Medical Management of Idiopathic (Bell’s) Palsy

Early deterioration in Bell's palsy: prognosis and effect of prednisolone

OBJECTIVE

To assess if early deterioration is a negative prognostic factor in Bell's palsy and if prednisolone treatment reduces early progression and enhances recovery.

STUDY DESIGN

Data extracted from the randomized, double-blind, placebo-controlled multicenter, Scandinavian Bell's palsy study.

SETTING

Sixteen tertiary referral centers in Sweden and one in Finland.

PATIENTS

A total of 829 patients aged 18 to 75 years with Bell's palsy.

INTERVENTION

The study design was factorial; 416 patients were given prednisolone, whereas 413 did not receive the drug. Data were analyzed with a modified intention-to-treat principle and the last-observation-carried-forward method.

MAIN OUTCOME MEASURES

Facial function was assessed within 72 hours before treatment start, at Days 11 to 17, and at 12 months. Sunnybrook was used as the main facial grading system with complete recovery defined as Sunnybrook 100.

RESULTS

In 236 (28%) of 829 patients, the palsy deteriorated from baseline to the first follow-up at Days 11 to 17. Complete recovery at 12 months was 45% among subjects with early deterioration compared with 73% in patients with no initial deterioration (p < 0.0001). In the early deterioration group, complete recovery at 12 months was 62% in patients treated with prednisolone and 31% in those not treated (p < 0.0001).

CONCLUSION

Early deterioration in Bell's palsy is a negative prognostic factor for complete recovery at 12 months. Prednisolone given within 72 hours may reduce early progression and improve the outcome of palsy.

Diagnostic Testing for Vocal Fold Paralysis: Survey of Practice and Evidence-Based Medicine Review

OBJECTIVES/HYPOTHESIS

Vocal fold paralysis continues to be a dominant topic in laryngology. Although the majority of cases can be attributed to a known etiology, a significant number of patients present without a clear precipitating event. Over 1,500 studies regarding vocal fold paralysis exist in the medical literature, although only a small percentage report on the use of serum or radiographic testing for the evaluation of idiopathic paralysis. Despite this, patients are routinely subjected to diagnostic evaluation to investigate the underlying cause. To characterize contemporary practice, a national survey of the American Broncho-Esophagological Association (ABEA) membership was undertaken. It is hypothesized that the current practice of diagnostic testing for idiopathic vocal fold paralysis is not well supported by an evidence-based medicine (EBM) review of the available medical literature.

STUDY DESIGN

The authors conducted a national survey, systematic EBM review of existing literature.

METHODS

Surveys were mailed to all active ABEA members; responses regarding practice specialization as well as serum/radiographic diagnostic preferences for idiopathic vocal fold paralysis were tabulated and subjected to statistical analysis. To compare contemporary practice with evidence in the available literature, an EBM review was first performed. Articles for evaluation were selected from a Medline search of English-language abstracts related to adult vocal fold paralysis. The publications were individually reviewed and an EBM level and grade were assigned and compared with the survey results.

RESULTS

Eighty-four of 249 active members responded with 76 (31%) replies submitted for analysis. Specific serum tests were advocated by 41 of 76 (54%) respondents, although the majority (52 of 65 [80%]) felt that they were only "occasionally" or "never" necessary. The most common tests were rheumatoid factor (38%), Lyme titer (36%), erythrocyte sedimentation rate (34%), and antinuclear antibody (33%). Fifty-one of 71(72%) felt that computed tomography (CT) was "always" or "often" necessary and 50 of 72 (69%) replied that chest radiography (CXR) was "always" or "often" necessary. There was no significant difference between CT and CXR ordering (P < .51). In contrast, magnetic resonance imaging (MRI) was described as "always" or "often" necessary in 28 of 71 (39%) of the surveys, significantly less than CT (P < .0001). There was no statistical impact of practice specialization on ordering of serum tests (P = .25) or imaging (P = .50 for CT; P = .46 for CXR; P = .45 for MRI). Following analysis of 1,510 vocal fold paralysis abstracts, 19 publications were found to be appropriate for an EBM review of serum testing with 15 available for review of radiographic imaging. Only one study presented level III evidence; the remainder were levels IV and V comprised of retrospective series and case reports. The evidence supporting serum or radiographic testing toward the evaluation of idiopathic vocal fold paralysis is given an overall grade of "C."

CONCLUSIONS

Serum and radiographic testing for the evaluation of vocal fold paralysis is supported by grade "C" evidence only. There are no existing prospective studies estimating the clinical impact of testing on diagnosis or patient outcome. Current practice, as estimated by a survey of the ABEA membership, is not well founded for serum testing and only by retrospective case series with regard to imaging. Further study into the nature of idiopathic vocal fold paralysis and outcomes assessment of diagnostic paradigms may improve clinical practice.

