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EARLY CARE

THE DIAGNOSIS ...
Bell's palsy is a diagnosis of exclusion. During the first visit to a doctor, questions will be asked, and tests may be ordered. These procedures will help the doctor determine the cause of the facial weakness, or rule out conditions which are known to be linked to facial paralysis. When no underlying cause is found, Bells palsy is the diagnosis. For example, blisters in the ear or mouth, dizziness or reduced hearing on the affected side may suggest a diagnosis of Ramsey Hunt syndrome.

Slowly progressing paralysis, weakness in areas other than the face, an enlarged parotid gland or paralysis that spares the eye and brow are also among the symptoms may indicate the presence of an underlying condition requiring additional medical attention.

After taking a history and carefully observing the symptoms, tests that may be ordered include various blood tests, MRI, or CAT scan. These tests shouldn't be a cause for concern. They will either add conviction to a diagnosis of Bell's palsy, or provide the physician with the information needed to proceed in another direction.

Facial paralysis is a result of nerve damage, and many people look no further for help than to a neurologist. Patients may be unaware that the condition also falls into the realm of otolaryngology, and that (ENTs) are generally quite knowledgeable in diagnostics and treatment.

IN GENERAL ...
The first priority in treating Bell's palsy or any type of facial paralysis is to eliminate the source of damage to the nerve as quickly as possible. Minor compression for a short time period can result in mild and temporary damage. As time goes on with constant or increasing compression, damage to the nerve can also increase. If you decide to use medications that may help relieve the compression (Prednisone and antivirals), they should be started as quickly as possible. The "window of opportunity" for starting these medications is thought to be 7 days from the onset of Bell's palsy. Prednisone may be prescribed later if it appears the inflammation has not subsided.

Rest is important. The body has had an injury, and will heal most efficiently with enough rest to maintain strength and immunity at peak levels. It's normal to feel more tired than is usual during recovery. If you choose to work or exercise immediately after onset, be smart about it - when your body tells you it needs a break, indulge it if you have that option.

Food particles can lodge between the gum and cheek, so take extra steps to maintain oral hygiene.

Wear eyeglasses with tinted lenses, or sunglasses (see eye care for additional important information).

Take extra care to keep your eye moist while working on a computer. Even under normal circumstances people tend to blink less frequently while at a computer. For a dry, non-blinking eye, this can be more of a problem. Keep eye drops handy, and remember to manually blink your eye with the back of the index finger.

If sounds appear painfully loud, don't hesitate to ask people to speak softly. Exaggerated perception of volume isn't a symptom that people are likely to be aware of, so you may need to explain that it's a symptom associated with Bells Palsy. An earplug can help, although if you have a history of any inner or middle ear problems or have had surgery in the ear, check with your doctor before using an earplug.

Immediate exercising is not recommended. Unlike skeletal muscles, facial muscles do not immediately start to atrophy. Until the nerve starts to send a signal to the muscles, the muscles simply cannot move. Forcing movement before seeing signs that the nerve is starting to transmit signals again may create long-term problems. Even while the muscles appear flaccid, some nerve threads may be functional. When you try to force movement under these circumstances, you can inadvertently signal the wrong muscles to jump in and help. As time goes on, these inappropriate movement patterns can become automatic. They can result in asymmetrical and synkinetic types of motion. Instead of pushing it in the early days, try to be patient, and remind yourself that in time movement will return. Massage or tapping can provide gentle stimulation without risk.

For pain or discomfort, moist heat can help. There are gel packs and thera-bead packs that can be heated in a microwave for fast, easy and portable help with the soreness. They can usually be found in drugstores and pharmacies, in the section with old fashioned heating pads. In a pinch, ordinary rice in a sock can be heated in a microwave. For a treat, try an herbal heating pack. Doctors are not all aware that significant pain can be part of the ordeal. If you need medication, ask for it. If the doctor doubts the pain is real, refer him to the recently published "The Facial Nerve, 2nd Edition" for documentation. Severe, or long lasting pain is more consistently associated with Ramsey Hunt Syndrome. There are several medications that provide relief including Neurontin. This is a relatively new drug for neuropathic and post-herpetic pain. It's effective for the pain caused by shingles and Ramsay Hunt syndrome, and has relatively minimal adverse effects. Common side effects include drowziness, dizziness and nausea. Interactions with other drugs are nearly non-existent.

