial nerve. This condition often demands regular utilization of healthcare resources. However, knowledge of the incidence and prevalence of this condition is based on scarce studies. This research aimed to identify the incidence and prevalence of HFS in Finland's largest hospital district. METHODS This retrospective study was conducted in the largest hospital district in Finland (Helsinki and Uusimaa). The study included consecutive HFS patients who visited the departments of Neurology and Neurosurgery in the Hospital District of Helsinki and Uusimaa between 2014 and 2019. The demographics included sex, side of the spasm, treatment allocations, duration of symptoms before diagnosis, and age at the time of diagnosis. RESULTS 279 patients were identified from the medical records. 62% of patients were women and had left-sided spasms. The crude mean incidence among women was almost double that of men (1.86 vs. 0.94). The highest crude mean annual incidence among men was in the age group 60-79 years, while among women, it peaked in the age group 80 years and over. The mean annual age-standardized incidence of HFS was 1.53, 1.94 in women, and 1.05 in men. The mean age-standardized yearly prevalence was 10.62, 11.62 among women, and 9.31 among men. The annual age-standardized prevalence of HFS increased steadily from 2014 to 2019. CONCLUSIONS The incidence and prevalence of women outnumbered men. HFS is typically left-sided. The HFS incidence peaked after 80 years in women and men aged 60-79 years.
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Affiliation(s)
- Paula Nurminen
- Hemifacial Spasm Research Group, Meilahti Hospital, HUS Neurocenter Haartmaninkatu 4, 00029 Helsinki, Finland.
| | - Johan Marjamaa
- Hemifacial Spasm Research Group, Meilahti Hospital, HUS Neurocenter Haartmaninkatu 4, 00029 Helsinki, Finland; Department of Neurosurgery, Töölö Hospital, HUS Neurocenter, Topeliuksenkatu 5, 00260 Helsinki, Finland.
| | - Mika Niemelä
- Hemifacial Spasm Research Group, Meilahti Hospital, HUS Neurocenter Haartmaninkatu 4, 00029 Helsinki, Finland; Department of Neurosurgery, Töölö Hospital, HUS Neurocenter, Topeliuksenkatu 5, 00260 Helsinki, Finland.
| | - Tiina Sairanen
- Hemifacial Spasm Research Group, Meilahti Hospital, HUS Neurocenter Haartmaninkatu 4, 00029 Helsinki, Finland; Department of Neurology, Meilahti Hospital, HUS Neurocenter Haartmaninkatu 4, 00029 Helsinki, Finland.
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Retrospective study of peripheral facial paralysis in a tertiary hospital over 3 years. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2023; 98:132-141. [PMID: 36738919 DOI: 10.1016/j.oftale.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE To identify clinical and epidemiological characteristics of patients with peripheral facial palsy (PFP) at a tertiary care hospital. METHOD This is a retrospective observational study of patients with PFP treated at a tertiary medical center. We gathered demographic data, etiology, laterality, recurrence, recovery, clinical ophthalmology, severity according to the House-Brackmann (HB) scale, electrophysiological tests, medical services attended, medical and surgical treatment. RESULTS Two hundred and eighty-three PFP were included, 135 (48%) were men and 148 (52%) were women p = 0.47). All patients had unilateral involvement. The mean age was 54 ± 20 years. The main etiology was idiopathic in 215 (76%) patients. Median recovery time was 7 weeks. Recovery was complete in 190 (67%) patients. One hundred and seventy (84%) patients with idiopathic PFP had complete recovery, versus 30 (16%) patients with non-idiopathic PFP (p < 0.01). The 84% of patients with HB grade II, recovered completely, while with HB grade VI only 17% recovered (p = 0.003). Two hundred and twenty-nine patients (81%) had lagophthalmos. The majority received ocular surface care treatment in 271 (96%) patients and of these 249 (88%) patients received oral corticosteroid therapy. Thirteen patients (5%) required ophthalmologic surgery. CONCLUSIONS PFP affects all age ranges, without predilection for sex and unilateral. Its main cause is idiopathic. Recovery is complete in most cases, being more favorable in mild and idiopathic affections. Most only require medical treatment.
