Bell's PalsyAMRESH Ku MAR. B. P. R. BHATIA, M. K. MALIK.

Thirty four patients of Bell's

Palsy have been studied over a

period of one and half years.

Various aetiological factors,

diagnostic tests and therapy

have been reviewed.

Inspite of the great advancement

in the field of medical science, Bell's

Palsy still remains a dilemma to the

treating otolaryngologists. Several

factors have been held responsible

to affect the severity and the out-

come of the disease (Adourt and

Wingerd 1974). Nerve excitability

test has been found useful in predic-

ting the prognosis of the disease

(Camp Bell 1962). Decreased or

loss of response on paralysed side by

Nerve excitability test is supposed to

indicate poor prognosis (Mark May

1978). Electrogustometry has been

used to determine the site of injury

and the prognosis of the patient.

Decreased lacrimal flow on the para-

lysed side by Schirmer's test also

indicates bad prognosis (Mark May

1978). Controversy exists about

the effect of diabetes mellitus on the

severity and prognosis of the disease,

(Korczyn 1971 and Boddie 1972),

(Sardana et. al', 1978).

In the present study, various as-

pects of this disease have been

studied and discussed.

Material and Method

Thirty four patients of Bell's Palsy

have been examined and followed up

Amresh Kumar, Lecturer; B. P. R. Bhatia,Reader & Head; M. K. Malik, Lecturer,Department of E. N. T., L. L. R. M. MedicalCollege, Meerut

over a period of one and half years

to study the various aspects of the

disease. The diagnosis of the Bell's

Palsy was made on the following

criteria :

(1) Sudden onset of partial or

complete paralysis of the mus-

cles of expression on one side

of face.

(2) The absence of history of

erruptions or vesicles over the

face or in the ear.

(3) The absence of any disease of

middle ear which could have

involved the facial nerve.

(4) The absence of any symptom

or sign of the disease of the

central nervous system.

After establishing the diagnosis of

Bell's Palsy, the detail history of the

patient was taken. Special emphasis

was laid on the following points :

(1) Any history of pain in or around

the ear preceding palsy.

(2) History of exposure to cold

preceding palsy.

Detail clinical examination of the

facial nerve was done to determine

whether the patient had clinically

complete paralysis or the partial

paralysis.

(1) Nerve Excitability Test : It

was done with the help of a

nerve stimulator to find any

evidence of partial or complete

denervation.

(2) Electrogustometry Test :

It was done with the help of

electrogustometer based on the

circuit of Krarup's modification.

(3) Schirmer's Test : Lacrimal

flow was compared on the

healthy and paralysed side.

Certicosteroids were not given to

any patient and the patients either

showed spontaneous recovery or the

surgical decompression of the nerve

was done.

Incidence of Diabetes Mellitus was

determined in these patients and its

effect on the severity and the

prognosis of the palsy was observed.

Observations and Results

These are based on the study of

thirty four patients.

Table-1 shows the age and sex of

these patients. The table-1 shows

TABLE I

Showing Age and Sex distributionof the patients

Male Female Total

3 2 51 4 58 7 151 3 41 3 43 2 5

Nil Nil Nil

16 18 34

(3) History of change in taste after Age in yearsdeveloping palsy.—

0-1011-2021-3031-4031-4041-5051-60

Total

Address for reprints Assessment of the function ofDr. Amresh Kumar facial nerve was done by the follow-D-5, Medical College CampusMeerut. ing tests

that the males and females were

about equally affected. Maximum

number of patients were encountered

Indian Journal of Otoloryngology, Volume 36, No. 3, September, 1984 105

BELL'S PALSY—KUMAR, et at.

in the age group of 21-30 years. The

youngest patient sutfering from the

disease was a two years old female

child.

Involvement of right side was seen

in 19 (55.9%) cases while left side

was affected in 15 (44.1%) cases.

Table-II shows presentation of

Bell's Palsy and its relation to prog-

nosis.

The table-II indicates that pain and

change in taste do not affect the

prognosis of the disease. It also in-

dicates that history of exposure to

cold was found only in 6 (17.6%)

cases.

TABLE 1.1

Showing presentation of Bell's Palsyand its relation to Prognosis

Number Per- Prog-Presentation of cases centage nosis

History of painin ear 23 67.6% Good

History ofexpsoure to cold 6 17.6% Good

History of changein taste 10 29.4% Good

Out of these 34 patients, 22 were

studied in a period of one year from

January to December and the other

twelve (12) were studied in next

six months.

Table-III indicates the seasonal

distribution of the 22 patients studied

between January to December.

It is clearly evident from the table-III

that the maximum number of cases

(22.7%) were encountered in the

month of April which is fairly hot.

History of exposure to cold was also

present only in (17.6%) cases. It is

therefore apparent from the present

analysis that cold is not an important

factor in the causation of the disease.

