Bell's palsy and tinnitus during pregnancy: predictors of pre-eclampsia? Three cases and a detailed review of the literature

Association between hypertensive disorders and Bell's palsy in pregnancy: protocol for a systematic review and meta-analysis

BACKGROUND

Bell's palsy is an idiopathic peripheral nerve palsy involving the facial nerve. Pregnancy, diabetes mellitus and hypertension are the risk factors for Bell's palsy. However, the association between hypertensive disorders and Bell's palsy during pregnancy or the puerperium remains unclear. This systematic review will comprehensively summarise the literature and evaluate the association between Bell's palsy and hypertensive disorders during pregnancy or the puerperium.

METHODS AND ANALYSIS

Systematic searches of PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials will be undertaken using prespecified search strategies. Observational studies (cross-sectional studies, cohort studies, case reports and series case reports) written in English that investigate the association between hypertensive disorders of late pregnancy and Bell's palsy during pregnancy or the puerperium will be included. Different authors will independently conduct the eligible study selection, perform data extraction and appraise the quality of included studies. Subgroup analysis will be carried out based on the age of pregnant women (≤35 years old, >35 years old), parity (primipara, multipara) and fetus number (singleton or multiple-gestation pregnancy).

ETHICS AND DISSEMINATION

This review will be based on published literature, and thus there is no requirement for ethics approval. The results of this study will aid in the knowledge of the relationship between Bell's palsy during pregnancy or the puerperium and hypertensive disorders of late pregnancy. The results of this systematic review will be shared through publication in a peer-reviewed journal with good visibility for the field of obstetrics and presentations at academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42023422902.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Bell's Palsy Unmasked: A Compelling Case Study of Facial Nerve Palsy During Pregnancy

Facial paralysis occurs more frequently in pregnant individuals, affecting them two to four times more often than those who are not pregnant, making it the most frequent unilateral cranial nerve pathology in pregnancy. This case report describes a 29-year-old primigravida's presentation, examination, and treatment of left-sided (unilateral) facial nerve palsy during 32 weeks of gestation. Concerns regarding possible underlying reasons were raised when the patient suddenly developed left-side facial weakness. We examined her history, clinical assessment, and diagnosis methods, which included laboratory and neuro-imaging tests. The difficulties of managing this illness during pregnancy are explored, taking into account the well-being of the developing fetus and mother. There are several causes for facial nerve palsy during pregnancy, including idiopathic causes, vascular problems, and viral infections. Here, we emphasize the value of a multidisciplinary approach comprising obstetricians, neurologists, and other medical professionals to guarantee the best possible care. The paper also underscores the necessity for prompt diagnosis and suitable interventions to reduce problems and foster a successful outcome. This case report adds to the limited literature on facial nerve palsy in pregnancy by highlighting individualized medical care and teamwork in addressing this uncommon but serious condition.

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.

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.

Otological manifestations in pregnant women - A study at a tertiary care hospital of eastern India

Background

There are several physiological changes found in pregnant women and amongst them, otological changes are quite important. The otological manifestations in pregnant women are mainly due to changes of sex hormones levels, which return to normal in the postpartum period.

Objective

To report otological manifestations among pregnant women.

Materials and methods

Eighty-four pregnant women participated in this prospective study. A questionnaire was administered in all participants for assessing otological manifestations. The pregnant women were in the age range of 22-35 years. They underwent thorough otological and obstetric examinations. Pure tone audiometry (PTA) was done for assessment of hearing loss.

Results

The mean age of the pregnant women in this study was 26.23 years. The most common otological manifestation was sensation of ear blockage. Eustachian tube dysfunction was common in the last trimester of pregnancy. Other manifestations included vertigo and tinnitus.

Conclusion

The alteration of hormonal milieu in pregnant women can lead to several otological manifestations, including eustachian tube dysfunction, hearing impairment, otitis externa, Bell's palsy, vertigo and tinnitus. Despite these otological manifestations found in pregnant women, yet they are often neglected in clinical practice.

[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 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.

Multiple concomitant cranial nerve palsies secondary to preeclampsia

A 32-year-old primigravid woman developed pre-eclampsia after delivery of twins along with left fifth, sixth, and seventh cranial neuropathies. She also had evidence of hepatic and renal involvement. Results of patient evaluation were otherwise unremarkable, and the palsies completely resolved over 3 months after treatment with valacyclovir and systemic corticosteroids.

