Various Methods for Treatment of Bell's Palsy

M hammad ,bed Hindy Baghdad Teaching Hospital) Baghdad) 0ra4+ Talal ,bd l 3amad

MJB

Abstract
Forty - five patients with Bell's palsy attending the Department of Physical Medicine and Rehabilitation in Baghdad Teaching Hospital These patients were divided into three gro ps ! The first gro p consisted of "# patients and were treated with steroid $ %& mg prednisolone 'day for the first "& days ( and physiotherapy $ galvanic stim lation ) Facial e*ercises and massage (+ The second gro p consisted of "# patients and were treated by steroid only $ %& mg prednisolone 'day for the first "& days(+ The third gro p consisted of an other "# patients who were treated by physiotherapy only in the from of galvanic stim lation ) facial e*ercises and facial message+ ,ll these gro ps were re- e*amined after % wee-s ) " month and % months and their responses to the treatment assessed clinically according to Ho se-Brec-mann grading system+ The responses to the treatment were more evident in the first gro p than the second gro p and followed by third gro p+ & #$% "! , ( ) -7 -6 354 34 $2 , #$% 01 #+(! + .$/ -(+! "! ,*) +(' :; 89: C9@( ; AB$ )$+ ?> -< =6 .E5" (@AB$ )$+ ?> BD< 6 .!, +< 4 .E5" !, C9 3F+< 4 < 6 $5" DD HI0 5" C9 3F++1 354 34 ,F F , 1 #+" - ? ; G "#. 7 .@ ?. J) 3: BD F4 - "! =%6 D? L1 C9 +1K< B? .DD MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM

gland secretion and other which convey taste imp lses from the anterior two-thirds of the tong e1"2+ The n cle s of the facial nerve is sit ated in the ventral part of the pons+ 0ts fibers pass bac-ward to emerge from the lateral aspect of the lower border of the pons medial to the eight nerves from which the seventh is separated by pars intermedia+ The facial nerve crosses the posterior fossa to enter the petro s

Introduction The Facial Nerve Anatomy and Physiology The facial nerve has a motor root and a sensory root $nerv s intermedi s(+ The nerve leaves the lateral end of the / nction of pons and med lla+ The roots pass laterally in the posterior cranial fossa with the vestib locochlear nerve and enter the internal aco stic meat s+ 0t is also accompanied by fibers which stim late the salivary

Ty es of Facial Paralysis The following varieties are recogni:ed! "- , s pran clear or pper motor ne ron lesion involves the pyramidal fibers concerned with vol ntary facial movements+ The movements of the lower part of the face is affected more severely than those of the pper+ %- 3 pran clear lesion involving the fibers concerned with emotional movement of the face leading to mimic paralysis) rarely occ rs and is in frontal lobe lesion =->esions involving the lower motor ne rons in the n cle s) or facial nerve+ These lesions destroy the common pathway and are li-ely to affect) to e4 al e*tent) both vol ntary and emotional movements and as a r le the pper and lower facial m scles are e4 ally wea-ened+ , lower motor ne ron lesion) whether n clear or infran clear) ca ses atrophy of facial m scles+ 3 pran clear lesions do not prod ce atrophy1%)=2+ 8- Disorders of facial m scles! 3 ch as mysthenia gravis) facioscap lo h meral m sc lar dystrophy and dystrophia myotonica+ The lesion is bilateral and involves both pper and lower facial m scles+ Patients and Methods Forty . five patients with bell's palsy attended the Physical Medicine and Rehabilitation Department in Baghdad Teaching Hospital+ These patients were st died within one year+ 6omplete history was ta-en from all patients) and physical e*amination incl ding a thoro gh cranial nerves e*amination also done for all patients+ The patients were also was sent for ?@T e*amination to e*cl de ?@T problems+ The vast ma/ority of the patients were seen with in #-7 days after the onset of paralysis+

portion of the temporal bone where it occ pies the a4 e d ct s falloppii or facial canal+ 5ithin the bone it t rns first o twards then bac-wards and then downwards to emerge from the s- ll at the stylomastoid foramen+ 5ithin the facial canal the nerve gives off a branch to the stapedi s m scle and after emerging from the stylomastoid foramen it gives off a branch to the stylohyoid m scle) to the occipital belly of the digastic and the occipital belly of the occipitofrontalis then it divides within the parotid gland into a n mber of branches which innervate the m scles of the e*pression incl ding the b ccinator and platysma+ Bell's Palsy Bell's facial paralysis named after 3ir 6harles Bell $"778-"98%() is a facial paralysis of ac te onset attrib ted to non- s pparative inflammation of the facial nerve with in the stylomastoid foramen1%2+ regarded as a benign ne rological it is disorder and its almost always nilateral mono ne ritis182+ 0t may occ r at any age1#2) b t appears to be most common in yo ng ad lt males than females+ The ca ses are n-nown sometime attrib ted to e*pos re to dra ght and may follow infection of nasopharyn* in small proportion of cases+ 0t has been proved to be d e to the vir s of Herpes :oster 1%)8);2 b t in most cases no ca se is discoverable+ 6 rrent hypotheses concerning pathogenesis ass me an ischemic process+ The primary ischemic theory post lates dysf nction of a tonomic nervo s system prod cing arteriolar spasm and thrombosis of the vessel s pplying the nerve within the rigid bony fallopian canal 17)92+ The secondary ischemia hypothesis1<2 attempts to relate a primary inflammatory $viral( 1"&2 or imm nological( edema to s bse4 ent dist rbances of microcirc lation) leading to loss of nerve cond ctivity

