bells palsy slides 070214

8/14/2019 Bells Palsy Slides 070214

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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


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


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



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Com plet e Rec overyCom plet e Rec overy


71

6


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Inc om plet e vs. Com plet eInc om plet e vs . Com ple t e



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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%



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Predic t ing Musc ular SequelaePredic t ing Musc ular Sequelae


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



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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



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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



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Tim ing o f Dec om press ionTim ing of Dec om press ion


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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

bells palsy slides 070214

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