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When you’re diagnosed with Bell’s Palsy, if it’s among the more severe types of Bell’s Palsy, you will undergo electrophysiologic testing. This means that you’re sent to an otologist or a neurotologist (which is an ear, nose, and throat trained doctor), along with a physiologist or a neurophysiologist and they will measure the electrical stimulation of your face. If you meet certain criteria and you’re severely debilitated from this, instead of undergoing the regular treatment with corticosteroids, you will undergo decompression surgery. This is very, very rare. It’s extremely rare, but sometimes it’s necessary. If you’re one of those few people who has very, very poor stimulation and it’s one that is not going to recover, they send you for decompression surgery. Decompression surgery means that you go to the narrowest point of the canal that the facial nerve goes through, you drill away the bone so that this nerve (instead of being compressed and inflamed in one small area) can now expand and receive its proper blood supply. If it’s compressed into this narrow canal that it’s normally born in, the blood supply is constricted and the nerve can die in that area. What later follows, which is called wallerian degeneration (and regeneration, for that matter) afterwards is so severe that the nerve never grows back. This is why decompression surgery is performed.
Acupuncture has not been shown to help for Bell’s Palsy. Acupuncture has been shown to help with patients with other nerve disorders such as Trigeminal Neuralgia, postoperative pain and these have been shown. We don’t know if it works on every patient. We just know that it works in some patients.
Bell’s Palsy does not have any proven medication for improvement other than a corticosteroid like prednisone or dexamethasone. You should not try to treat it with homeopathics. You would only be putting yourself at risk. In general, the most potent of homeopathic anti-inflammatories that I’ve seen is most likely tumeric, and unfortunately even tumeric would never be able to touch the amount of inflammation that you need to take down with things like Bell’s Palsy. So as far as homeopathics go, unfortunately you would never be able to use them by themselves unless you want to put yourself at risk. If you want to use them in conjunction with other medications, just make sure to ask your doctor to make sure that the two medications don’t conflict. In general, homeopathic medications are not dangerous by themselves. The danger comes when your only solution is a non-homeopathic medication and the patient (without consulting with a doctor) goes and takes the homeopathic medication themselves (not taking the medication they’re prescribed) assuming that whatever they read on Google or in a book is factual. This could lead to permanent damage. Again, it’s always up to the patient to do what they want to do. However, my advice is for everybody to understand that we’re living in a new world now. Most of the doctors who are out there now (especially the younger ones) are very, very in tune with homeopathic medications. They do use them. However, they know the full array of effects of each medication and they’re best able to describe to you the risks and benefits of taking each one. If you are interested in taking a homeopathic medication, bring it up to one of these doctors who is knowledgeable in that (which most of them are at this point) and they will advise you why or why not to take the medication either alone or with whatever medication most doctors would prescribe you.
To date, we have no recommendation on diet for patients with Bell’s Palsy. In general, you just want to keep yourself healthy and rested. That’s the most important thing for preventing things like Bell’s Palsy, which tend to come out in patients whose bodies are really not surveilling very well.
If Bell’s Palsy is ignored, it might resolve. Even if it’s not ignored, it might resolve, it might not. In general, if Bell’s Palsy continues and you have the facial paralysis on one side of the face or the other, the main issues that you’re dealing with: first and foremost is the issue of poor closure of the eye. If you can’t close the eye long-term, you have to always deal with maintaining moisture with eye drops, with ointment. The next move is to surgically try to correct it because we can’t regain that function very well around the sphincter of the eye (or the Obicularis.) People actually tend to put in a piece of gold – so we’d take a little bit of a gold weight and we put it into the upper eyelid and the gravity helps the eye close, whether it’s in the daytime or nighttime when you’re asleep. Other parts of the face are treated for more severe cases of Bell’s Palsy. If you’re in that moderate to severe range, then it becomes worth it to try to fix the other issues that you see with facial asymmetries. If you’re in the mild range, there are no good treatments except for Botox and fillers to try to make the face more symmetrical. The type of procedures I’m talking about – for the more severe ones are facial sling procedures or animation procedures, where we either reconnect nerve, we reconnect muscles, or we actually statically or stiffly go back and move the eyebrow to a higher position or the cheek to a higher position. Again, for mild situations of asymmetry, botox is the way to go because you can just use botulinum toxin on the opposite side of the face to weaken it, to match this side of the face, so facial asymmetry is not as much of a problem.
