Evaluation and management of Bell’s palsy Chunfu Dai Otolaryngology Department Fudan University.

Evaluation and Evaluation and management of Bell’s palsymanagement of Bell’s palsy

Chunfu DaiChunfu Dai

Otolaryngology DepartmentOtolaryngology Department

Fudan UniversityFudan University

DefinitionDefinition

Rapid onset of the facial palsyRapid onset of the facial palsy Minimal associated symptomsMinimal associated symptoms Spontaneous recovery (80%)Spontaneous recovery (80%) The diagnosis is made after the exclusion The diagnosis is made after the exclusion

of other possibilityof other possibility

EtiologyEtiology

Vascular congestion with secondary ischeVascular congestion with secondary ischemia to the nervemia to the nerve Vasospasm would lead to ischemia, nerve edVasospasm would lead to ischemia, nerve ed

ema, and secondary compression within the fema, and secondary compression within the fallopian canal.allopian canal.

Viral polycranioneuropathyViral polycranioneuropathy Herpes simplex virus and herpes zoster virusHerpes simplex virus and herpes zoster virus

Clinic featuresClinic features

Less common before the age of 15yLess common before the age of 15y The incidence in men and women is The incidence in men and women is

similarsimilar Approximately 6-9% develop recurrent Approximately 6-9% develop recurrent

Bell’s PalsyBell’s Palsy Facial paresis alone occurred in 31%Facial paresis alone occurred in 31% Completely paralysis in 69%Completely paralysis in 69%

Clinic featuresClinic features

71% of patients with completely paralysis 71% of patients with completely paralysis achieve a H-B G1achieve a H-B G1

13% a H-B G213% a H-B G2 The remaining 16% in this complete The remaining 16% in this complete

paralysis group have a fair to poor paralysis group have a fair to poor recovery (H-B 3-5)recovery (H-B 3-5)

Prognosis Prognosis

All patientsAll patients with complete or partial paralyswith complete or partial paralysis, approximately 85% recover to normal wis, approximately 85% recover to normal with one year without treatment.ith one year without treatment.

Patient experienced delayed recovery over Patient experienced delayed recovery over 3 months, all developed sequelae3 months, all developed sequelae

Return of at least some facial function was Return of at least some facial function was noted in all patients.noted in all patients.

Evaluation of acute facial paralysisEvaluation of acute facial paralysis

House-Brackman grade systemHouse-Brackman grade system I, Normal: Normal facial functionin all areasI, Normal: Normal facial functionin all areas II, Mild dysfunction: slight weakness noticeablII, Mild dysfunction: slight weakness noticeabl

e only on close inspectione only on close inspection At rest: normal symmetry and toneAt rest: normal symmetry and tone Motion: some to normal movement of foreheadMotion: some to normal movement of forehead

Ability to close eye with minimal effortAbility to close eye with minimal effort Ability to move corners of mouth with maximal effort and Ability to move corners of mouth with maximal effort and

slight asymmetryslight asymmetry No synkinesis, contractur, or hemifacial spasmNo synkinesis, contractur, or hemifacial spasm


House-Brackman grade systemHouse-Brackman grade system III, moderate dysfunction: III, moderate dysfunction:

obvious but not disfiguring difference between two sideobvious but not disfiguring difference between two side No function impairment No function impairment Noticeable but not severe synkinesis, contracture, and hemifacial spasNoticeable but not severe synkinesis, contracture, and hemifacial spas

mm At rest: normal symmetry and toneAt rest: normal symmetry and tone Motion: Motion:

slight to no movement of foreheadslight to no movement of forehead Ability to close eye with maximal effort and obvious asymmetryAbility to close eye with maximal effort and obvious asymmetry Ability to move corners of mouth with maximal effort and obvious asymemetrAbility to move corners of mouth with maximal effort and obvious asymemetr

yy Patients with obvious but not disfiguring synkinesis, contracture, and hePatients with obvious but not disfiguring synkinesis, contracture, and he

mifcial spasm are grade 3 regardless of degree of motor activity.mifcial spasm are grade 3 regardless of degree of motor activity.


