of 50
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Bel lBel l s Palsy:s Palsy:
To Treat o r Not t o TreatTo Treat o r Not t o Treat
K. Kevin Ho, M.D.Shawn D. Newlands, M.D., Ph.D., M.B.A.University of Texas Medical Branch at GalvestonGrand Rounds Presentation February 14, 2007
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Hist or ic a l Perspec t ivesHist or ic a l Perspec t ives
Sir Charles Bell (1774-1842)
Studied facial anatomy
extensively during Battle ofWaterloo
Concluded that facial nerve
controlled facial expression
Respiratory nerve of the Face
Sir Charles Bell (1774-1842)
Studied facial anatomy
extensively during Battle ofWaterloo
Concluded that facial nerve
controlled facial expression
Respiratory nerve of the Face
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AnatomyAna tomy
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Bel l s PalsyBe l l s Palsy
Idiopathic facial paralysis Diagnosis of Exclusion
Most common diagnosis(> 60%) for acute facial palsy
30 per 100,000 Peripheral neuropathy
Generally unilateral
Rapid onset < 48 hours
Idiopathic facial paralysis Diagnosis of Exclusion
Most common diagnosis(> 60%) for acute facial palsy
30 per 100,000 Peripheral neuropathy
Generally unilateral
Rapid onset < 48 hours
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Age Dis t r ibut ionAge Dis t r ibu t ion
Peitersen E. Am. J. Otology. 1982
2002
Peitersen E. Acta Otolaryngol 2002;549:430.
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Com plet e Rem ission & AgeCom ple t e Rem ission & Age
Peitersen E. Acta Otolaryngol 2002;549:430.
9084
75
64
36
0-14 15-29 30-44 45-59 > 60Age
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Ret urn of Musc u lar func t ionRet urn of Musc u lar func t ion
Peitersen E. Acta Otolaryngol 2002;549:430.
85 %
Months
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Tim e of beg inn ing rem iss ion &Sequelae
Tim e of beginn ing rem iss ion &Sequelae
Peitersen E. Am. J. Otology. 1982
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Com plet e Rec overyCom plet e Rec overy
Peitersen E. Acta Otolaryngol 2002;549:430.
71
6
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Inc om plet e vs. Com plet eInc om plet e vs . Com ple t e
Peitersen E. Acta Otolaryngol 2002;549:430.
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Symptomato logySymptomato logy
Reduced Stapedial reflex 71%
Complete palsy @ presentation 69%
Tear flow 67%
Post-auricular pain 52%
Dysgeusia 34%
Hyperacusis 14%
Reduced Stapedial reflex 71%
Complete palsy @ presentation 69%
Tear flow 67%
Post-auricular pain 52%
Dysgeusia 34%
Hyperacusis 14%
Peitersen E. Acta Otolaryngol 2002;549:430.
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Predic t ing Musc ular SequelaePredic t ing Musc ular Sequelae
Peitersen E. Acta Otolaryngol 2002;549:430.
91
83
91
63
27
5
Taste Stapedial Lacrimation
Normal
Abnormal
% Muscular
Sequelae
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Favorable prognosis for
fu l l rec overy
Favorab le prognosis for
fu l l rec overy
Incomplete palsy
Early recovery
Young patients
Normal taste, stapedial reflex, lacrimation
Lack of post-auricular pain
Incomplete palsy
Early recovery
Young patients
Normal taste, stapedial reflex, lacrimation
Lack of post-auricular pain
Peitersen E. Acta Otolaryngol 2002;549:430.
