Bells Palsy Slides 070214

Bell’s Palsy: To Treat or Not to Treat

K. Kevin Ho, M.D. Shawn D. Newlands, M.D., Ph.D., M.B.A. University of Texas Medical Branch at Galveston Grand Rounds Presentation February 14, 2007

Historical Perspectives •

Sir Charles Bell (1774-1842) – Studied facial anatomy extensively during Battle of Waterloo – Concluded that facial nerve controlled facial expression – “Respiratory nerve of the Face”

Anatomy

Bell’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

Age Distribution 2002

Peitersen E. Acta Otolaryngol 2002;549:4–30. Peitersen E. Am. J. Otology. 1982

Complete Remission & Age 90

84 75 64

36

0-14

15-29

30-44 Age 45-59

> 60

Peitersen E. Acta Otolaryngol 2002;549:4–30.

Return of Muscular function 85 %

Months Peitersen E. Acta Otolaryngol 2002;549:4–30.

Time of beginning remission & Sequelae

Peitersen E. Am. J. Otology. 1982

Complete Recovery 71

6

Peitersen E. Acta Otolaryngol 2002;549:4–30.

Incomplete vs. Complete

Peitersen E. Acta Otolaryngol 2002;549:4–30.

Symptomatology • • • • • •

Reduced Stapedial reflex Complete palsy @ presentation Tear flow Post-auricular pain Dysgeusia Hyperacusis Peitersen E. Acta Otolaryngol 2002;549:4–30.

71% 69% 67% 52% 34% 14%

Predicting Muscular Sequelae 91

91 83

% Muscular Sequelae

Abnormal 63

Normal

27

5 Taste

Stapedial

Lacrimation

Peitersen E. Acta Otolaryngol 2002;549:4–30.

Favorable prognosis for full recovery • • • • •

Incomplete palsy Early recovery Young patients Normal taste, stapedial reflex, lacrimation Lack of post-auricular pain Peitersen E. Acta Otolaryngol 2002;549:4–30.

Pathophysiology • •

Exact etiology unknown Viral infection – Herpes Simplex

• • •

Vascular ischemia Autoimmune disorder Hereditary

Role of HSV-1

Murakami: Ann Intern Med, Volume 124(1).January 1, 1996.27-30

Diabetes Mellitus •

Bell’s patients with DM – – –

• •

14 % (Korczyn (Korczyn AD AD ’71) ’71) 21 % (Alford (Alford BR BR ’71) ’71) 38 % (Yasuda (Yasuda K K ’75) ’75)

66% demonstrate glucose intolerance Functional recovery poorer in diabetics

Pregnancy •

Incidence of Bell’s 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 pregnant women with facial palsy

Differential Diagnosis Acute facial 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

Early Grading System

Peitersen E. Am. J. Otology. 1982

House-Brackman Grading System

MRI

Post-GAD Pre-GAD Kinoshita T et al. Clin. Radiology 2001; 56: 926-32

Contrast Enhancement: Bell’s Palsy vs. Control Bell’s Palsy

Control

Kinoshita T et al. Clin. Radiology 2001; 56: 926-32

Topognostic Test •

Lacrimal – Schirmer’s Test

• • •

Stapedial reflex Taste Salivary flow

Electrical Test • • • •

Nerve Excitation test Maximal Stimulation test Electroneurography Electromyography

(NET) (MST) (ENoG) (EMG)

Sunderland classification of peripheral nerve injury Neurapraxia

Axonotmesis

Neurotmesis

Electroneurography (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)

Time course of Degeneration

Gantz: Laryngoscope, Fisch U. Am Volume J. Otology. 109(8).August 1984 1999.1177-1188

Fisch 1984

Fisch U. Am J. Otology. 1984

Electromyography (EMG) • • • •

Recording of voluntary muscle action potentials by needles electrodes Does not differentiate axonotmesis & neurotmesis More useful 2-3 weeks after onset of complete paralysis Perform EMG if ENoG > 95% degeneration

EMG Interpretation •

Active voluntary motor units (MU) –

•

Myogenic fibrillation potention & Absent voluntary MU –

•

Complete nerve degeneration

Fibrillation + MU –

•

Intact motor axon

Partial degeneration

Polyphasic MU –

Regenerating nerve

Management of Bell’s Palsy • •

Observation Medical Treatment – –

•

Surgery – –

•

Steroid Anti-viral agents Decompression Dynamic vs. static reanimation

Facial Rehabilitation

Cochrane review on Efficacy of steroids • • • • • • • •

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 giving steroids to Bell’s palsy patients Drawbacks: Individual studies underpowered. Steroid regimens differ.

Efficacy of Steroid treatment • • • • • • •

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.

Steroids in Complete paralysis •

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 Æ I – Steroid group has 17% higher rate of CR than control (placebo/ no treatment) Ramsey MJ et al. Laryngoscope 2000; 110: 335-341

Steroid vs. Steroid + Acyclovir • •

Double-blind RCT 99 Bell’s 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 1996 Ann Otol Rhinol Laryngol. 1996 May;105(5):371-8

Steroid vs. Steroid + Acyclovir • Prednisolone

•

Prednisolone + Valacyclovir

• •

Prospective RCT of 150 patients Prednisolone (20 tid x 5d, 10 tid x 3 d, 10 qD x 2 d) Predisolone + Valacyclovir (500 bid x 5 d) No significant difference in recovery

Kawaguchi: Laryngoscope, Volume 117(1).January 2007.147-156

Timing of Medical Treatment

Hato N. Otol & Neurotol: 24(6) 2003

Sample Treatment •

Corticosteroids –

•

Anti-viral –

•

Prednisone 60 mg PO daily x 5 days, taper 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

Surgical Decompression • • • • •

Middle Fossa Transmastoid Translabyrinthine Retrolabyrinthine Retrosigmoid

History of Surgical Decompression

Adour KK. 2002 Jan;259(1):40-7

Anatomy of Facial Canal

Tympanic 1.53 mm

Mastoid 1.48 mm

Labyrinthine 1.02 mm 0.68 mm

Coker NJ. Atlas of Otologic Surgery p.339

Controversy over Surgical Decompression •

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

Results of Middle Fossa Approach 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

Michigan Study: MCF vs. Steroids 70 60 50

%

40

Steroids

30

MCF

20 10 0

I

II

III

IV

Grade Glasscock M, Shambaugh G: Facial nerve surgery. In Surgery of the ear, 1990:434-465.

Early MCF

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Timing of Decompression

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Algorithm

Gantz: Laryngoscope, Volume 109(8).August 1999.1177-1188

Factors to consider for Surgical Decompression • • •

Age Comorbidities ENoG – Endpoint – Progression / velocity of degeneration

• •

Days from onset of paralysis Return of muscle function

Thank you