Bell’s Palsy affects about 40,000 people in the United States each year. It can affect anyone of any gender and age but usually the highest incidence is the 15-45 age group.
The incidence is equal between men and women.
Incidence higher is pregnant women and lower in children.
Idiopathic form of Bell’s Palsy accounts for 60-75% of the cases.
7-40 cases arise per 100,000 persons per year.
Bell’s Palsy is also known as idiopathic facial palsy. It is a temporary facial paralysis or weakness usually on one side of the face. It is caused by a dysfunction of the seventh cranial nerve (facial nerve) which innervates the muscles on one side of the face. These muscles control eye blinking and closing and the muscles that control facial expressions such as smiling. The facial nerve also sends impulses to the tear glands, the saliva glands and the middle ear. This nerve also transmits the sensation of taste from the tongue.
Bell’s Palsy in the most common cause of facial paralysis and the cause is usually unknown. (idiopathic). In most cases, it affects only one side of the face but in rare cases it can present bilaterally.
Symptoms usually appear suddenly over a 48–72-hour period and gradually improve over weeks to months. In rare cases, residual muscle weakness can persist and may be permanent.
- Rapid onset of mild weakness to total paralysis on the muscles on one side of the face
- Difficulty of making facial expressions or closing of your eye
- Loss of taste
- Pain around the jaw or behind your ear
- Sensitivity to sound on the affected side
- Dry eye due to lack of tears
- Decreased saliva
Peripheral facial nerve palsy can be distinguished clinically from a central facial nerve palsy (due to a stroke) by its involvement of the muscles of the forehead. If the frontalis muscle functions normally but the middle and lower face are affected the lesion is probably central. The typical features of peripheral facial nerve palsy are a lack of wrinkling of the forehead, low eyebrow position, incomplete lid closure, hanging corner of the mouth and a flat nasolabial fold. However, an incomplete facial nerve palsy can be difficult to distinguish from a central nerve lesion.
Most cases of Bell’s Palsy are idiopathic meaning no etiology is found. It is commonly related to viral infections such as:
- Herpes Simplex
- Chickenpox and shingles (Herpes Zoster)
- Mononucleosis (Epstein Barr)
- Respiratory Virus such as adenovirus
- German Measles (Rubella)
- Hand Foot and Mouth Disease
Most scientists believe that it is caused by a reactivation of an existing dormant virus and the virus is triggered by stress, sleep deprivation, trauma, minor illness or any of the autoimmune disorders. As the facial nerve swells and becomes inflamed due to infection, it causes pressure within the Fallopian canal. This canal is where the nerve travels to the side of the face. The inflammation in this canal causes restriction of the blood flow depriving the nerve cells of oxygen. This can cause damage to the myelin sheath which is the fatty covering insulating the nerve. In the autoimmune hypothesis, the palsy is considered a variant of Guillain Barre syndrome with elevation of inflammatory cytokines.
Other conditions associated with Bell’s Palsy are
- Brain tumor
- Myasthenia gravis
- Lyme’s Disease.
Typically, a mild case of Bell’s Palsy resolves within a month (85% of cases). However, the more severe cases where there was complete facial paralysis can have varied complications such as;
- Irreversible damage to the facial nerve
- Irregular regrowth of the nerve fibers causing involuntary muscle contractions. This synkinesis can cause muscles of the other side of the face to contract when muscles on the affected side are used.
- Partial or complete blindness of the eye due to damage of the protective covering of the eye (excessive dryness and corneal abrasions)
There are no specific tests for Bell’s Palsy. If symptoms persist, testing may be recommended
- Electromyography or EMG. This test can confirm the presence or absence of nerve damage and gauge the severity. This test measures electrical activity of a muscle in response to stimulation. It measures the conduction velocity of an electrical impulse along a nerve.
- MRI of CT. These tests may be done if a tumor is suspected or in the face of trauma where a fracture can be putting pressure on the nerve.
- Laboratory analysis. Lab testing is of little value initially in the differential diagnosis but borrelia serology is recommended especially if borrelia is strongly suggested by history and physical. Borrelia is extremely high in children (34-56%) also varicella zoster virus infections.
