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CLINICAL REVIEW: N Julian Holland and Graeme M Weiner Recent developments in Bell's palsy BMJ 2004; 329: 553-557 [Full text]

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BELL'S PALSY REVISITED

CELIO LEVYMAN,MD,MSc   (3 September 2004)

Confused of Newbury: does a more recent single research paper trump a systematic review?

James A Cave   (4 September 2004)

Is specialist referal always necessary?

Ken R Walton   (5 September 2004)

Who should provide the care?

Adam Sandell   (5 September 2004)

Hypertension in Children

David Stevens   (5 September 2004)

Rule out Lyme neuroborreliosis

Mats Reimer   (5 September 2004)

Is Bell's palsy "herpetic facial paralysis"?

Ayokunle. T. Abegunde   (6 September 2004)

Undescribed symptom of Bell's palsy?

Alexander J Howie   (6 September 2004)

HTA funded trial in progress for Bell’s Palsy in Scotland.

Frank Sullivan   (6 September 2004)

The Evidence for Referral

Nigel S de Kare-Silver   (6 September 2004)

Corticosteroids are Not Proven for Treatment of Bell's Palsy

Michael E. Stuart, Sheri A. Strite   (7 September 2004)

Serology testing and borrelial infection

Ann B Tweedie   (7 September 2004)

Bell's palsy : My experience

Edward Teague   (7 September 2004)

How to establish what's the "best" EBM evidence

Jeffrey Mann   (8 September 2004)

More research evidence for facial retraining

Todd C. Henkelmann   (9 September 2004)

Should BMJ be more 'Evidence-Based' in publishing 'Clinical Reviews' ?

Kumara Mendis   (10 September 2004)

Making claims in the face of the evidence

Martin J Burton, Richard Hughes   (12 September 2004)

Patients Agree

Alessandro B. Osvaldt, Brazil   (12 September 2004)

Authors Response

Graeme M Weiner, N Julian Holland   (12 September 2004)

Acute facial palsies: seasonal variations and a cultural myth?

Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Dr.Ibrahim A. Al-Hoqail, Dean, College of Medicine, MOH, Riyadh, Saudi Arabia.   (13 September 2004)

Surgical efficacy in Bell's Palsy

Jay T Rubinstein, MD, PhD   (14 September 2004)

Beware preeclampsia with Bell's palsy in pregnancy

Adam P Morton   (15 September 2004)

I think I can't add......

Declan P Fox   (20 September 2004)

Re: I think I can't add......

Peter Flegg   (21 September 2004)

Coeliac disease and recurrent Bell's palsy

john m hedley   (8 October 2004)

Bell's Palsy - another cause?

Alastair G Smith   (20 October 2004)

Another Possible Cause? My Experience

Darvin W. Dwyer   (10 November 2004)

Tretment of Bell's palsy with hyperbaric oxygen

Gojko Gosovic, Dr. Goran Račić, professor. MD, PhD, NTE Department, Clinical Hospital, Split, Croatia.   (7 December 2004)

Re: Beware preeclampsia with Bell's palsy in pregnancy

Mark A Kent   (20 December 2004)

Managing Bells Palsy -My experience

Nirmal Surya   (6 January 2005)

Underrecongnized use of oral B-12 for Bell's palsy

Irwin Abraham MD   (21 February 2005)

Location of vesicular eruption in Ramsay Hunt syndrome

Hui Liu   (8 July 2006)

Re: Undescribed symptom of Bell's palsy? More unaddressed symptoms:

L Gill   (11 November 2006)

Recent Development in Bell's Palsy

Carol Blackbird   (19 January 2007)

Re: Undescribed symptom of Bell's palsy?

John R Cherry   (20 January 2007)

