Acta Oto-Laryngologica

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Vestibular Symptoms in Idiopathic Facial Palsy

K. Lmmli & U. Fisch

To cite this article: K. Lmmli & U. Fisch (1974) Vestibular Symptoms in Idiopathic Facial Palsy,
Acta Oto-Laryngologica, 78:1-6, 15-18, DOI: 10.3109/00016487409126320

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 Acta Otolaryng 78: 15-18, 1974
VESTIBULAR SYMPTOMS I N IDIOPATHIC FACIAL PALSY
K. Lammli and U. Fisch
From the Department of Otolaryngology, the University of Zurich, Zurich, Switzerland
(Received December 28, 1973)
Abstract. One week after the onset of the paralysis 75 %
respectively 92 % of the patients with Bell's palsy presen-
ted with a spontaneous or/and positional nystagmus. The
spontaneous vestibular symptoms are discrete and usually
not subjectively realized by the patients. No direct corre-
lation between the degree of the vestibular disturbance
and the severity of the facial nerve palsy has been found
in the first week after onset of the paralysis. Only the
Acta Oto-Laryngologica 1974.78:15-18.
time evolution of the spontaneous vestibular signs (partic-
ularly of the positional nystagmus) showed whether the
lesion of the VII nerve was reversible or not. The present
study does not confirm therefore the hypothesis that the
vestibular signs present in Bell's palsy may be used for
the prognostic assessment of the lesion. The quality and
evolution of the vestibular signs found in Bell's palsy
do confirm, on the other hand, the surgical observation
that the most common site of lesion of the facial nerve
in idiopathic palsy is the entrance of the Fallopian Canal
and not in its more distal course.
Vestibular symptoms occur quite frequently in
presence of idiopathic facial palsy (Philipszoon,
1962; Robert & Pfaltz, 1970). Their origin is
most probably related to the compression of
the superior branch of the vestibular nerve by
the edematous facial nerve fibres in the region
of the meatal fundus (Fisch & Esslen, 1972;
Fisch, 1973). The aim of the present study was
to determine the pattern and time evolution of
the vestibular disturbances observed in Bell's
palsy and to analyse whether the vestibular
symptoms correlate with the degree of severity
of the palsy.
MATERIAL AND METHODS
The spontaneous and positional nystagmus as
well as the caloric reaction of 25 patients (aver-
age age 33 years) have been recorded by electro-
nystagmography at regular intervals for 6 months
after the onset of a unilateral idiopathic facial
paralysis. The caloric test was performed by
irrigating the external ear canal with 20 cc of
water of 27 at 47C. The following parameters
of the caloric nystagmus were analysed: dura-
tion, average maximal velocity of the slow com-
ponent, frequency, and total maximal intensity.
In order to correlate the electronystagmographic
findings with the degree of the palsy, the per-
centage of degenerated facial nerve fibres was
determined by recording the summating poten-
tials of the paralysed muscles of the face accord-
ing to a method recently described by Esslen
(1973).
RESULTS
The evolution of the spontaneous vestibular
signs in 25 patients with idiopathic facial palsy
are shown in Fig. 1. One week after the onset
of the paralysis 75% respectively 92% of the
patients evidenced a spontaneous nystagmus or/
and respectively a positional nystagmus. The
average velocity of the slow component of the
spontaneous nystagmus was, on average, 2-3
O/sec, its maximal velocity 5" per sec. The number
of patients with spontaneous vestibular signs
decreasing rapidly in the first 4 weeks and slow-
ly thereafter. The percentage of patients with
spontaneous nystagmus reached normal average
values (16% of the cases) 4 months after onset
of the palsy. The positional nystagmus was still
present in 40 % of the patients at the end of the
observation of 6 months. The direction of the
Acta Otolaryng 78
 16 K. Lammli and U . Fisch

% No ofpatients clear results than that of the spontaneous vestib-

100 r ular signs. The ear of the affected side was

8ol-h hypoactive in one-half and hyperactive in the

other half of the cases (Fig. 2). Later on, the
prevailing hyperactivity (second week) is fol-
lowed by a definite trend towards hypoactivity
(third and fourth month). A similar pattern is
shown by the few cases (less than 20%) having
26
a significantly reduced or increased caloric
resp0nse.l The directional preponderance (Fig.
2B) is mostly oriented towards the side of the
i ' 2 3 4 5 6
months affer onset o f tbepa/sy palsy, particularly during the first 2 months
after onset of the palsy.
Fig. I . Time evolution of the spontaneous and positional
nystagmus in 25 patients with idiopathic facial paralysis. Fig. 3 shows the spontaneous vestibular signs
The broken lines represent the percentage of spontaneous in relation to the degree of the facial paralysis.
(16 %) and positional (26 %) nystagmus found in a group Four groups of patients have been formed, ac-
of normal individuals with the same age as the investigated
population. cording to the results of the neuro-electrical
tests:
Acta Oto-Laryngologica 1974.78:15-18.

