Bells palsy

This appears to be the most reasonable and appropriate action to be taken once the initial steroid therapy is failed.

Hyperacusis (Phonophobia) occurs due to undue sensitivity to loud sounds.

• Stapedius muscle dampens excessive vibrations of the stapes caused by high pitched sounds in order to protect the internal ear.
• If this protective reflex is not elicited it indicates stapedius paralysis and results in hyperacusis.

Bells Palsy

• It is the commonest cause of facial palsy in adults
• Lower motor neuron type paralysis
• It is idiopathic in nature°
• Bells palsy manifests as an acute, unilateral paresis or paralysis of the face.
• The onset and evolution are rapid – typically less than 48 hours. 
• The incidence reaches a maximum between the ages 15 and 45 years. It has a predominance in women younger than 20 years and a slight predominance in men older than 40 years, although it is more or less equaL°
• Recurrence rate of Bells palsy is 4.5-15% 
• Familial incidence = 4.1%
• Bells palsy is uncommon in pregnancy, however the prognosis is significantly worse in pregnant women with Bells palsy than among non pregnant women with palsy.
• Several authors have also demonstrated, a correlation between diabetes mellitus and Bells palsy in developing countries.
• Infectious causes have also been implicated in the origin of Bells palsy – viz:

FISV 1 and HSV 2, human herpes

Varicella zoster virus

Influenza B

Adenovirus

Cox sackie virus

– Epstein Barr virus

Recently it has been demonstrated that an inactivated intranasal influenza vaccine increased the risk of Bells palsy.

• Normal function is usually regained within 3 months in about 2/3 rd of patients
• No further recovery is expected after a period of 6 months.
• Majority of the patients with Bell’s palsy recover completely

Surgical decompression of facial nerve in Bells palsy is needed only in indicated cases, i.e.

• In case of complete paralysis and
• If electroneurography of facial nerve shows >90% of degeneration. When done it should be within 2 weeks of onset of palsy.

• Bells paralysis is a LMN type of facial nerve palsy of unknown etiology i.e. idiopathic nature.
• Lower motor neuron type of palsy causes ipsilateral paralysis therefore bells palsy causes ipsilateral facial paralysis.
• Other neurological examinations are normal in Bells palsy

Bell’s palsy is an acute onset lower motor neuron type of palsy – there will be Ipsilateral loss of :

• Taste sensation, lacrimation and salivation
• Facial paralysis
• Noise intolerance (hyperacusis)
• Eye balls will turn up and out (Bells phenomenon) on attempting to close eyes but ptosis will not be seen.

In Bells palsy – Facial paralysis is usually preceeded by pain behind the ear.

Medical Management

I. Steroid therapy:

• Oral prednisolone has been used extensively to treat patients with Bells palsy.
• Proof of efficacy is however controversial.
• Steroids are considered useful because they have an anti inflammatory response.
• Because the cost of therapy is less and it has low risk of side effects, predinosolone is commonly started at the initial visit
• Initiation of therapy during the first 24 hours of symptom confers a higher likelihood of recovery

II. Antiviral therapy:

• It represents a newer adjunct in treating acute facial palsy of viral origin (Both Bells palsy and Ramsay hunt syndrome)
• Oral acyclovir is the DOC
• Some studies have shown that patients who receive prednisolone plus oral acyclovir have a higher recovery rate and reduced rates of synkinesis in comparison to those who receive prednisolone alone.
• Based on above evidence most surgeons advocate combination of steroids and antiviral drugs.

The usual recommended regime is predisolone 1mg/kg/day for five days followed by a ten day taper and oral acyclovir (200-400 mg 5 times daily) for ten days.

Physical Management

Includes :

Electrical stimulation: It is done to maintain membrane conductivity and reduce muscle atrophy

• It is generally used in patients left with partial defects

Eye care:The cornea is vulnerable to drying and foreign body irritation in acute facial palsy due to orbicularis oculi dysfunction. So measures conferring corneal protection are recommended such as

• Artificial tears drops at daytime
• Ocular ointment at night
• Use of sunglasses etc

In long standing cases: Reducing the area of exposed cornea by implanting a gold weight in the upper lid (tarsorapphy) is done.

Surgical Management

Nerve decompression

• Axonal ischemia can be reduced by the decompression of nerve segments presumed to be inflammed and entrapped.
• Decompression of the facial nerve is done in cases who have a poor prognosis for complete recovery with medical treatment alone.