BELL'S PALSY REVISITED 3 September 2004
CELIO LEVYMAN,MD,MSc, Senior Neurologist Headache and Neurology Clinic,Sao Paulo,Brazil Send response to journal: Re: BELL'S PALSY REVISITED	Holland and Weiner's paper shows a great advance in the vision of otolaryngology’s specialists (ORL) in regard to Bell’s palsy versus the neurological one. Even today, many ORLs prefer indicate an immediate surgical decompression of the facial nerve – and in the benign Bell disease, not in a case such as trauma. The guidelines shown in the text seem logical and very good in practice, despite one aspect, slightly touched on by the authors: the use of oral acyclovir. Actually the bioavailability from oral ingestion of the drug is really very bad, and the benefit of its use seems to be nothing. Perhaps the new generation could help in the future of these kind of oral antiviral drugs. And a theme of huge and prolonged debate in the literature for many years perhaps encountered a happy end: the use of corticosteroids in the first seven days. Bell’s palsy is a very common presentation disease to neurologists and ORLs, and the guidelines shown in BMJ, as cited above, are more then reasonable for clinical and practical use. Competing interests: None declared
Confused of Newbury: does a more recent single research paper trump a systematic review? 4 September 2004
James A Cave, GP Newbury RG20 8UY Send response to journal: Re: Confused of Newbury: does a more recent single research paper trump a systematic review?	I think somebody once said if you must be frank do it beautifully, so I will try. As a jobbing GP this paper left me confused. To treat somebody is a hard decision, not to treat somebody even harder. In 2002 the BMJ published an article about Recent Advances in Neurology that felt that there might be a case for prednisolone but none so far for anti-viral agents. This was based on systematic reviews. ( http://bmj.bmjjournals.com/cgi/content/full/324/7338/656?max toshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=10 56746711705_11348&stored_search=&FIRSTINDEX=0&volume=324&firstpage=656&r esourcetype=1,2,3,4,10&journalcode=bmj ) This article quotes from just two more recent papers (Axelsson and Murakami) and suggests that now the evidence base is clearly in favour of using antivirals. Given that further RCT are in the pipeline the authors full support of antiviral use is more opinion than evidence, is it not? Does a single more recent research paper trump a previous sytematic review? I was also concerned by the statement in the Blue box at the start of the paper that claimed under Recent Developments that "Treatment of partial Bell's Palsy is controversial: a few patients don't recover if left untreated". Is it not also true that a few patients don't recover even if treated? In addition I thought the article muddled and unhelpful. Should patients be admitted? what do the authors mean by psychological support? Every year or so when I see a case of Bell's Palsy I phone my local teaching hospital and ask the neurology registrar what the latest news is. The only thing I learnt from this article is perhaps I also ought to ask the ENT reg too: perhaps we could have a live debate? Dr James Cave Competing interests: None declared
Is specialist referal always necessary? 5 September 2004
Ken R Walton, GP Ridgeway Surgery Harrow HA2 7DU Send response to journal: Re: Is specialist referal always necessary?	The "This week in the BMJ" summary and the article both conclude that "patients with Bell's Palsy should should start treatment immediately and be referred to a specialist as soon as possible." The article quotes evidence for early treatment but where is the evidence that specialist referral is needed in all cases? Prompt treatment, support and follow-up can all be effectively delivered in general practice with the option to refer patients who fail to improve or have poor prognostic indicators. In an NHS where resources are so scarce, advice to refer patients who will not benefit from outpatient attendance is wasteful of resources and means that PCTs will be unable to purchase care in other areas of need. Competing interests: PEC chair of a deficit PCT
Who should provide the care? 5 September 2004
Adam Sandell, General Practitioner Adelaide Medical Centre, Newcastle upon Tyne, NE4 8BE Send response to journal: Re: Who should provide the care?	Bell's palsy is mostly managed in primary care in the UK.[1] In Holland and Weiner's thorough and helpful account of its management the authors recommend that patients should be referred to a specialist as soon as possible.[2] It would be interesting to know more about their thinking: this would represent a change in practice for many GPs who routinely provide comprehensive and evidence-based assessment and care for patients with new-onset Bell's palsy, referring to specialists when specialist input is needed. Holland and Weiner are apparently both otolaryngologists, so well- qualified to advise on the management of Bell's palsy. I wonder whether their review would have been much altered had a general practitioner been included in its authorship. [1] Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy in the UK. Eur J Neurol 2002;9: 63-7. [2] Holland NJ, Weiner GM. Recent developments in Bell's palsy. BMJ 2004;329: 553-557 Competing interests: None declared