Clinically complete paralysis was

found in 26 (76.5%) patients while 8

(23.5%) had partial paralysis.

TABLE Ill

Showing seasonal distributionof the patients

MonthNumberof cases Percentage

January Nil —

February 4 18.2%March 1 4.5%April 5 22.7%May 2 9.0%June 1 4.5%July 1 4.5%August 1 4.5%September 3 13.7%October 1 4.5%November 2 9.0%December 1 4.5%

Tota 1 22

Nerve Excitability test showed

partial denervation in 4 patients. Out

of these 4 patients, only one could

recover.

Electrogustometry showed maxi-

mum difference of 48 microamperes

on paralysed and healthy side.

Lacrimal flow by Schirmer's test

was equal on both the sides in all

the cases and did not prove of much

value.

Table-IV shows the recovery of the

disease.

TABLE IV

Showing recovery of the Palsy

Number Per-Outcome of cases centage

Overall complete recovery 27 79.4%Spontaneous recovery 25 73.5%Recovery after facial nerve

decompression (out of 4) 2 50.0%

The table-IV indicates that the

overall recovery of the disease was

79.4% and 73.5% cases recovered

spontaneously.

Out of 4 patients who underwent

surgical decompression of the nerve,

two were those patients who initially

showed partial denervation. These

patients did not recover even after

the surgical decompression of the

nerve.

The incidence of diabetes mellitus

was found to be 14.7% among these

patients and diabetes mellitus was

not found to have any effect either

on the severity of the palsy or on

the prognosis of the palsy.

Discussion

Adour et. aL, (1978) studied 1048

patients of Bell's Palsy and found

highest incidence of the disease in

the third decade of life. In our

analysis also, the maximum number

of patients are encountered between

the age of 21-30 years. This indicates

that the disease is more common in

young persons.

The females and males are equally

involved in both the series which

indicates that the incidence is not

higher in any sex. However Adour

et. al., (1978) reported higher inci-

dence in women during first fourteen

days of menstrual cycle. The analysis

of both the studies also indicates that

history of pain and change in taste

do not affect the outcome of the

disease.

In our analysis, maximum number

of patients were encountered in the

month of April. Adour et. a/., (1978)

also reported that cold has no impor-

tance in the causation of the disease.

Nerve excitability test proved helpful

in predicting the prognosis of these

patients and those showing evidence

of denervation had poor prognosis,

of these patients and those showing

evidence of denervation had poor

prognosis. Mark May (1978) also

reported that decreased response by

nerve excitability test is an un-

favourable factor in the prognosis

of the disease. Electrogustometry

showed maximum difference of 48

microamperes on two sides. However,

a critical difference of 10 micro-

amperes which is supposed to indi-

cate bad prognosis was not found in

any patient. Decreased lacrimal flow

on the paralysed side indicates bad

106 Indian Journal of Otolaryngology, Volume 36, No. 3, September, 1984

BELL'S PALSY—KU MAR, et al.

prognosis (Mark May (1978, Adour

et. aL, 1978), but it did not prove

of much value in our study and

lacrimal flow was equal on both the

sides in all the cases.

Diabetes mellitus was not found

to have any effect on the severity of

the palsy and the outcome of the

disease as also reported by Boddie

(1972) and Sardana et. al., (1978) in

the earlier study.

References

1. Amos, D. Korczyn : Bell's Palsy andDiabetes Mellitus. Lancetl : 108,1971.

2. Adour, K. K., M. D., John Wingerd, M. A. :"Idiopathic facial paralysis (Bell's Palsy),factors affecting severity and outcome in446 patients" Neurology (Minneap)24 (12) : 1112, 1974.

3. Boddie, H. G. : Recurrent Bell's Palsy.Journal of Laryngology and Otology.86 : 1117-20, 1972.

4. Camp Bell, E. D. R., ETAL : 'value ofNerve excitability, measurement in pro-gnosis of facial palsy. British MedicalJournal. 2 : 7-10, 1962.

5. Krarups, B. : Electrogustometry, Amethod for clinical taste examination.Acta Otology. 49 : 294, 1958.

6. Kedar K. Adour, M.D., Frederick M.Bly, M.D., Raymond L. Hilsingar, Jr.M. D. Z. M. Khan, M.D. and M. I.Sheldon, M.D. : The true nature of Bell'sPalsy. Analysis of 1,000 consecutivepatients. Laryngoscope. 88 : 787, 1978.

7. Mark May, M.D. : Bell's Palsy : Pro-gressive ascending paralysis, therapeLticimplications. Laryngoscope. 88 : 61,1978.

8. Sardana D. S., Gupta Om. K., Kumar A.Role of diabetes mellitus in the aetiologyof Bell's Palsy. Indian Journal ofOtolaryngology: 30 (2) : 61, 1978.

Indian Journal of Otolaryngology, Volume 36, No. 3, September, 1984 107