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Pathophysio logyPathophysio logy
Exact etiology unknown
Viral infection Herpes Simplex
Vascular ischemia
Autoimmune disorder
Hereditary
Exact etiology unknown
Viral infection
Herpes Simplex
Vascular ischemia
Autoimmune disorder
Hereditary
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Role of HSV-1Role o f HSV-1
Murakami: Ann Intern Med, Volume 124(1).January 1, 1996.27-30
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Diabet es Mel l i t usDiabet es Mel l i t us
Bells patients with DM
14 % (Korczyn AD 71)
21 % (Alford BR 71)
38 % (Yasuda K 75) 66% demonstrate glucose intolerance
Functional recovery poorer in diabetics
Bells patients with DM
14 % (Korczyn AD 71)
21 % (Alford BR 71)
38 % (Yasuda K 75) 66% demonstrate glucose intolerance
Functional recovery poorer in diabetics
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PregnancyPregnancy
Incidence of Bells palsy 3-4 x higher
(Hilsinger, Cohen et al.)
Third trimester with highest risk
Higher risk of complete palsy
Lower chance of complete recovery(Gillman et al.)
Preeclampsia 6 x prevalence in pregnantwomen with facial palsy
Incidence of Bells palsy 3-4 x higher
(Hilsinger, Cohen et al.)
Third trimester with highest risk
Higher risk of complete palsy
Lower chance of complete recovery(Gillman et al.)
Preeclampsia 6 x prevalence in pregnantwomen with facial palsy
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Dif ferent ia l DiagnosisAc ut e fac ial pa lsy
Di f ferent ia l Diagnosi sAc ut e fac ial palsy
Infection Herpes Zoster Oticus(Ramsey Hunt Syndrome)
Lyme disease Acute Otitis media +/- mastoiditis
Congenital Treacher Collins syndrome
Mobius syndrome Trauma
Temporal Bone fracture Barotrauma
Metabolic- Diabetes- Hypothyroidism
Vascular Benign intracranial hypertension
Neoplasm Facial neuroma Acoustic neuroma
Toxic
Thalidoide Iatrogenic
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Earl y Grad ing Syst emEar ly Grading Syst em
Peitersen E. Am. J. Otology. 1982
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House-Brac k m an Grad ing Syst emHouse-Brac k m an Grad ing Syst em
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MRIMRI
Pre-GADPost-GAD
Kinoshita T et al. Clin. Radiology 2001; 56: 926-32
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Cont rast Enhanc em ent :Bel l s Palsy vs . Cont ro lCont ras t Enhanc em ent :Bel l s Palsy vs. Cont ro l
Kinoshita T et al. Clin. Radiology 2001; 56: 926-32
Bells Palsy
Control
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Topognost ic TestTopognost ic Test
Lacrimal
Schirmers Test
Stapedial reflex
Taste
Salivary flow
Lacrimal
Schirmers Test
Stapedial reflex
Taste
Salivary flow
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Elec t r i c a l Test
Nerve Excitation test (NET)
Maximal Stimulation test (MST)
Electroneurography (ENoG)
Electromyography (EMG)
Nerve Excitation test (NET)
Maximal Stimulation test (MST)
Electroneurography (ENoG)
Electromyography (EMG)
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Sunder land c lass i f i c a t ion o f per iphera l nerve in jurySunder land c lass i f i c a t ion o f per iphera l nerve in jury
Neurapraxia
Axonotmesis
Neurotmesis
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Elec t roneurography (ENoG)Elec t roneurography (ENoG)
Transcutaneous stimulation (Evoked EMG)
Compound muscle action potential (CMAP)
Most useful in acute phase within
3 days 3 weeks of palsy
But no info on class of injury
(axonotmesis vs. neurotmesis)
Transcutaneous stimulation (Evoked EMG)
Compound muscle action potential (CMAP)
Most useful in acute phase within
3 days 3 weeks of palsy
But no info on class of injury
(axonotmesis vs. neurotmesis)
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Tim e c ourse o f Degenerat ionT im e c ourse o f Degenerat ion
Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188Fisch U. Am J. Otology. 1984
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Fisch U. Am J. Otology. 1984
Fisc h 1984Fisc h 1984
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Elec t rom yography (EMG)Elec t rom yography (EMG)
Recording of voluntary muscleaction potentials by needleselectrodes
Does not differentiateaxonotmesis & neurotmesis
More useful 2-3 weeks afteronset of complete paralysis
Perform EMG if ENoG > 95%
degeneration
Recording of voluntary muscleaction potentials by needleselectrodes
Does not differentiateaxonotmesis & neurotmesis
More useful 2-3 weeks afteronset of complete paralysis
Perform EMG if ENoG > 95%
degeneration
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EMG In t erpret a t ionEMG Int erpret a t ion
Active voluntary motor units (MU) Intact motor axon
Myogenic fibrillation potention &Absent voluntary MU
Complete nerve degeneration
Fibrillation + MU Partial degeneration
Polyphasic MU Regenerating nerve
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Managem ent of Bel l s PalsyManagem ent of Bel l s Palsy
Observation
Medical Treatment
Steroid
Anti-viral agents
Surgery Decompression
Dynamic vs. static reanimation
Facial Rehabilitation
Observation
Medical Treatment
Steroid
Anti-viral agents
Surgery Decompression
Dynamic vs. static reanimation
Facial Rehabilitation
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Coc hrane review on Ef f ic ac y o f s te ro ids
Coc hrane review on Ef f ic ac y o f s te ro ids
4 trials of 179 patients Trial 1: Cortisone vs. placebo
Trial 2: Prednisone + vitamins vs. vitamins
Trial 3: High dose prednisone vs. saline Trial 4: Methylprednisolone
Primary endpoint: VII recovery @ 6 mos Conclusions: NO significant benefit for givingsteroids to Bells palsy patients
Drawbacks: Individual studies underpowered.Steroid regimens differ.
4 trials of 179 patients Trial 1: Cortisone vs. placebo
Trial 2: Prednisone + vitamins vs. vitamins
Trial 3: High dose prednisone vs. saline Trial 4: Methylprednisolone
Primary endpoint: VII recovery @ 6 mos Conclusions: NO significant benefit for givingsteroids to Bells palsy patients
Drawbacks: Individual studies underpowered.Steroid regimens differ.
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Ef f ic ac y of St eroid t reat m entEf f ic ac y o f St ero id t reat m ent
Prospective RCT 56 patients
Arm I: Steroids Arm II: Placebo Success = HB I or II
F/u @ 3 and 6 weeks No significant difference in response in the
2 groups
Prospective RCT 56 patients
Arm I: Steroids Arm II: Placebo Success = HB I or II
F/u @ 3 and 6 weeks No significant difference in response in the
2 groups
Turk-Boru U et al. Kulak Burun Bogaz Ihtis Derg. 2005;14(3-4):62-6.
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St ero ids in Com plet e para lys isSt ero ids in Com plet e para lys is
Meta-analysis of 3 prospective trials 230 patients with HB VI
Treatment within 7 days of onset
Total prednisone dose > 400 mg
(405-425 mg)
Complete Recovery: HB VI I Steroid group has 17% higher rate of CR
than control (placebo/ no treatment)
Meta-analysis of 3 prospective trials 230 patients with HB VI
Treatment within 7 days of onset
Total prednisone dose > 400 mg
(405-425 mg)
Complete Recovery: HB VI I Steroid group has 17% higher rate of CR
than control (placebo/ no treatment)
Ramsey MJ et al. Laryngoscope 2000; 110: 335-341
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St ero id vs . St ero id + Ac yc lov i r St ero id vs . St ero id + Ac yc lov i r
Double-blind RCT 99 Bells palsy patients
53 treated with acyclovir- prednisone
46 with placebo prednisone Prednisone dose 400 mg five times daily x 10 days
Combined therapy is better in terms of:
Return of muscle motion
Prevention of partial nerve degeneration
Double-blind RCT