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.

LMN Facial Palsy in Pregnancy: An Opportunity to Predict Preeclampsia-Report and Review

Facial paralysis is the most frequent unilateral cranial nerve pathology affecting pregnant population 2 to 4 times more often than the nonpregnant population. There exists an association with preeclampsia but this has largely been overlooked. Clinicians often dismiss it for idiopathic palsy as seen in the present case. A 30-year-old woman, Gravida 4, Para 3, presented at 26 weeks pregnancy with complaints of facial weakness, blurring of vision, altered taste sensation, increased noise sensitivity for 1 month, headache since 18 days, and vomiting since 2­3 days. Her pulse was 90/min, BP was 170/120, and RR was 18/min. Uterus was 18 weeks size and proteinuria++ was present. Ultrasonography revealed a 26 weeks fetus, severe bradycardia, and absent liquor. HELLP syndrome was diagnosed after investigations. Six units of fresh frozen plasma were transfused. An informed decision for termination of pregnancy was made. She delivered a 450 gram stillborn. The third stage was complicated with postpartum hemorrhage but it was managed successfully. Women with Bell's palsy during pregnancy should be evaluated critically as in some it may precede preeclampsia which has serious maternal and fetal implications. Therefore, these women should be in regular followup of the obstetrician.

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.

Headache and neurological disease in pregnancy

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetrician's attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.

[Idiopathic facial palsy during pregnancy]

BACKGROUND

Idiopathic facial (Bell's) palsy occurring during pregnancy or post partum is a rare disease. Reports regarding incidence, prognosis and associated risk factors are still inconsistent.

MATERIAL AND METHODS

We performed a retrospective analysis of patients presenting with idiopathic facial palsy who had been treated in cooperation between obstetric and otorhinolaryngological departments (tertiary referral centers). The time of onset of paralysis, grading according to House and Brackman, treatment modalities and results were analyzed for the years 1999-2010.

RESULTS

The incidence of Bell's palsy in pregnancy was 56 in 100,000 live births. Preeclampsia was reported in one case only. Therapy included prednisolone, methylprednisolone and/or pentoxifylline (up to 2005). All results were favorable (House-Brackman 1-2).

CONCLUSION

The incidence of Bell's palsy in pregnancy within our cohort is not increased with regard to the international reports. Early treatment with corticosteroids in consultation with the treating obstetrician is indicated in both pregnant and post-partum patients to achieve optimal results.

Adverse events following administration to pregnant women of influenza A (H1N1) 2009 monovalent vaccine reported to the Vaccine Adverse Event Reporting System

OBJECTIVE

The objective of the study was to evaluate and summarize reports to the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting system, in pregnant women who received influenza A (H1N1) 2009 monovalent vaccine to assess for potential vaccine safety problems.

STUDY DESIGN

We reviewed reports of adverse events (AEs) in pregnant women who received 2009-H1N1 vaccines from Oct. 1, 2009, through Feb. 28, 2010.

RESULTS

VAERS received 294 reports of AEs in pregnant women who received 2009-H1N1 vaccine: 288 after inactivated and 6 after the live attenuated vaccines. Two maternal deaths were reported. Fifty-nine women (20.1%) were hospitalized. We verified 131 pregnancy-specific outcomes: 95 spontaneous abortions (<20 weeks); 18 stillbirths (≥20 weeks); 7 preterm deliveries (<37 weeks); 3 threatened abortions; 2 preterm labor; 2 preeclampsia; and 1 each of fetal hydronephrosis, fetal tachycardia, intrauterine growth retardation, and cleft lip.

CONCLUSION

Review of reports to VAERS following H1N1 vaccination in pregnant women did not identify any concerning patterns of maternal or fetal outcomes.

Ear, Nose, and Throat Manifestations during Pregnancy

Objective. The objective of this clinical review is to highlight the otolaryngological symptoms that occur in pregnancy. Where available, the authors discuss the current evidence of the etiology and management of the various presentations. While it is appreciated that many of these complaints are transient, their impact on the maternal quality of life can be significant, and therefore, medical practitioners should be aware of what to expect in order to provide reassurance to patients and also to safely manage such symptoms.

Data Sources. MEDLINE and EMBASE databases were searched for publications related to otolaryngology and pregnancy.