Bell’s Palsy (from our understanding) if it is true Bell’s Palsy does not have any chance of having mortality or killing anybody. There are situations where we believe Bell’s Palsy is what’s going on and in fact, it’s not Bell’s Palsy. There are other situations where it’s a more severe virus – it is a stroke or it could be an infection at the skull base, especially in diabetes (called Otitis Externa) which can actually spread to the brain and brainstem. Bell’s Palsy in itself should not be fatal, should not have any long-term problems other than potential weakness in the face. However, you have to make sure that these other things aren’t going on. That’s why it’s not something to diagnose or treat yourself – you always go to a doctor to have them evaluate it properly.
Bell’s Palsy (whether or not it’s treated) has a very, very high chance of resolving by itself in mild to moderate circumstances. For the more severe ones, it has a very low chance – even if you treat it. Still, most people would say if you’re going to throw out a number, about 90% of cases will resolve either fully or nearly back to normal with treatment.
Bell’s Palsy can happen more than once. Nobody knows how, nobody knows why, and nobody knows which side it will happen on – but it can definitely happen more than once. If it does, you certainly need to be checked to see if it’s Bell’s Palsy or if there’s another disorder that you have that’s causing it.
If you’re having surgery for Bell’s Palsy, your prognosis is already very bad. Most likely the nerve will not completely recover in those patients – that’s the likelihood of it. That does take up to a year. In general, you assume that any kind of nerve growth, minimal amounts of nerve growth takes about 3 months. Any type of longer distance nerve growth takes up to a year. Past the year, you typically don’t see much of an improvement, although you still can see improvements for up to 3 years. You can determine this or if there’s going to be any changes with electrophysiology, doing testing to look for fibrillation potentials and myogenic potentials – meaning the potentials of the nerve themselves and the muscles as they react when the nerve gives a signal. The recovery from Bell’s Palsy varies from person to person on the severity of the degradation of the nerve. Patients with very mild cases tend to resolve within the first 3 weeks. Patients with more significant or severe debilitation from it usually take 6 months to a year to resolve if they resolve.
If you know that somebody in your family has had Bell’s Palsy before, there’s not much you can do to prevent it other than living a healthy and normal lifestyle. Stress-free, sleeping well – those kind of basic things that keep your immune response a little more potent and vigilant. If you have one of the other syndromes that cause facial paralysis, then it really just depends what the cause is of that. In those cases, there are preventions. In cases of neurofibromatosis or other genetic disorders, there are other very specific things you have to do throughout time for them.
With Bell’s Palsy, there been numerous clinical trials. The two main ones: one was that about 6 years ago and the other one was done about 20 years ago. There have been numerous since then – much research (actually around here at the House Ear Institute). The general outcomes of those trials: the first one, the outcome said that we should use antivirals and steroids. The second one, which was a much longer running trial said that we should just use steroids for the treatment of Bell’s Palsy. There haven’t been any other really significant advances since then – to my knowledge.
Insurance covers treatments for Bell’s Palsy in the immediate state, meaning you go to the emergency room. It is considered an urgent medical matter. They always have to cover it legally. Once you get to facial reanimation, it really varies from insurance to insurance. Most insurances do have to cover it, especially when it’s dealing with the eye – poor eye closure and eye function – because that can be severely debilitating for patients who don’t treat it properly.
I’m Dr Ben Talei. I’m a facial plastic surgeon out here in Beverly Hills, California. I’m a native to Southern California, but I did my training out in New York at Columbia and Cornell, followed up by a couple of fellowships at NYU and Einstein. My main focuses now are facial cosmetic surgery, reconstructive surgery, Hemangiomas and other vascular birthmarks, and I also focus in injectable or noninvasive techniques for the face.