- Because 25-40% of the cases are not idiopathic, neurologic exam, otoscopy and lumbar puncture for cerebrospinal fluid examination may be recommended.
Borrelia is a tick-borne illness caused by the bacteria Borrelia Burgdorferi. Deer ticks carry the bacteria that causes Lyme’s Disease.
Most people with Bell’s Palsy recover fully with or without treatment. Symptomatic treatment such as eye lubrication and eye protection will protect the eye from damage.
Physical therapy to stimulate the facial muscles to prevent atrophy. Paralyzed muscles can shorten or shrink. The therapy can help prevent permanent damage.
Surgery is extremely rare for this condition. In the past, surgery was used to decompress the nerve and to release the pressure on it as it passes through the canal. Facial nerve injury and permanent hearing loss are possible risks associated with this surgery.
Plastic surgery may be needed for persistent facial defects. Facial reanimation surgery may make the face more symmetrical and, in some cases, restore some facial movement. Examples of this type of surgery include eyebrow lift, eyelid lift, facial implants and nerve grafting.
Corticosteroids are the typical medications given for this condition. They can reduce swelling around the facial nerve and restore function. Early steroids in this disease can improve the likelihood of complete recovery.
Normal doses of drug treatment consists of prednisolone 25mg twice a day for 10 days followed by a taper off in increments of 10mg per day.
Anti-virals are commonly given with the corticosteroids. In some studies, anti-virals have not shown any benefit yet they are commonly used.
Virostatic drugs are optional in severe cases with intense pain or suspicion of herpes zoster and mandatory in cases of varicella zoster.
This condition has a good prognosis even if untreated. However, some 13% of patients go on to have a mild residual facial asymmetry that is considered non-distressing while 4% have severe residual paresis and 7% develop pathological accompanying synkinesia. Synkinesia are considered to reflect an abnormal pattern of re-innervation of the nerve.
Platelet Rich Plasma is an autologous blood product with higher than baseline concentrations of growth factors and cytokines. It is used in multiple medical applications to repair and regenerate damaged tissues. Although, this author could not find many studies on the use of Platelet Rich Plasma for residual Bell’s Palsy, in theory, PRP should provide positive outcomes in these cases. One such case is presented below.
Plast Reconstructr Suro Glob Open 2017 Jun;5(6): e1376 PMID 28740784
This is a case of a 27-year-old female patient who presented with a 26-year history of right sided Bells Palsy of uncertain etiology. The first signs were observed at age 6 months. Between the ages of 2 and 5 months, she received immunizations according to normal birth immunization schedule. She received DPT, polio and smallpox. She additionally received 2 more doses of polio. Physical exam after immunization revealed facial asymmetry due to right sided deviation of the mouth, obliteration of the nasal labial fold, and drooping angle of the mouth. She was unable to completely close her eye and had inability to raise the brow.
She had a full neurologic, ENT and serologic evaluation.
At age 27 she was admitted and was given repeated autologous peripheral blood mononuclear cells and PRP 9 times over the next year.
A total of 10 ml was locally injected in even proportions on the right side of the face into the temporal, orbicularis, buccinator, levator anguli, orbicularis, zygomaticus major and minor and levator labii. This treatment was repeated 9 times within the year.
Post treatment revealed significant improvement in the voluntary motion of the facial muscles. There was remarkable improvement in facial contouring and the facial asymmetry was significantly reduced. Nasolabial fold and tear trough were noticeably developed on the right side. Cheek augmentation emerged on the right side. Contours of the asymmetrically drooping corners of the lips were improved. Following treatments, the patient was able to close her eyelid completely.
Conclusion- According to the significant recovery that was observed after transplantation of autologous PBMC and platelet rich plasma, this therapy has the potential to restore neuronal muscular atrophy and provides a promising future strategy to cure facial atrophy.
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our FDA approved Platelet Rich Plasma Kits are designed for safety and effectiveness. Platelet Rich Plasma has been well documented in the osteoarthritis arena. The effectiveness far surpasses other therapies in the longevity of relief of symptoms caused by this disease.
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Dr. Robert McGrath