!esults Table " shows that most of the patients attended directly the rehabilitation nit) while the others were referred from general practioners) ?@T clinic) medical nits and ne ros rgeon+ Table @o+ % ! shows that most of the patients were at the age gro p %&=& years) and the total n mber of patients were %# male and %& patients were females+ Patients responses to the treatment were assessed clinically according to Ho se-Brac-mann grading system 1";)"72+ The first gro p $treated by steroid and physiotherapy( as shown in table @o+=+ two of the patients ac4 ired B 0 after % wee-s of treatment) si* patients ac4 ired B 0 after " month of treatment and twelve patients ac4 ired B 0 after % months of treatment + Cne patient remained in each of grades 00) 000 and D+ 0n the second gro p $on steroid treatment only(+ Cne patient ac4 ired B0 after % wee-s of treatment) fo r patients ac4 ired B0 after " month and nine patients ac4 ired B 0 after % months of treatment+ The remaining patientsA three were in B0 two were in B000 and one was in B0D+ 0n the third gro p $on physiotherapy only(! Two patients ac4 ired B0 after % wee-s of treatment and the same patients remained in B0 after " month of treatment after % months of treatment seven patients ac4 ired B0) fo r patients ac4 ired B00) one patient ac4 ired B000 and one patient ac4 ired B0D+ Two patients remained in BD as they were at this grade at the start of treatment+

These patients were divided into three gro ps each gro p consisted of fifteen patients+ The first gro p $"# patients( was treated by prednisolone and physiotherapy and treatment started at the time of diagnosis1"")"%2A predinsolone was given in a dose of %&mg'day for the first ten days and tapered as follow! a- The first three days! " tab $#mg( * 8 b- The second three days! " tab+ $# mg( *= c- The third three days ! " tab+ $# mg( *% d- The tenth day ! " tab+ $#rng( * " The physiotherapy treatment was given in the form of electrical stim lation $galvanic c rrent 1"=)"82( for m scles re- ed cation and e*ercises and massage 1;)"82 to the affected side) and this treatment was done every other day ntil patients recovery+ The patients were re-assessed after % wee-s) " month and % months 1#2+ The second gro p $"# patients( was treated by prednisolone only and regimen similar to that sed in the first gro p) and they were assessed after % wee-s) " month and % months+ The third gro p $"# patients( was treated by physiotherapy only 0n the same regimen of physiotherapy sed in the first gro p+ They were re-assessed after % wee-s)" month and % months+ ?MB st dy was done for si* patients only beca se of the limitation of facilities) two of these patients showed severe denervation and the other fo r showed partial denervation+

Table " 3hows so rces of referral of all patients Referral Rehabilitation Medicine Beneral Practitioner ?@T clinic Medicine Enit @e ros rgeon Total @o+ of patients @o+ of patients "7 "= ; 8 # 8#

Table # 3hows the distrib tion of the Patients according to the age gro ps and se* ,ge ' years &- < "& -"< %& . %< =& . =< 8& and above Total @o+ @o+ of Patients 8 "% "7 "& % 8# Male " # "" 7 " %# 3e* Female = 7 ; = " %&

Table $ 3hows the responses and follow . p of all the gro ps of patients according to Ho se . Brac-mann grading system+ Patients %rou s The first grou &treated by steroid and hysiothera y' Brading of patients at start of treatment Brading of patients after % wee-s follow . p Brading of patients after " month follow . p Brading of patients after % months follow - p The second grou &treated by steroid only' Brading of patients at start of treatment Brading of patients after % wee-s follow . p Brading of patients after " month follow . p Brading of patients after % months follow . p The third grou &treated by hysiothera y only' Brading of patients at start of treatment Brading of patients after % wee-s follow . p Brading of patients after " month follow . p Brading of patients after % months follow . p Ho se . Brac-mann grading system B0 B00 B000 B0D BD BD0 8 # # " = 8 # = = = ; 8 7 # % " ; 7 8 % 9 7 8 " = % " 8 % " " % " " " " " " " % " " % % % %