Bell’s Palsy is what most people would look at as a type of paralysis or weakness in the face. In fact, it’s a very specific kind that has an acute onset – meaning it happens rapidly, it happens to one side of the face and it’s not one of the types of paralysis that you would really see from birth or anything else like that. In those cases, it’s called facial paralysis or it’s part of a different syndrome. It’s not actually called Bell’s Palsy, which came from Charles Bell who tried to initially name or describe the syndrome. Bell’s Palsy happens to probably 1% of the population (or so) at some point in their life. Sometimes it’s so mild that you wouldn’t notice it. Sometimes it’s so severe and debilitating that you’d have a complete inability to move the face. We’ve come up with a rating scale to describe the severity and it’s from 1-6. This grading scale allows the physician not only to diagnose the type of Bell’s Palsy or the severity of it, but also give a prognosis or outcome to the patient. In general, you would assume that if Bell’s Palsy is not treated, you would still have a fairly good outcome and the majority of patients. 85% or so who develop a mild or moderate Bell’s Palsy will resolve on their own within the first 3 weeks. Beyond that, you have the patients with more severe Bell’s Palsy or more severe paralysis and they tend to have a poorer prognosis. The question is: what do you do about it to increase your chances of healing from Bell’s Palsy? Number one is: you go and see the doctor right away. Any emergency room doctor can handle this. The treatment that we know now is to use very, very strong corticosteroids. Corticosteroids are different than the type of steroids that you would take for exercising. These are steroids that decrease the effect of your immune system in your body. The current course of treatment that ranges from person to person or doctor to doctor, but it’s generally 1-2 weeks of a high dose tapered corticosteroid. Previously, we thought that the syndrome was caused by a virus in the herpes family and we gave shingles-type medications like Valtrex, Valcyclovir, Acyclovir. Several studies have been done since that time showing that it has no benefit, however many physicians still prefer to give it because of the low chance of any side effects. What you need to determine, though, is: am I having Bell’s Palsy, if anything ever happens? Stroke can give a similar appearance with really, really subtle differences. There’s other syndromes called Ramsay Hunt Syndrome that do happen from the same type of herpes viruses and there are a whole host of other things that can cause it. So in general, the best thing is to see a doctor immediately and seek treatment immediately. The people who get treated immediately, they tend to respond much, much better than other patients.
The confusion that comes around Bell’s Palsy is that there are not different types of Bell’s Palsy – there are different types of facial paralysis or facial paresis. Facial weakness (or weakness of the muscles in the face) can be caused by a large, large number of things. When that cause is unknown, it is “acute” meaning it’s sudden onset and it’s on one side of the face. Those criteria – that makes it Bell’s Palsy and that is when you’re really guided down the road of treating someone like they have Bell’s Palsy. Still, you do need to work up other things so people would send you for an MRI or a CAT scan to make sure you’re not having a stroke or any other issues unless it is a clear cut Bell’s Palsy.
Bell’s Palsy is a condition that occurs suddenly. It usually progresses over the first 3 days that you would notice it and the things that you notice is weakness on one side of the face. Typically, you notice that weakness from the top of the face all the way down (meaning it includes the forehead, includes the midface, includes the lower face.) Some people might feel like they can’t swallow as well, they can’t close their eye as well, they start to develop dryness. In addition, because it involves a facial nerve, you can have an effect on the nerve that travels through the ear, down to the tongue, and you can get a difference in sensation or tastes around your tongue. Typically over the course of about 3 days, you would notice it worsening and it can continue to worsen over the course of about a week. A patient or a person who is not in the medical field will not know if they have Bell’s Palsy or not. They can only see that they’re developing weakness on one side of the face or both sides of the face. If that happens, you go straight to the emergency room and you seek diagnosis from the physician who’s in the emergency room. You can also be treated by a neurologist, or you can be treated by an ear, nose, and throat doctor. Those are the 3 main types of doctors who treat Bell’s Palsy. Bell’s Palsy specifically only affects one side of the face. It is defined as an acute onset, idiopathic unilateral facial paralysis.
One of the main issues that we see with Bell’s Palsy is that the entire side of the face is weakened. In some situations, this would weaken the mouth – people can deal with that. In other situations, it would weaken the wrinkling of your nose – people can deal with that. Some people can’t raise up the eyebrows to make a funny face – people can deal with that. The one thing that we’re trying to treat (other than the inflammation itself around the nerve) is to make sure that we protect the eye. The eye is the only thing that we really care about in the first several weeks or in the long-term for Bell’s Palsy. The reason is: the muscle that controls the closure of the eye is controlled by the facial nerve. If that muscle is not working, you have a very weak blink reflex. In addition, when you sleep, you can’t close your eye and maintain the moisture. So the main thing that the main problem that arises is keratitis, keratoconjunctivitis, different types of irritation of the eyeball itself. So when you’re going through treatment of Bell’s Palsy, the main things that we advise for patients: number one is to take the steroids they’re given. If the doctor elects, they will give them the antiviral as well. However, the most important thing that they need to do is to make sure their eye is maintained in a very, very moist and controlled way. Meaning they would either use ointment and the eye at night, tape on the eye at night, or put a moisture chamber on the eye at night. These are all available over the counter.
Bell’s Palsy (per person) – you can’t really say what the percentage chance is that they’ll ever get it, but in general 1% (or a little bit over that) will have it in the course of their lifetime. The overall incidents, you assume is about one in a thousand people.