House-Brackman grade systemHouse-Brackman grade system IV, moderate severe dysfunction:IV, moderate severe dysfunction:

Obvious weakness and disfiguring asymmetryObvious weakness and disfiguring asymmetry At rest: normal symmetry and toneAt rest: normal symmetry and tone motion: motion:

no movement of forehead no movement of forehead Inability to close eye completely with maximal effortInability to close eye completely with maximal effort Asymmetrical movement of corners of mouth with maximal effortAsymmetrical movement of corners of mouth with maximal effort

Patients with synkinesis, mass action, and hemifacial spasm sevPatients with synkinesis, mass action, and hemifacial spasm severe enough to interfere with function are grade 4 regardless of dere enough to interfere with function are grade 4 regardless of degree of motor activity egree of motor activity


House-Brackman grade systemHouse-Brackman grade system V, severe dysfunction:V, severe dysfunction:

Only barely perceptible motionOnly barely perceptible motion At rest: possible asymmetry with droop of corner of mouth and dAt rest: possible asymmetry with droop of corner of mouth and d

ecreased or absent nasolabial foldecreased or absent nasolabial fold Motion: Motion:

No movement of foreheadNo movement of forehead Incomplete closure of eyeIncomplete closure of eye Slight movement of corner of mouth Slight movement of corner of mouth

Synkinesis, contracture, and hemifacial spasm usually absent Synkinesis, contracture, and hemifacial spasm usually absent VI, total paralysis: no movement VI, total paralysis: no movement


Fisch grade systemFisch grade system Rest 20, forehead movement 10, eye closure Rest 20, forehead movement 10, eye closure

30, smile 30, month blow 10.30, smile 30, month blow 10. Each is given 0, 30%, 70% or 100%. Each is given 0, 30%, 70% or 100%.


A careful history of the patients illnessA careful history of the patients illness Sudden in onset and frequently evolve Sudden in onset and frequently evolve

over 2-3 weeks after onsetover 2-3 weeks after onset Any palsy progression over 3 weeks Any palsy progression over 3 weeks

should be evaluated for a neoplasmshould be evaluated for a neoplasm Any palsy persist for 6 month without any Any palsy persist for 6 month without any

recovery should be considered for a recovery should be considered for a neoplasm. neoplasm.


Ramsay-Hunt syndrome Ramsay-Hunt syndrome It is manifest by a facial palsy with a vesicular It is manifest by a facial palsy with a vesicular

eruption over a distribution of a cranial nerveeruption over a distribution of a cranial nerve Sensorineural hearing loss and vertigo may alSensorineural hearing loss and vertigo may al

so be present in up to 20% of cases.so be present in up to 20% of cases. Prognosis is poor than Bell’s palsyPrognosis is poor than Bell’s palsy


Audiometry: to rule out any involvement of Audiometry: to rule out any involvement of the auditory nervethe auditory nerve

CT and MRI: for patient without fully recovCT and MRI: for patient without fully recovery, to identify the site of lesion.ery, to identify the site of lesion.

Electrophysiologic testing to determine proElectrophysiologic testing to determine prognosis.gnosis.


Schirmer test, stapedial reflex, electrogustSchirmer test, stapedial reflex, electrogustometry, and salivary flow has be obsolete.ometry, and salivary flow has be obsolete.

Serologic studies can be considered to evSerologic studies can be considered to evaluation for lyme disease, autoimmune disaluation for lyme disease, autoimmune disorders, or other central nervous system disorders, or other central nervous system diseaseease

Managements Managements

Medical treatment:Medical treatment: Steroid 1mg/kg/daySteroid 1mg/kg/day VasodilationVasodilation Anti-virusAnti-virus Vitamine BVitamine B

Physical therapyPhysical therapy HypobaroxygenHypobaroxygen Protection of cornerProtection of corner

Management Management

SurgerySurgery Degeneration of facial nerve more than 90% Degeneration of facial nerve more than 90%

indicates facial nerve decompressionindicates facial nerve decompression Approach: Approach:

middle fossa cranionectomymiddle fossa cranionectomy Combination of middle fossa and mastoidectomCombination of middle fossa and mastoidectom

yy

Thank you!

Evaluation and management of Bell’s palsy Chunfu Dai Otolaryngology Department Fudan University.

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