Evaluation and management of Bell’s palsy

Evaluation and management of Bell’s palsy Chunfu Dai Otolaryngology Department Fudan University 复旦大学眼耳鼻喉科医院

Definition • Rapid onset of the facial palsy • Minimal associated symptoms • Spontaneous recovery (80%) • The diagnosis is made after the exclusion of other possibility

Etiology • Vascular congestion with secondary ischemia to the nerve • Vasospasm would lead to ischemia, nerve edema, and secondary compression within the fallopian canal. • Viral polycranioneuropathy • Herpes simplex virus and herpes zoster virus

Clinic features • Less common before the age of 15y • The incidence in men and women is similar • Approximately 6-9% develop recurrent Bell’s Palsy • Facial paresis alone occurred in 31% • Completely paralysis in 69%

Clinic features • 71% of patients with completely paralysis achieve a H-B G1 • 13% a H-B G2 • The remaining 16% in this complete paralysis group have a fair to poor recovery (H-B 3-5)

Prognosis • All patientswith complete or partial paralysis, approximately 85% recover to normal with one year without treatment. • Patient experienced delayed recovery over 3 months, all developed sequelae • Return of at least some facial function was noted in all patients.

Evaluation of acute facial paralysis • House-Brackman grade system • I, Normal: Normal facial functionin all areas • II, Mild dysfunction: slight weakness noticeable only on close inspection • At rest: normal symmetry and tone • Motion: some to normal movement of forehead • Ability to close eye with minimal effort • Ability to move corners of mouth with maximal effort and slight asymmetry • No synkinesis, contractur, or hemifacial spasm

Evaluation of acute facial paralysis • House-Brackman grade system • III, moderate dysfunction: • obvious but not disfiguring difference between two side • No function impairment • Noticeable but not severe synkinesis, contracture, and hemifacial spasm • At rest: normal symmetry and tone • Motion: • slight to no movement of forehead • Ability to close eye with maximal effort and obvious asymmetry • Ability to move corners of mouth with maximal effort and obvious asymemetry • Patients with obvious but not disfiguring synkinesis, contracture, and hemifcial spasm are grade 3 regardless of degree of motor activity.

Evaluation of acute facial paralysis • House-Brackman grade system • IV, moderate severe dysfunction: • Obvious weakness and disfiguring asymmetry • At rest: normal symmetry and tone • motion: • no movement of forehead • Inability to close eye completely with maximal effort • Asymmetrical movement of corners of mouth with maximal effort • Patients with synkinesis, mass action, and hemifacial spasm severe enough to interfere with function are grade 4 regardless of degree of motor activity

Evaluation of acute facial paralysis • House-Brackman grade system • V, severe dysfunction: • Only barely perceptible motion • At rest: possible asymmetry with droop of corner of mouth and decreased or absent nasolabial fold • Motion: • No movement of forehead • Incomplete closure of eye • Slight movement of corner of mouth • Synkinesis, contracture, and hemifacial spasm usually absent • VI, total paralysis: no movement

Evaluation of acute facial paralysis • Fisch grade system • Rest 20, forehead movement 10, eye closure 30, smile 30, month blow 10. • Each is given 0, 30%, 70% or 100%.

Evaluation of acute facial paralysis • A careful history of the patients illness • Sudden in onset and frequently evolve over 2-3 weeks after onset • Any palsy progression over 3 weeks should be evaluated for a neoplasm • Any palsy persist for 6 month without any recovery should be considered for a neoplasm.

Evaluation of acute facial paralysis • Ramsay-Hunt syndrome • It is manifest by a facial palsy with a vesicular eruption over a distribution of a cranial nerve • Sensorineural hearing loss and vertigo may also be present in up to 20% of cases. • Prognosis is poor than Bell’s palsy

Evaluation of acute facial paralysis • Audiometry: to rule out any involvement of the auditory nerve • CT and MRI: for patient without fully recovery, to identify the site of lesion. • Electrophysiologic testing to determine prognosis.

Evaluation of acute facial paralysis • Schirmer test, stapedial reflex, electrogustometry, and salivary flow has be obsolete. • Serologic studies can be considered to evaluation for lyme disease, autoimmune disorders, or other central nervous system disease

Managements • Medical treatment: • Steroid 1mg/kg/day • Vasodilation • Anti-virus • Vitamine B • Physical therapy • Hypobaroxygen • Protection of corner

Management • Surgery • Degeneration of facial nerve more than 90% indicates facial nerve decompression • Approach: • middle fossa cranionectomy • Combination of middle fossa and mastoidectomy

Thank you! 复旦大学眼耳鼻喉科医院

Evaluation and management of Bell’s palsy