Bell’s Palsy can affect children as well. However, it is much more rare. It is more common in the adult population for a variety of reasons. When it happens in children, we worry about different types of syndromes causing it. If a child is born with it, that itself is in a unique set of syndromes. When it happens in children, we treat it the same initially. However, we do do the workup and then we follow them, both with genetic testing and we follow them serially over time to see if it happens again. Again, that would throw them into a certain set of syndromes (of which there are probably three) where it happens in different ways.
There are many, many things that can cause facial paralysis or facial weakness. The first and most concerning, especially in an older population is stroke. In a younger population, you’re worried about syndromes, you’re worried about other types of infections (congenital infections) that you can be born with. In the older population, you’re also worried about different types of viruses that can cause that problem. Ear infections that can cause that problem. Even a regular middle ear infection can cause that problem as part of the facial nerve runs around and in the middle year.
The causes of Bell’s Palsy are currently unknown. We believe that there is some relationship to the herpes simplex virus family. This has not been proven. We have seen that in patients with Bell’s Palsy, they do test positive for it. However, there’s no correlation between the two at this time – so we’re not sure. We just know that it’s caused by some inflammation around the nerve. We do not know if any of the viruses cause Bell’s Palsy. Specifically, the herpes simplex family of viruses has been shown to cause problems with the facial nerve. However, these are more consistently shown with different syndromes such as Ramsay Hunt Syndrome, which is slightly different than Bell’s Palsy.
Ramsay Hunt is definitively caused by herpes virus. Bell’s Palsy, we know there’s something causing inflammation around the nerve but it has never been proven to be a herpes virus when they do biopsies. But when you do an MRI, you’ll see that the nerve itself is inflamed and pissed off.
Bell’s Palsy in general is more likely to develop in immuno-incompetent patients or people with immune problems. This ranges from people who don’t take care of themselves, people who are massively stressed, have consistently high cortisol levels, and most commonly would happen to diabetics. Diabetics (because of the high glucose level, if it’s not maintained) do have a poorer immune response than other patients do.
At this point, we’re not sure if Bell’s Palsy is congenital, genetically related, or runs in the family. However, there does seem to be a predisposition within families, so if you do have somebody within your family who was had it at some point in your life, you are slightly more predisposed to getting Bell’s Palsy than the rest of the population. We don’t know why. We don’t know what genetics are involved when it’s Bell’s Palsy. If it’s facial paralysis due to other genetic disorders, it’s not called Bell’s Palsy, and then we do know.
When somebody goes to the emergency department or to another physician because of the facial paralysis, whether to see if it’s Bell’s Palsy or not, they are technically doing a diagnosis of exclusion. Meaning: they’re assuming that it’s Bell’s Palsy only if everything else is negative. The things they check for is: they’re going to do blood tests to check for lyme disease, they check for inflammation in the blood via several different tests, they check your white cell count, and they will do some kind of head imaging to make sure that there’s nothing going on inside your ear or your brain that’s causing it rather than the nerve itself. So the first thing you do for Bell’s Palsy is a physical examination. The physical examination is probably 90+% of your diagnosis. The rest is a diagnosis of exclusion. So you do the testing with the imaging in the head, you do the blood testing. If everything else is negative, you are definitively diagnosed as having had Bell’s Palsy and that’s when you assume treatment. That’s when you take the steroids and possibly you’ll get antivirals at the same time – again, just depending on the dealer’s choice.
Bell’s Palsy typically will resolve in the first 3 weeks in mild to moderate circumstances. In more severe circumstances, it can take up to a year to resolve and in many situations it actually will not resolve, where some patients will only recover some or partial function.
I think the most important thing to know about Bell’s Palsy is that it is often misdiagnosed. People think everything is Bell’s Palsy when you get weakness in the face and that is not the case. Most people really need to understand that it’s not for them to determine. It’s much better to go to a doctor. Google is not going to give you the answers that you need, nor is any other search engine. If you do have Bell’s Palsy, if you do have another syndrome, you need to be treated and checked immediately. That’s the most important thing to remember about this – waiting a week gives a significant, significant difference in prognosis and outcome.
If you think you’re in a position where your face is getting weaker on one side or both sides, you should immediately go to the emergency department. You don’t need to take anything with you – just your list of medications and things like that. The one thing you’d really want to tell the doctor is if you’re diabetic because the treatment will directly affect diabetics. It’s a very, very strong steroid and people have actually died or gone into shock from having steroids with poorly controlled diabetes.
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