MEDICATION
If the origin of the palsy is viral, both the virus and the inflammation are likely to run their natural course in a short period of time even without medication. There is no firm proof that medication is beneficial for Bell's palsy. The number of quality studies published to date (non-biased with correct controls & methods) is limited. It is likely that medications will be effective only if administered shortly after onset. For Bell's palsy, seven days is viewed as the outside limit. For Ramsey Hunt Syndrome, if no anti-viral was given immediately after paralysis, it can be started at any time blisters appear, even if the 7-day period has passed.

The medications currently used for Bells palsy and Ramsey Hunt Syndrome are the same: an anti-viral and Prednisone, which is an efficient, fast acting anti-inflammatory agent.

In a study released by the Quality Standards Subcommittee of the American Academy of Neurology (May 2001), Drs. Patrick Grogan and Gary Gronseth pooled the data of existing studies published from 1996 through 2000 regarding the effectiveness of steroids, anti-virals, and decompression surgery as treatment for Bell's palsy. Their conclusions are:

1. Regarding the use of steroids:
Steroids are "safe and probably effective in improving facial functional outcomes in patients with Bell’s palsy." Results show significantly better outcomes with steroids. However, they do not find any difference in the time frame for recovery.

2. Regarding the use of antivirals used in combination with steroids:
Based on the limited data available, "acyclovir (combined with prednisone) is safe and possibly effective in improving facial functional outcomes in patients with Bell’s palsy."

3. Regarding decompression surgery:
"The risk of bias in all studies describing facial outcomes in surgically treated Bell’s palsy patients was too high to support evidence-based conclusions. Additionally, serious complications, including permanent hearing loss, were reported from surgical facial nerve decompression."

The number of well controlled, unbiased studies available was limited. It is clear that further research is necessary to fully assess the potential benefit of these treatments.

PREDNISONE FOR BELL'S PALSY...
Prednisone is a synthetic hormone that mimics a natural steroid called cortisol that the body produces. Under stress (injury or illness) cortisol production is increased fourfold as part of the body's normal reaction to the stress. Prednisone has approximately five times the potency of cortisol. 20mg of Prednisone is roughly equal to the amount of cortisol the body normally produces in a day while under stress.

Inflammation is an integral component of the body's response to an injury or illness. Among the many things that occur, substances called cytokines are secreted as part of the immune system response to the stress. Cytokines work to "rev up" the immune system. As the immune system functions increase under stress, antibodies are produced and inflammation results. The antibodies kill cells that the body interprets are foreign, such as viruses and bacteria.

In part, Prednisone works as an anti-inflammatory by its effect on immune cells. It acts as an immuno-suppressant, inhibiting the secretion of cytokines. The result is that antibody production is suppressed, and the inflammatory process is slowed and weakened, quickly reducing the inflammation compressing the nerve. Because Prednisone works by an immuno-suppressant process, it cannot be administered to patients with existing immune system problems.

Prednisone's rapid anti-inflammatory action makes it a worthwhile medication for most patients in spite of its effect on the immune system.

Assuming there are no medical conditions that would negate the use of Prednisone, it can be used by children and adults.

BEFORE TAKING PREDNISONE
Some conditions that may affect a doctor's decision to prescribe Prednisone...

Diabetes
Heart Problems
Recent Surgery
Pending Surgery
Seizures
Some cancers

Stomach or intestinal disorders
Under-active thyroid
Pregnancy
Nursing
Compromised immune system
HIV


Medications that may interact or interfere with Prednisone...

Diuretics
Birth Control Pills
Blood Thinners
NSAIDS
Ibuprofen
Barbutuates

Acetazolamide
Amphotericin B
Digoxin
Phenytoin
Rifampin
Rifabutin


Adverse effectsSide effects are sometimes associated with Prednisone. They tend to be directly related to the amount of Prednisone taken, and how long it's taken. For facial paralysis, usage is short term. The effects tend to decrease as you reduce your dosage, and disappear rapidly when you stop taking the medication.