Treatment of nasal valve collapse with transcutaneous and intranasal electric stimulation

We conducted a prospective, randomized, double-blind pilot study of patients presenting with symptoms of obstructed nasal breathing to determine whether electrotherapy could provide nonsurgical symptom relief. Forty patients were divided into an electrotherapy group (n = 20) and a placebo group (n = 20). All selected patients demonstrated nasal valve stenosis with a positive Cottle maneuver and clinically evident nasal valve collapse. Treatment consisted of high-frequency transcutaneous and intranasal electric stimulation of nasal muscles for 15 minutes, 3 times a week for 10 weeks. Treated patients were followed for 10 to 12 months. Twelve patients in the electrotherapy group (60%) exhibited subjective improvement; in 8 cases (40%), the improvement was proved objectively. In the placebo group, 7 patients (35%) indicated subjective improvement; and in one case (5%), the improvement was proved objectively. Follow-up visits showed a rapid decline of positive results when treatment was discontinued. Therefore, we concluded that sure relief of nasal valve stenosis and collapse cannot be achieved with treatment by electric stimulation alone, and this method appears to have limited application. However, further studies are needed to determine whether electrotherapy used in combination with other treatments (e.g., biofeedback training or nasal springs) may provide more lasting relief for patients who want to avoid endonasal surgical intervention.

A New Classification System for Facial Paralysis in the Clinical Setting

A review of the literature on clinical manifestations of facial paralysis shows a lack of well-integrated, cohesive methods of classification. The aim of the classification system presented here is to provide a clinically relevant, generalized scheme for categorization, focusing on clinical presentation and general etiology. This article will also describe some of the more common conditions that have shaped the organization of the classification charts.

Bell's Palsy and Herpes Zoster Oticus

Normal facial movement is required for chewing, swallowing, speaking, and protecting the eye. Bell's palsy causes most cases of acute, unilateral facial palsy; infection with herpes simplex virus (HSV) type 1 may be its major cause. Varicella zoster virus (VZV) reactivation (Ramsay Hunt syndrome) is less common, but may appear without skin lesions in a form indistinguishable from Bell's palsy. Symptoms improve in nearly all patients with Bell's palsy, and most patients with Ramsay Hunt syndrome, but many are left with functional and cosmetic deficits. Steroids are frequently used to optimize outcomes in Bell's palsy, but proof of their effectiveness is marginal. Oral prednisone has been studied extensively, although some reports have suggested a higher recovery rate with intravenous steroids. Given the existing data, we support the use of oral prednisone in those patients with complete facial palsy, and no contraindications to their use (Fig. 1). In this author's opinion, the greatly increased cost and inconvenience of intravenous steroids cannot be justified by the data available. Antiviral agents may also be effective in treatment of Bell's palsy; HSV is susceptible to acyclovir and related agents. There have been few investigations of acyclovir treatment in Bell's palsy, but one controlled study showed added benefit when the drug was used with prednisone. The risk and cost of acyclovir is low enough that we support its use, with oral steroids, in those patients with complete facial paralysis. Several small studies have implied that oral acyclovir improves the outcome of facial palsy for patients with Ramsay Hunt syndrome. Although these studies do not prove efficacy, evidence for the benefits of antiviral agents in other forms of zoster is strong enough to recommend their use when the facial nerve is involved. VZV is less sensitive to acyclovir than HSV, so higher doses are recommended to treat Ramsay Hunt syndrome. Because some Ramsay Hunt syndrome patients with partial facial palsy do not fully recover, we recommend oral antiviral agents in all patients suspected of having zoster. There is weak evidence to suggest additional benefit of oral steroids in facial zoster, and their use can be supported in immunocompetent individuals. Facial nerve decompression surgery for Bell's palsy and herpes zoster oticus has experienced varying levels of enthusiasm over the years. Recent work implies that early, extensive decompression of the nerve through a middle fossa craniotomy may benefit patients at high risk for persistent deficits. However, until this procedure is subjected to a rigorous, controlled trial comparing it with maximal medical therapy, it is difficult to justify the very high costs and risk.

The facial nerve. Current trends in diagnosis, treatment, and rehabilitation

Facial paralysis is a potentially devastating disorder with numerous implications. Multiple entities must be considered in its etiology, and recent advances in microbiology, radiographic imaging, electrodiagnostic testing, and microsurgery have provided great insight into the pathophysiology, diagnosis, treatment, and rehabilitation of the facial nerve. Recent DNA PCR testing has shed new insight into the potential cause for Bell's palsy. This article focuses on the evaluation, differential diagnosis, medical treatment, and rehabilitation of facial nerve pathology with primary emphasis on facial paralysis. Surgical management is also discussed, including reanimation of the paralyzed face.

Otolaryngologic manifestations of human immunodeficiency virus infection

Patients infected with HIV have become a steadily increasing part of most medical practices. Because most patients with HIV-related problems have manifestations in the head and neck, it is important that these be understood and recognized. This article briefly reviews the various otolaryngologic manifestations of HIV infection, including otologic, nasal, and paranasal sinus; oral cavity, pharynx, and larynx; and the neck.