99 Bells palsy patients
53 treated with acyclovir- prednisone
46 with placebo prednisone Prednisone dose 400 mg five times daily x 10 days
Combined therapy is better in terms of:
Return of muscle motion
Prevention of partial nerve degeneration
Adour KK 1996Ann Otol Rhinol Laryngol. 1996 May;105(5):371-8
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Tim ing of Medic a l T reat m entT im ing o f Medic a l T reat m ent
Hato N. Otol & Neurotol: 24(6) 2003
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Sam ple Treat m entSam ple Treat m ent
Corticosteroids Prednisone 60 mg PO daily x 5 days, taper
Anti-viral
Valacyclovir 1000 mg PO TID Eye care
Glasses/ Sunglasses/ avoid contact lens
Artificial tears, lacrilube Taping
Gold weight to upper eyelid
Opthalmologic consultation
Corticosteroids Prednisone 60 mg PO daily x 5 days, taper
Anti-viral
Valacyclovir 1000 mg PO TID Eye care
Glasses/ Sunglasses/ avoid contact lens
Artificial tears, lacrilube Taping
Gold weight to upper eyelid
Opthalmologic consultation
Pensak ML. Assessment and Management of the Paralyzed face. Otol. & Neurotol. Update. Nov 2006
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Surg ic a l Dec om press ionSurg ic a l Dec om press ion
Middle Fossa
Transmastoid Translabyrinthine
Retrolabyrinthine
Retrosigmoid
Middle Fossa
Transmastoid
Translabyrinthine
Retrolabyrinthine
Retrosigmoid
Hi t f S i l D iH is t ory of Surg ic a l Dec om press ion
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Hist ory o f Surg ic a l Dec om pressionHis t ory o f Surg ic a l Dec om press ion
Adour KK. 2002 Jan;259(1):40-7
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Anat om y of Fac ia l CanalAnat om y of Fac ia l Canal
Coker NJ. Atlas of Otologic Surgery p.339
0.68 mm
Labyrinthine1.02 mm
Tympanic1.53 mm
Mastoid1.48 mm
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Cont roversy over Surg ic a l Dec om press ion
Cont roversy over Surg ic a l Dec om press ion
In favor of: Gantz BJ 99
Sillman JS 92 Huges GB 88
Goin DW 82
Fisch U 81
Brackmann DE 80
Giancarlo HR 70
In favor of: Gantz BJ 99
Sillman JS 92
Huges GB 88
Goin DW 82
Fisch U 81
Brackmann DE 80
Giancarlo HR 70
Against: Adour KK 01
Aoyagi M 88 May M 84
Gacek RR 81
McNeill R 74
Adour KK 71
Mechelse K 71
Against: Adour KK 01
Aoyagi M 88
May M 84
Gacek RR 81
McNeill R 74
Adour KK 71
Mechelse K 71
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Resu lt s of Midd le Fossa Approac hResu l t s of Midd le Fossa Approac h
Grade Iowa Michigan Baylor Total
I 3 5 0 8
II 7 2 6 15
III 1 1 0 2
IV 0 1 0 1
Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188
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Mic h igan St udy:MCF vs . St eroidsMic h igan St udy:MCF vs . St eroids
010203040506070
I I I I I I IV
S t e r o i d sMCF
Grade
%
Glasscock M, Shambaugh G: Facial nerve surgery. In Surgery of the ear, 1990:434-465.
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Ear ly MCFEar ly MCF
Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188
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Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188
Tim ing o f Dec om press ionTim ing of Dec om press ion
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Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188
Algor i thmAlgor i thm
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Fac t ors t o c ons ider fo r Surgic a lDecompress ion
Fac t ors t o c onsider fo r Surgic a lDecompress ion
Age Comorbidities
ENoG Endpoint
Progression / velocity of degeneration Days from onset of paralysis
Return of muscle function
Age Comorbidities
ENoG Endpoint
Progression / velocity of degeneration Days from onset of paralysis
Return of muscle function
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Thank you
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Thank you