spontaneous vestibular signs did not change
during the recovery from the palsy, pointing
towards the healthy side in 213 and towards the
affected side in 1/3 of the cases. 20% of the
patients developed a direction changing positio-
(1) patients with axon-blockade only
(2) patients with less than 50% degenerated
facial nerve fibres
1 According to the normal distribution of the caloric

rial nystagmus shortly before the disappearance nystagmus the unilateral response is significantly reduced
or increased if values of more, respectively less, than 25 %
of their spontaneous nystagmus. are obtained bv the formula: (1 + 3) - (2 f4)/1+ 2 + 3 + 4
The analysis of the caloric response gave less x 100%.

A. Hypa - or hyperacfivify B. Djrecfjonal preponderance

o f fbe involved side
% No ofpatients % No. o f p a t l e n f s
100 r 700 r

20

Fig. 2. Time evolution of the

intensity of the caloric nys-
tagmus (maximal velocity of

1u0L
I C I I I I I 1 I I
8o
I00 t 1
I

2 3
l l

4 5
l l

6
the slow phase) in 25 patients
with idiopathic facial para-
lysis. Note that only a very
? 2 3 4 5 6 limited group of patients
months affer onset months
o f {hepalsy with Bell's palsy presented
with significantly disturbed
+--a all cases 0---o sfafjsfical/y significan f cases caloric response.