Review Methods. All literature was searched for and reviewed by 2 authors independently. Search results were then cross-examined, and any differences were settled by consensus.

Results. Pregnancy leads to circulatory changes and increased susceptibility to viral reactivation, and along with the exertion of parturition, it can lead to tinnitus, facial palsies, and deafness. Rising levels of sex hormones and heightened sensitivity to allergens may influence the nasal mucosa, precipitating epistaxis and rhinitis. Increased progesterone and the increased intra-abdominal pressure of the growing fetus can lead to symptoms and sequelae of laryngopharyngeal reflux. Evidence for the treatment of pregnancy-induced symptoms is principally restricted to case reports and retrospective studies.

Conclusion. Recognition and understanding of pregnancy-related ear, nose, and throat complaints will allow otolaryngologists to reassure and manage these patients, improving their experience of the gestational period. High-quality evidence for their management is limited, with further research required.

Acute neurological issues in pregnancy and the peripartum

Acute neurological diseases requiring hospitalization are relatively rare in women of childbearing age. However, during pregnancy and the postpartum period, several diseases increase in prevalence. Some are unique to the pregnant/postpartum state including preeclampsia and delivery-associated neuropathies. Others, although indirectly related to pregnancy, such as cerebral venous thrombosis, ischemic stroke, and intracerebral hemorrhage, increase in frequency and carry considerable risk of morbidity and mortality. In addition, treatment options are often limited. This review discusses the diseases more commonly seen during pregnancy and the postpartum period, with a focus on emergent neurological diseases and their management. Interventional therapies will also be discussed.

[Pre-eclampsia and facial paralysis]

We describe here the case of a patient affected with pre-eclampsia and who had idiopathic facial palsy and HELLP syndrome during the puerperium. It developed favourably with a treatment associated with an antihypertensive medicine, corticoid therapy and ophtalmological care. There is an association between pre-eclampsia and idiopathic facial palsy during pregnancy. This can be explained by identical physiopathological mechanisms. Facial palsy generally appears in the course of the third trimester of pregnancy or during the early puerperium. The prognosis is usually good and does not seem to be influenced by pregnancy. When idiopathic facial palsy appears during pregnancy, evidence of pre-eclampsia must be looked for.

Adverse events in pregnant women following administration of trivalent inactivated influenza vaccine and live attenuated influenza vaccine in the Vaccine Adverse Event Reporting System, 1990-2009

OBJECTIVE

The objective of the study was to characterize reports to the Vaccine Adverse Event Reporting System (VAERS) in pregnant women who received seasonal influenza vaccines to assess for potential vaccine safety concerns.

STUDY DESIGN

We searched VAERS for reports of adverse events (AEs) in pregnant women who received trivalent inactivated influenza vaccine (TIV) from July 1, 1990 through June 30, 2009, or live attenuated influenza vaccine (LAIV) from July 1, 2003, through June 30, 2009.

RESULTS

A total of 148 reports after TIV and 27 reports after LAIV were identified. Twenty TIV (13.5%) and 1 LAIV (4%) reports were classified as serious. No specific AEs were reported in 30 TIV (20.3%) and 16 LAIV (59%) reports. The most common pregnancy-specific AE was spontaneous abortion: 17 after TIV (11.5%) and 3 after LAIV (11%). The reporting rate of spontaneous abortion was 1.9 per million pregnant women vaccinated.

CONCLUSION

No unusual patterns of pregnancy complications or fetal outcomes were observed in the VAERS reports of pregnant women after the administration of TIV or LAIV.

Bell's palsy: the answer to the riddle of Leonardo da Vinci's 'Mona Lisa'

The smile of the famed portrait 'The Mona Lisa' has perplexed both art historians and researchers for the past 500 years. There has been a multitude of theories expounded to explain the nature of the model's enigmatic smile. The origin of the model's wry smile can be demonstrated through a careful analysis of both documented facts concerning the portrait--some gathered only recently through the use of modern technology--and a knowledge of the clinical presentation of Bell's palsy. Bell's palsy is more prevalent in women who are either pregnant or who have recently given birth. This paper postulates that the smile of the portrait's model was due to Leonardo da Vinci's anatomically precise representation of a new mother affected by Bell's palsy subsequent to her recent pregnancy.

