Facial Paralysis: Bell’s Palsy
Guest: Dr. Ted Meyer – Otolaryngology - Head & Neck Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Ted Meyer who is Assistant Professor of Ear, Nose and Throat or Otolaryngology. I want to talk, in this podcast, Dr. Meyer, if we could, about facial paralysis, and one common form of that, Bell’s Palsy. Can you describe, let’s say, a classic presentation of facial paralysis, if there is such a thing?
Dr. Ted Meyer: Sure. There are acute facial paralyses or gradual facial paralyses. The most common acute facial paralysis is termed Bell’s Palsy. Bell’s Palsy is thought to be caused by the herpes virus. Bell’s Palsy is a sudden onset of a facial paralysis on one side, typically over the course of several hours to several days. If the face stops moving altogether, that’s termed paralysis. If the face is still moving to some extent, we term that a paresis or a facial weakness on one side.
There are many causes of facial paralysis. Bell’s Palsy would be, by far, the most common. In the state of South Carolina, there are probably around 1000 cases per year of Bell’s Palsy. But other things can cause facial paralysis, such as otitis media or ear infections, cholesteatoma, acoustic neuromas or other tumors involving the seventh or eighth nerves, other skull base infections and, unfortunately, cancers can cause facial paralysis too. Every month or two, I see somebody in my practice whose been diagnosed with Bell’s Palsy that turns out, actually, to have a cancer or other tumor that’s caused their facial paralysis.
Dr. Linda Austin: So, when you evaluate a patient in order to make sure that there isn’t a tumor or something more serious, how do you evaluate that patient?
Dr. Ted Meyer: Every patient comes in, gets a hearing test. Every patient gets a thorough head and neck exam to feel for masses, to look in the middle ear for fluid, for infection, for cholesteatoma, things like that. If somebody is diabetic, a simple external ear infection or swimmer’s ear in a diabetic can lead to a facial paralysis. In fact, over the past three months, I’ve seen five patients in my practice who’ve had skull base infections due to their diabetes. And a couple of them have had facial paralysis associated with that. If need be, we then order a CAT scan or an MRI scan, or a different type of scan, to help us determine what’s going on.
Dr. Linda Austin: Now, clearly, in the situation where there’s a tumor, you have to treat the tumor. But let’s imagine it’s a more common, garden variety, Bell’s Palsy. How do you go about treating that?
Dr. Ted Meyer: The important thing for a patient who comes in with Bell’s Palsy, after we determine that it really is a Bell’s Palsy, is to determine whether the face is moving or not moving. If the face is moving, even just a little bit, facial nerve function will ultimately return to normal or very near normal. When the face is not moving on that particular side, that warrants further study. Further study is performed in an electrophysiology lab where we actually can stimulate the facial nerve and then monitor the face for movement. If these studies show signs of neural degeneration then the patient may be a candidate for a surgical procedure to decompress the nerve. This doesn’t happen very often, and it’s a big decision to undergo a major surgery to help with a facial paralysis. The important thing for patients with facial paralysis is to start treatment early.
Dr. Linda Austin: How, then, do you go about treating it?
Dr. Ted Meyer: Treatment for facial paralysis in Bell’s Palsy is typically done with oral steroids. We give high-dose oral steroids for a week, sometimes longer. We also give anti-viral therapy. Bell’s Palsy, again, is thought to be caused by a herpes virus, so we use medication, acyclovir or valtrex, or a similar medication, to help stop viral replication. The most important thing, however, for patients with facial paralysis, is protection of the eye. The muscles supplied by the facial nerve actually allow you to close your eye, not open your eye, and if the eye is not allowed to close, you can get an exposure keratitis that can eventually lead to blindness. So, patients sometimes need to tape their eyes closed at night. They need to be on lubrication for the eyes, usually drops during the day, and an ointment at night.
Dr. Linda Austin: And what’s the outlook or prognosis for patients with Bell’s Palsy?
Dr. Ted Meyer: The prognosis for patients with Bell’s Palsy is very good. The majority of patients will have motion. And as long as a patient has motion, there’s an excellent chance of recovery. In the small percentage of patients who do not have motion and have degeneration, even 50 percent of them will return to normal, just with medical treatment. If it reaches the point of degeneration and they contemplate surgery, the odds of recovery increase to 90 percent.
Dr. Linda Austin: Now, you mentioned earlier that there are other causes of facial paralysis besides Bell’s Palsy. Would tumor, benign or malignant, be the next most common cause?
Dr. Ted Meyer: Probably the next most common cause is actually an infection of the ear, so, otitis media or middle ear infection. This happens because the facial nerve is actually exposed in the middle ear in up to 50 percent of patients. It runs in a bony canal, but there can be holes in this bony canal.
Benign tumors, in general, don’t cause facial paralysis. Even very large benign tumors, such as an acoustic neuroma, very rarely cause a facial paralysis. But I have seen three patients since I’ve been in South Carolina with acoustic neuromas present with acute facial paralysis. This is truly a strange presentation. Any sort of cancer around the ear, such as skin cancer or cancers in the parotid, can cause facial paralyses, the difference being that the majority of these facial paralyses are gradual onset. They do not appear like a Bell’s Palsy. Too often, unfortunately, the patient is told they have a Bell’s Palsy when in fact they’ve had a gradual facial paralysis. And by the time they reach me, it’s often quite late in the disease, the cancer has spread and it’s very difficult to treat.
Dr. Linda Austin: So, I guess that’s a good advertisement, then, for getting evaluation early.
Dr. Ted Meyer: Absolutely.
Dr. Linda Austin: Dr. Meyer, thanks so much for talking with us.
Dr. Ted Meyer: Thank you.
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