Potential side effects...
Stomach pain (take medication with a meal, milk or antacid)
High blood pressure (restrict salt usage)
Increased appetite & weight gain
Acne
Sweating
Insomnia (take the medication in the morning if possible)
Mood swings
Personality changes
Sensitivity to the sun
Temporary muscle weakness
Fluid retention (restrict salt usage)
Hyperglycemia
Reduced immunity to infections
Increased potassium depletion (eat fruit with high potassium levels)
Swelling of the face, back of neck or ankles

ANTI-VIRALS FOR BELL'S PALSY AND RAMSEY HUNT SYNDROME...
Antivirals work by binding to viral enzymes so that the cells cannot replicate. Unable to replicate, the virus runs its course faster. The inflammation at the nerve should be less than without an anti-viral and is eliminated in a shorter time.

Famciclovir (Famvir) and acyclovir (Zovirax) are frequently prescribed anti-virals. A newer anti-viral, valacyclovir (Valtrex) appears to work faster. Adverse effects of valacyclovir can include headache, nausea, diarrhea, constipation and dizziness.

With a diagnosis of Ramsay Hunt syndrome, administration of an anti-viral should start within 72 hours of the blisters' appearance, even if blisters do not appear until a week or more after onset of facial palsy. Secondary infections may occur with RHS. The patient should be made aware of this, and be instructed to notify the physician of any signs indicating a bacterial infection. An antibiotic will be prescribed in addtion to the antiviral.

HIV carriers may find they are resistant to the standard anti-virals. Immuno-compromised patients should ask about Foscarnet (Foscavir), a recently approved anti-viral that may be more effective for compromised immune systems.

The AAN 2001 evaluation mentioned above states that antivirals are possibly effective. It should be noted that the term "possibly" must be used with only one study considered acceptable for evaluation. A single study can not provide sufficient data for a firm conclusion or recommendation. The conclusions of that single study (Adour '96) were favorable to treatment with acyclovir plus Prednisone.

B VITAMINS..
Many of the B vitamins are essential for proper nervous system functioning. Addition of a basic B-complex vitamin to the daily routine may be a good idea during recovery. Some B's that may be particularly beneficial are:

B1 - enhances circulation (circulation is reduced in muscles that are not active) and may retard muscle atrophy.

B6 - assists in the creation of amino acids needed in the creation of new cells.

B12 - when taken as part of a "B-complex" vitamin, may help reduce inflammations and strengthen the immune system. Methylcobalamin is a form of B12 that is not a component of basic B-complex vitamins, and is important to nerve growth and maintenance.

METHYLCOBALAMIN ...
Methylcobalamin is an essential component in the process of building nervous tissue. It is important contributor to nerve growth, and maintains and repairs the critical, protective nerve sheath.

Methylcobalamin's action is directed at the nerve's myelin sheath, which is like a layer of insulation around the nerve. It protects the nerve and helps the signal travel along its designated path correctly. It appears to promote protein synthesis, accelerating cell division. Myelin sheath formation at the site of the damage is enhanced. This may, in part, explain recent findings that ultra-high doses may enhance nerve regeneration.

A small 1995 Malaysian study (MA Jalaludin) concluded that the subjects had faster recoveries with Prednisone plus methylcobalamin versus Prednisone alone. However, the results of this study have not been validated, and the quality of the study and its references require evaluation. While methylcobalamin is showing potential as treatment for some neuropathologies, it is not acknowledged as a treatment with any benefit for Bell's palsy. The primary therapeutic benefit of methylcobalamin relates to pernicious anemia, which is not a factor in Bell's palsy. There is no proof of its effectiveness for Bell's palsy. Its benefit, even for new cases, is still considered to be questionable. There don't appear to be any adverse effects associated with high doses of methylcobalamin, so it may best come under a heading of "it can't hurt to try". Methylcobalamin is not known to be therapeutically beneficial in cases of longstanding facial paralysis, nor is there reason to believe that it can help prevent recurrences.


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2/21/02
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