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Ostropolets A, Li X, Makadia R, Rao G, Rijnbeek PR, Duarte-Salles T, Sena AG, Shaoibi A, Suchard MA, Ryan PB, Prieto-Alhambra D, Hripcsak G. Factors Influencing Background Incidence Rate Calculation: Systematic Empirical Evaluation Across an International Network of Observational Databases. Front Pharmacol 2022; 13:814198. [PMID: 35559254 PMCID: PMC9087898 DOI: 10.3389/fphar.2022.814198] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/17/2022] [Indexed: 01/01/2023] Open
Abstract
Objective: Background incidence rates are routinely used in safety studies to evaluate an association of an exposure and outcome. Systematic research on sensitivity of rates to the choice of the study parameters is lacking. Materials and Methods: We used 12 data sources to systematically examine the influence of age, race, sex, database, time-at-risk, season and year, prior observation and clean window on incidence rates using 15 adverse events of special interest for COVID-19 vaccines as an example. For binary comparisons we calculated incidence rate ratios and performed random-effect meta-analysis. Results: We observed a wide variation of background rates that goes well beyond age and database effects previously observed. While rates vary up to a factor of 1,000 across age groups, even after adjusting for age and sex, the study showed residual bias due to the other parameters. Rates were highly influenced by the choice of anchoring (e.g., health visit, vaccination, or arbitrary date) for the time-at-risk start. Anchoring on a healthcare encounter yielded higher incidence comparing to a random date, especially for short time-at-risk. Incidence rates were highly influenced by the choice of the database (varying by up to a factor of 100), clean window choice and time-at-risk duration, and less so by secular or seasonal trends. Conclusion: Comparing background to observed rates requires appropriate adjustment and careful time-at-risk start and duration choice. Results should be interpreted in the context of study parameter choices.
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Affiliation(s)
| | - Xintong Li
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, United Kingdom
| | - Rupa Makadia
- Janssen Research and Development, Titusville, NJ, United States
| | - Gowtham Rao
- Janssen Research and Development, Titusville, NJ, United States
| | - Peter R. Rijnbeek
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Talita Duarte-Salles
- Fundacio Institut Universitari per a la Recerca a L’Atencio Primaria de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Anthony G. Sena
- Janssen Research and Development, Titusville, NJ, United States
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Azza Shaoibi
- Janssen Research and Development, Titusville, NJ, United States
| | - Marc A. Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Human Genetics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA, United States
| | - Patrick B. Ryan
- Columbia University Medical Center, New York, NY, United States
- Janssen Research and Development, Titusville, NJ, United States
| | | | - George Hripcsak
- Columbia University Medical Center, New York, NY, United States
- New York-Presbyterian Hospital, New York, NY, United States
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Risk factors for Bell's palsy based on the Korean National Health Insurance Service National Sample Cohort data. Sci Rep 2021; 11:23387. [PMID: 34862431 PMCID: PMC8642421 DOI: 10.1038/s41598-021-02816-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/23/2021] [Indexed: 11/08/2022] Open
Abstract
The associations between hypertension, diabetes, and dyslipidemia with Bell's palsy have been controversial and only a few studies have assessed risk factors for Bell's palsy based on population-based data. The aim of the present study was to evaluate whether sociodemographic factors such as sex, age, residence, household income, and metabolic diseases such as hypertension, diabetes, and dyslipidemia were risk factors for Bell's palsy using the National Health Insurance Service National Sample Cohort data of Korea. Patients who visited an outpatient clinic twice or more or had one or more admission and received steroid medication under the International Classification of Diseases diagnostic codes for Bell's palsy from 2006 to 2015 were defined as patients with Bell's palsy in this study. The associations between sociodemographic factors and metabolic diseases to Bell's palsy were analyzed with univariate and multivariate Cox proportional hazard regression models. There were 2708 patients with Bell's palsy recorded from 2006 to 2015. Male sex, advanced age, residence in a location other than the capital and metropolitan cities, hypertension, and diabetes were significant risk factors for Bell's palsy. This study is significant for patients and providers because we analyzed the relationships using a population-based database over a long-term follow-up period.
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