[Understanding refraction disorders and oculomotor problems during pregnancy]

During pregnancy, hormonal and hemodynamic modifications can generate a number of organic consequences, specifically ocular, more or less regressive in systemic disease. Refraction disorders are marked by myopization, often not very significant and always regressive within six weeks after the childbirth. Pregnancy could cause a thickening of the cornea and a modification of its curvature. Likewise, contact lens intolerance is common, secondary to the modification of lacrimal film, but does not systematically contraindicate lens wearing. Photorefractive surgeries are ill-advised during pregnancy. Hemeralopia is the most common visual complaint of the pregnant woman. Oculomotor disorders are exceptional. Convergence insufficiency or accommodation disorders are the most common anomalies described. These disorders usually regress in the postpartum period. Oculomotor palsies could be the first symptoms of pre-eclampsia or an associated intracranial pathology. They are specific palsies such as in the abducens nerve and the oculomotor nerve in very unusual cases. Nevertheless, oculomotor paralysis in the pregnant woman should motivate neuroradiological exploration. Intensive labor can be rhegmatogenous in women with severe myopia. Examination of the retinal periphery is systematic before and during pregnancy in these cases. Systematic cesarean section is not formally indicated. It is nevertheless preferable to facilitate delivery with epidural anesthesia.

Simultaneous bilateral Bell's palsy during pregnancy

Idiopathic bilateral facial paralysis, although rare, seems to be more frequent during the last trimester of pregnancy and in the early puerperium. Unlike unilateral facial paralysis where the cause is mostly idiopathic, bilateral facial palsy is less often idiopathic, and various etiologies had been suggested.We present herein, an unusual case of simultaneous idiopathic bilateral Bell's palsy during the third trimester of pregnancy.

Bell's palsy and pregnancy

OBJECTIVE

To describe the epidemiology, pathophysiology, presentation, treatment, and prognosis of Bell's palsy (BP) in pregnancy.

RESULTS

The incidence of BP in pregnant women is not significantly greater than expected compared to all women of childbearing age. There is a high incidence of cases in the third trimester and corresponding low incidence during early pregnancy.

CONCLUSION

There is no conclusive evidence that the etiology of BP in pregnancy is different than in nonpregnant patients. Altered susceptibility to herpes simplex viral reactivation during pregnancy is the most likely explanation for concentration of cases in the third trimester. Outcome may be poorer in pregnant patients, though historically, treatment is often withheld from these patients.

SIGNIFICANCE

Management of BP in pregnancy can mirror that of nonpregnant individuals with the exception of first-trimester cases.

Idiopathic facial paralysis (Bell's palsy) in the immediate puerperium in a patient with mild preeclampsia: a case report

INTRODUCTION

Idiopathic peripheral facial palsy is the most common and frequent unilateral cranial neurological disorder characterized by an isolated facial nerve paralysis.

CASE REPORT

We report a case of an idiopathic facial paralysis (Bell's palsy) in the immediate puerperium in a patient with mild preeclampsia and diagnosed fetal IUGR. Additionally, the presence of Bell's palsy in the puerperium of the mother of our patient suggests a familiar tendency.

DISCUSSION

Every gynaecologist and obstetrician should be aware of this quite uncommon complication during pregnancy and the puerperium. This case report illustrates that Bell's palsy can occur in the immediate post-partum after mild preeclamptic symptoms. For these women, a maternal surveillance can be recommended. A fast and accurate diagnosis with a subsequent immediate treatment might be very important in avoiding worsening of the symptoms and therefore improve the recovery prognosis.

Beidseitige H�rminderung in der Gravidit�t

Neurological impairment during pregnancy is also commonly found in otorhinolaryngology. Cranial nerve palsy, e.g. of the facial nerve or changes in signal processing of the hearing system, are described. Apart from changes in electrolyte balance, these neurological alterations are attributed to hormone fluctuations. The spontaneous remission of the neurological problems after delivery is frequently reported. This case report presents a 34 year pregnant patient suffering from binaural sensorineural hearing loss and tinnitus in the third trimester. Three weeks after delivery there was a spontaneous remission and a measurable improvement of the audiological findings. Although treatment with cortisone and antibiotics remained without effect, a pharmacological treatment during pregnancy has to be carefully and individually coordinated. An interdisciplinary approach in diagnostic and therapeutic measures together with gynaecologists appears obligatory.