Infections of the nervous system

Epidemiologic trends causing infections of the nervous system remain a significant source of morbidity and mortality one half-century after the introduction of penicillin. This article outlines common causes of bacterial meningitis, aseptic meningitis syndrome, encephalitis, abscess, spinal cord syndromes, and cranial and peripheral nerve problems. Recommendations for diagnostic evaluation and both empiric and definitive antimicrobial therapy are offered; controversial management issues are also discussed. The protean manifestations of varicella-zoster virus and Lyme diseases are outlined. In addition, special considerations in the immunocompromised host, including organ transplant recipients, cancer patients, and HIV-positive persons are explained, and antimicrobial therapy is discussed.

Neurophysiological evaluation of acute facial paralysis in children

Objective evaluation of facial nerve paralysis represents a unique challenge to the clinician. Electroneurography (ENoG) and the acoustic reflex (AR) have been widely used as neurophysiological tests in an assessment of facial nerve function. However, ENoG or AR alone does not suffice diagnostic and prognostic purposes of facial function evaluation in children. To further investigate the diagnostic aspects of facial nerve paralysis, the prognostic value of AR and ENoG, and the time course of the disease in pediatric population, a series of 30 children with acute facial paralysis were investigated by correlation of findings from video-taped House-Brackmann facial grading system. AR and ENoG. The results showed that AR was absent or abnormal for thresholds in 68.2% of patients with Bell's palsy and normal middle ear function. Shorter duration and higher percentage of recovery were found in the children with a normal AR than those with an abnormal AR. Three children showed an abnormal tympanogram and hearing loss associated with acute facial paralysis. These findings should alert the clinician to the presence of a specific, treatable disease in the evaluation of Bell's palsy. The percentage of electroneurographic response varied with different days after onset. ENoG showed minimal responses at weeks 1 3 after onset of Bell's palsy in most patients. The study of the time-course in the children with Bell's palsy demonstrated a functional gap in the early (< 1 week) and late clinical stage (after 6 weeks) of the disease, suggesting that ENoG predicted well only during weeks 1-4 after onset. In general, ENoG showed a good recovery in children, however, recurrent Bell's palsy becomes a concern. The need for neurophysiological follow-up for possible incomplete recovery of the facial nerve is emphasized. It is recommended that AR and ENoG should be included in the diagnostic workup when evaluating pediatric facial function.

MRI of the facial nerve in idiopathic facial palsy

The purpose of this prospective study was to define the enhancement pattern of the facial nerve in idiopathic facial paralysis (Bell's palsy) on magnetic resonance (MR) imaging with routine doses of gadolinium-DTPA (0.1 mmol/kg). Using 0.5T imager, 24 patients were examined with a mean interval time of 13.7 days between the onset of symptoms and the MR examination. Contralateral asymptomatic facial nerves constituted the control group and five of the normal facial nerves (20.8%) showed enhancement confined to the geniculate ganglion. Hence, contrast enhancement limited to the geniculate ganglion in the abnormal facial nerve (3 of 24) was referred to as equivocal. Not encountered in any of the normal facial nerves, enhancement of other segments alone or associated with geniculate ganglion enhancement was considered to be abnormal and noted in 70.8% of the symptomatic facial nerves. The most frequently enhancing segments were the geniculate ganglion and the distal intracanalicular segment.

Salivary flow rate and acute-phase proteins in Bell's palsy

The flow rate of extra-parotid and parotid saliva was compared in patients with Bell's palsy and in healthy volunteers. Samples were analysed for the concentration of total protein and seven acute-phase proteins. There was no difference between younger and older patients with regard to oral status, salivary flow rate, total protein or acute-phase proteins, in either extra-parotid or parotid saliva. No significant difference in flow rate for both extra-parotid and parotid saliva was found in the Bell's palsy patients in comparison with the controls. In the patients the salivary flow rate from the parotid gland on the paralysed side was slightly lower than on the healthy side, but not to a significant extent. The quantity of total protein was lower in the extra-parotid saliva in the patient group; there were no differences between the two groups with regard to parotid saliva. We were able to demonstrate small amounts of various acute-phase proteins in the control group. In the patients we found higher quantities per minute of acute-phase proteins in both extra-parotid saliva and parotid saliva than in the controls. In extra-parotid saliva there were significant differences in haptoglobulin, alpha 2-macroglobulin, C3-complement factor and ceruloplasmin; in parotid saliva the differences in haptoglobulin and ceruloplasmin were significant. However, there was a large inter individual variation in both groups studied. In the patient group no significant difference in the secretion of acute-phase proteins from the parotid gland could be demonstrated between the paralysed side and the healthy side.(ABSTRACT TRUNCATED AT 250 WORDS)