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Bilateral Bell's palsy?

Discussion in 'Otolaryngology' started by nadz, Mar 8, 2007.

  1. nadz

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    Hello everyone,I'm a master student from Malaysia. I want to know if anyone come accross such a case of bilateral bell's palsy?[​IMG]
     
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  2. resxn

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    Depends on whether you are asking about synchronous or metachronous lesions. For metachronous lesions, certainly Bell's can occur. The estimated incidence of recurrence is 12% and it's fairly well even between whether it occurs on the ipsilateral or contralateral side.

    For synchronous lesions, I would not use Bell's palsy as a diagnosis unless all others have been excluded. The 2 most common causes of synchronous B CNVII paralysis are Guillaine-Barre and Sarcoidosis (at least that's the answer we use on our board exams). I've seen different references cite both as the leading cause. Other potential causes include Lyme disease, Bell's palsy, leukemia, bacterial meningitis, syphilis, leprosy, Moebius syndrome (although that one should be pretty obvious), infectious mononucleosis, and skull fracture. There may be more that are much more rare or of which I'm not aware, but that is a reasonable list. I know that in Asia there are some unusual syndromes that are more prevalent such as Vogt-Koyanagi-Harada disease and Machado-Jesoph disease which I know nothing about that can also cause B facial paralysis.

    Hope that helps a little, not sure what you wanted to know. I personally have not seen B Facial Paralysis except in a 22yo African male who had non-HIV related massive base of skull endemic Kaposi's Sarcoma. He had lots of CN deficits though, not just VII.
     
  3. OP
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    nadz

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    Thanks for the info, actually I come accross a case of 39 year old lady presented with a week history of bilateral facial nerve palsy. She claimed that initially she had low grade fever for two day then followed by weakness of the left sided of the face then the right(looks like a poker face), no other associated symptoms or any ear symptoms.I found that only the motor function of the facial nerve were affected both sides(house-brackmann grade IV), other cranial nerves were intact,the taste and the ear were normal finding,hearing was normal.No history of trauma.Blood investigations revealed normal and CT scan also normal.

    Any suggestion for the management and what is the prognosis of patient.Any referal for me to read..

    Thank you very much..[​IMG]
     
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  4. resxn

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    I think that with HB IV the prognosis would be better than if it was completely out, but I think that only the ENoG really would give you a great idea in that if more than 90% of the nerve is out the prognosis worsens subtantially (based on Bell's palsy and trauma data, not on the other causes).

    However, the prognosis is probably much more dependent on the diagnosis. I'm not sure what more to say in terms of reaching a diagnosis other than ruling out the DDx I listed above or any other diseases of which I failed to think. The most reassuring thing for this pt is the negative CT. It may be worthwhile getting a high resolution MRI of the CPA just to see if you can see inflammation of the nerve. I don't have this capability at my facility, but many med centers now can quantify CNVII inflammation on MRI's. But then again, I doubt this would change your treatment.

    As far as reading goes, I'd just grab a standard text and flip through it. Dr. Mark May's book on the facial nerve is probably the most comprehensive if not most well-respected. As for each disease work-up, you'd probably do best by reading about each one individually.

    There are a lot smarter people on this forum than me, so hopefully they will offer some other ideas as well.
     
  5. OP
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    nadz

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    Thank you very much resxn,hopefully other members give thier respond to this thread. I did adviced the patient to go for MRI and by the same time i tried her with steroid therapy, Methylcobalamin and physiotherapy, she feel slightly improved, so that the patient refused to proceed with MRI. She just want to wait and see with the current management.

    Anyway if MRI showed something what could be the management?[​IMG]
     
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  6. resxn

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    Unless the MRI showed something in particular like a mass (very unlikely since you've got B symptoms--NFII being one possible exception) then it would likely just show some inflammation of the nerve which you would not treat any differently than with steroids +/- antivirals. That's why I don't think the MRI would provide much more than reassurance. I usually don't order tests unless it will change the treatment and I think that's unlikely to happen based on what you've described.
     
  7. OP
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    nadz

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    I think ,fair enough and the patient is satisfied with the current condition. I :thumbup:will reassured and follow up her.

    Thanks[​IMG]
     
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