Acta Otolaryng 78

no degenerafion degenerahun <50%
% No ofpafienfs
Fig. 3. Relation between spontaneous and positional
nystagmus and the degree of degeneration of the facial
nerve in 24 patients with idiopathic palsy. Note that
there is no direct correlation between the degree of vestib-
ular symptoms and the severity of the facial nerve degen-
(3) patients with 50 to 90% degenerated facial
nerve fibres
Acta Oto-Laryngologica 1974.78:15-18.
(4) patients with total degeneration of the facial
nerve
The spontaneous vestibular signs disappeared
more rapidly (4 weeks) in presence of an axon-
blockade only than in patients with partial or
total facial nerve degeneration.
This observation indicated that in Bells palsy
the time-evolution of the spontaneous vestibu-
lar signs reflects the degree of lesion of the nerve
fibres.
The correlation between the caloric nystagmus
Ysec fofa/maxima/ intens/fy
fs/ow component/
8olh
60
L I I I I I
1 2 3 4 5 6
monfbs af7er onsef of fbepa/sg
Fig. 4. Evolution of the total maximal intensity of the
caloric reaction of 25 patients with idiopathic facial para-
lysis. Note the increased maximal intensity for as long
as 3 months after onset of the paralysis.
2 - 142955
Vestibular symptoms in idiopathic facial palsy 17
degenerai/on50-90 % degener-at/on >90%
eration during the first week after onset of the paralysis.
The later time evolution of the spontaneous and partic-
ularly of the positional nystagmus are however delayed,
particularly if more than 90 % of the facial nerve fibres
are degenerated.
and the degree of the facial nerve lesion showed
that the axon-blockade is rather followed by the
hypoactivity whereas the degeneration of the
nerve fibres is followed by hyperactivity of the
vestibular response on the affected side.
The total maximal intensity of the caloric
response (Fig. 4) remained well above normal
average values during the first three months of
the palsy.
DISCUSSION
75 % respectively 92 % of the investigated patients
with idiopathic facial palsy presented with a
spontaneous orland positional nystagmus one
week after onset of the paralysis (Fig. 1). The
direction of the spontaneous vestibular signs
(towards the unaffected side) indicates that a
rather severe lesion of the utriculo-ampullar
nerve most probably due to compression from
the edematous facial nerve (Fisch & Esslen, 1972)
takes place in 2/3 of the patients suffering from
Bells palsy. The recovery from the vestibular
disturbance is very rapid during the first 2 weeks
after onset of the palsy and slows down there-
after. The time-evolution of the spontaneous
vestibular signs reflects therefore the acute phase
of Bells palsy, which is determinant for the
destiny of the facial nerve fibres and rarely
extends beyond the first 10-12 days after onset
of the palsy (Esslen & Fisch, 1971).
A c t a Otolaryng 78
 18 K. Lammli and U. Fisch
The correlation between presence, respective-
ly evolution of spontaneous vestibular signs and
the degree of degeneration of the facial nerve
fibres shows (Fig. 3):
(1) that the spontaneous vestibular signs are
more frequently observed in patients without
than in patients with degeneration of the VII
nerve, and
(2) that spontaneous and positional nystag-
mus disappeared more rapidly if the facial nerve
fibres did not degenerate.
According to these observations it is not the
presence but the time-evolution of the sponta-
neous vestibular signs which correlates with the
severity of the facial palsy. This is to be expected
since spontaneous and positional nystagmus can
result from a reversible axon-blockade or from
an irreversible degeneration of the afferent ves-
tibular nerve fibres. Only the time of recovery
Acta Oto-Laryngologica 1974.78:15-18.
will permit a differentiation between these two
different neural conditions. It is also logical to
suppose that the less important lesion producing
a reversible blockade for impulse conduction
in the facial nerve will also be followed by rever-
sible changes in the fibres of the utriculo-
ampullar division or the vestibular nerve.
In view of the discrete character of the regis-
tered spontaneous vestibular signs it is not sur-
prising that the caloric reaction of patients with
Bells palsy is only insignificantly disturbed.
This may also result from the fact that the intra-
meatal compression from the edematous facial
nerve involves particularly the utricular nerve,
which is closer to it and to a lesser extent the
lateral situated superior and horizontal ampul-
lar fibres.
In conclusion, there is no direct correlation
between the degree of the vestibular disturbance
and the severity of the facial nerve palsy during
the first week after onset of the paralysis. Only
the later time-evolution of the spontaneous
vestibular signs (particularly of the positional
nystagmus) shows whether the lesion of the VII
nerve was reversible or not. The present study
does not confirm, therefore, the hypothesis that
the vestibular signs present in Bells palsy may
be used for the prognostic assessment of the
Acta Otolaryng 78
lesion. The quality and evolution of the vestibu-
lar signs found in Bells palsy do confirm, on
the other hand, the surgical observation that the
most common site of lesion of the facial nerve
in idiopathic palsy is the entrance of the Fallo-
pian Canal and not its more distal course.
ACKNOWLEDGEMENT
We acknowledge the technical assistance of Mrs Liane
Regeler.
ZUSAMMENFASSUNG
Ein Spontan- oder Lagenystagmus wurde bei 75 % respek-
tive 92% von 25 Patienten mit einer einseitigen idio-
pathischen Parese beobachtet. Die spontanen vestibularen
Symptome sind im allgemeinen so diskret, dass sie von
den Patienten subjektiv nicht wahrgenommen werden.
Eine direkte Korrelation zwischen Grad der vestibularen
Storung und Schwere der Parese konnte in der ersten
Woche nach Einsetzen der Lasion nicht nachgewiesen
werden. Der weitere Verlauf der vestibularen Storungen
(vor allem der Lagenystagmus) zeigte dagegen, ob die
Lasion des Gesichtsnerven reversibel war oder nicht. Die
vorliegende Untersuchung zeigt, dass aus der vestibularen
Symptomatik kleine Schliisse in bezug auf die Prognose
einer Bellschen Parese gezogen werden konnen. Die Art
und der Verlauf der vestibularen Zeichen bei einer Bell-
schen Parese bestatigen, dass der Ort der Lasion am
haufigsten am Anfang des Fallopischen Kanals und nicht
weiter distal liegen muss.
REFERENCES
Bouche, J. 1969. Linteret de 16ctronystagmographiedans
les paralysies faciales spontankes. Ann Otol 86, 509.
Esslen, E. 1973. Surgery of the facial nerve, chap. 1V.
Urban & Schwarzenberg.
Fisch, U. 1973. Surgery of the facial nerve, chap. XII.
Urban & Schwarzenberg.
Fisch, U. & Esslen, E. 1972. Total intratemporal exposure
of the facial nerve. Arch Otolaryng (Chic.) 95, 335.
Lagerholm, S. & Toremalm, N. G. 1971. Peripheral
facial palsy. Actu Otolaryng (Stockh.) 71, 400.
Philipszoon, A. J. 1962. Nystagmus and Bells palsy.
Pract Otorhinolaryng (Basel) 24, 233.
Robert, F. & Pfaltz, C. R. 1970. Vestibulare Funktions-
storungen bei idiopathischer Facialisparese (Lokali-
sations- und Kompensationsprobleme). Arch Klin Exp
Ohr Nus Kehlkopfheilk 197, 183.
U. Fisch, M.D.
Dept. of Otolaryngology
Universitat Zurich
CH-8006 Zurich
Switzerland