% ; "% " 8 < % % 7

palsy+ Rochester Minnesota ,nn+ @e rology "<9;) %& #! ;%%-7) #- Macleod +) The nervo s system in Davidson) principles and practice of medicine) thirteenth edition 6h rchil >ivingestone "<9" p+ ;8<-78= ;- Mo ntain R ?) M rray I ,) Maynard 6 M) The ?dinb rgh facial palsy clinica! a review of three year activity coll+ s rg+ ?dinb+ =< octo+ "<<8+%7#-<+ 7- McBovern F H+ , review of the e*perimental aspect of Bell's palsy >aryngoscope 79+ =%8-== "<;9+ 9- 6lar-e) 6+R+,+ @e rological Disease+ 0n! clinical medicine+ F mar H 6lar- $?ditors(+ ;th edition) ?lsevier 3a nders+ ?dinb rgh+ %&&#AP!""97+ <- Bl nt M I+ The possible role of vasc lar changes in the eitiology of Bell's palsy+ I+ >aryngol+ Ctol+ 7&+ 7&""=) "<#;+ "&- >eibowit: D+ ?pidemic incidence of Bell's palsy Brain <% ! "&< - "8 "<;<+ ""- ,do r F+F) Byl F M) Hilsinger R >+ Ir) et al ! The tr e nat re of Bell's palsy analysis of "&&& consec ative patients >aryngoscope 99A 797 - 9%&) "<79 "%-Dictor M ) ,dams R) Diseases of cranial nerves in Harrison's principles of internal medicine McB+ Hill international 6o+ @ewgoris "<97 p %"#=-%&& "=- Bmova , and 5inster 3+ T+) The conservative treatment of Bell's palsy , review of literat re , M I Phy+ Med 8"A %"=) "<;%+ "8- 3hrod+ > 5) Treatment of facial m scle affected by Bell's palsy with high voltage electrical m scle stim lation+ @ational college of chiropractic) 6hicago 0 >) I manip lative physio+ "<<= I n) "; $#(! =87-#%+ "#- B stamante-Balcarcel ,! Panel disc ssion no+< incidence and management of Bell's palsy according to geographic distrib tion in Fisch E

(iscussion The st dy shows that the male $%# the patients( were affected more than female $%& patients() in contrast to 3alavica F+F+ st dy 182 which showed female predominance+ Most of the patients were at the age gro p %&-=& years which is similar to the res lt of Brodie 3+5 1"72 st dy+ ,c4 iring the disease d ring @ovember and December "<<# with history of cold e*pos re was doc mented in 88+8G of the patientsA this association was also mentioned in Richard B+ et al+ st dy1"92+ Two hypertensive patients) one 78 year old male other ;& year old female were at grade D $Ho se-Brac-mann grading( and were treated by physiotherapy b t did not show improvement after % months period of treatment a res lt which is similar to what ,do r F+F et al+ 1""2 stated in their st dy that old age and hypertension are negative risfactors infl encing recovery of Bell's palsy+ Most of the patients $from all gro ps( ;%+% G showed complete recovery within % months period of the treatment1"<2+ This res lt was similar to 3alavica F+F st dy182 which showed that complete recovery occ rs d ring this period+ Delay in recovery was more evident in the third gro p beca se those patients were not attending physiotherapy treatment at reg lar interval+ !eferences "- 3nell R+3+ 6linical ,natomy by Regions+ 9th edition) >ippincott 5illiams H 5il-ins+ %&&9A p! 7;=-7;8+ %- Bannister R+ The cranial nerves in Brains clinical ne rologyA C*ford niversity press+ "<9# p+ =#-97+ =- 3wash M+ The nervo s system in H tchison's 6linical Methods Baillier Tind l " <9< p+ %98-=9&+ 8- 3alavica F+ Fat sic+ 0ncidence) clinical feat re and prognosis in Bell's

led facial nerve s rgery) ed =+ J rich) international symposi m of F+ nerve s rgery "<7;+ ";- 3mith 0 M) M rray I , M) 6 ll R ?) 3lattery I+ , comparison of facial grading system clin+ Ctolaryngol+ "<<%! "7 =&=-7+ "7- Ho se I 5) Brac-mann D ?) Facial nerve grading system Cto0aryngol Head and nec- s rg+ "<9#A <=) "8;-7+ "9- Richard B+ Chye and ,ltenberger ? ,) Bell's palsy) Chio state niversity Chio) D+8& @o+% ,FP , g st "<9<A "#<-";#+ "<- Ropper ,+H+ and Brown R+H+ ! ,dams and Dictor's Principle of @e rology+ 9th edition+ McBraw-Hill) @ew Kor-+%&&#! p! ""9%+