Hypertension in Children 5 September 2004
David Stevens, Consultant Paediatrician Gloucestershire Royal Hospital.GL1 3NN Send response to journal: Re: Hypertension in Children	Dear Ed In their review of Bell's palsy, Holland and Weiner (1) draw attention to suppurative otitis media and Lyme disease as causes of Bell's palsy in childhood but fail to highlight the importance of measuring the blood pressure in all children with Bell's palsy. The link was first described 135 years ago by Moxon (1) , and more recent studies have found hypertension to be responsible for 3-17% of cases of facial palsy in childhood (2,3). Looking for suppurative otitis media and asking about symptoms that may indicate Lyme disease are emphasised by Holland and Weiner, but it seems likely that hypertension is a much more frequent cause in children in the UK. David Stevens Consultant Paediatrician Gloucestershire Royal Hospital 1.Holland NJ, Weiner GM, Recent developments in Bell's palsy.BMJ 2004;329:553-557 2. Moxon M. Apoplexy into canal of fallopius in a case of Bright's disease, causing facial paralysis. Trans Pathol Soc London 1869;20:420-422 3. Siegler RL, Brewer ED, Corneli HM. Hypertension first seen as facial paralysis: case reports and review of the literature. Paediatrics 1991;87:387-389[Medline]. 4. Lloyd AVC, Jewitt DE, Lloyd Still JD. Facial paralysis in children with hypertension. Arch Dis Child 1966;41:292-294[Medline]. Competing interests: None declared
Rule out Lyme neuroborreliosis 5 September 2004
Mats Reimer, Community Pediatrician 42671 Molnlycke Sweden Send response to journal: Re: Rule out Lyme neuroborreliosis	Borrelia can cause facial paralysis not only in children. To me it seems prudent to do a lumbar puncture in most (all?) cases of facial paralysis, and treat all cases who show CSF pleocytosis for possible neuroborreliosis. Without ruling out CSF pleocytosis I would worry about giving corticosteroids wich possibly could worsen neuroborreliosis. Competing interests: None declared
Is Bell's palsy "herpetic facial paralysis"? 6 September 2004
Ayokunle. T. Abegunde, physician University of Lagos medical centre,University of lagos,Nigeria Send response to journal: Re: Is Bell's palsy "herpetic facial paralysis"?	Sir, The role of Varicella zoster virus(VZV)in Ramsay -Hunt syndrome is undoubted.(1) However,the multiplicity of agents associated with acute facial paralysis make attribution of causality to Herpes simplex type 1(HSV- 1)difficult. This is supported by the fact that there is a paucity of epidemiological evidence regarding clustering of cases of Bell's palsy(BP) associated with HSV-1 by time and location. Additionally, a temporal relationship has not been established between infection/reactivation and onset of symptoms. Furthermore,studies testing for rising titres of HSV-1 and VZV antibodies in the blood and CSF of BP patients have been unreliable.(2,3) Polymerase chain reaction(PCR)has provided the strongest evidence for the association of HSV-1 with Bell's palsy. However,PCR does not distinguish between viral genomes which are in the latent phase and reactivated virus in an active infection.(4) Recently,strong evidence of clustering of 46cases of Bell's palsy was reported after the introduction of an intranasal influenza vaccine in Switzerland. 68patients(27.7%) and 8 controls(1.1%) had recieved the intranasal vaccine p< 0.001 This result further extends the list of numerous causative agents associated with BP.(5) Which BP cases are due to reactivation of HSV-1 and which ones are not? Further studies are needed in order to clearly identify the role of HSV-1 in the majority of cases considered to be BP. AT Abegunde References 1. Holland NJ,Weiner GM. recent developments in Bell's palsy.BMJ 329 553-6 2.Vahlne A, Edstrom S, Arstila P, Beran M, Ejnell H, Nylen O, Lycke E. Bell's palsy and herpes simplex virus. Arch Otolaryngol. 1981 Feb;107(2):79-81. 3.Birkmann C, Bamborschke S, Halber M, Haupt WF. Bell's palsy: electrodiagnostics are not indicative of cerebrospinal fluid abnormalities. Ann Otol Rhinol Laryngol. 2001 Jun;110(6):581-4. 4.Murakami S, Mizobuchi M, Nakashiro Y, Doi T, Hato N, Yanagihara N. Bell palsy and herpes simplex virus:identification of viral DNA in endoneurial fluid and muscle.Ann Intern Med. 1996 Jan 1;124(1 Pt 1):27-30. 5.Mutsch M, Zhou W, Rhodes P, Bopp M, Chen RT, Linder T, Spyr C, Steffen R. Use of the inactivated intranasal influenza vaccine and the risk of Bell'spalsy in Switzerland.N Engl J Med. 2004 Feb 26;350(9):896- 903. Competing interests: None declared
Undescribed symptom of Bell's palsy? 6 September 2004
Alexander J Howie, Professor of Renal Pathology Royal Free Hospital, London NW3 2QG Send response to journal: Re: Undescribed symptom of Bell's palsy?	In Bell's palsy I have heard described a symptom that I have not found in any account of the condition. On sniffing, the wing of the nose on the affected side immediately collapsed, with temporary obstruction of inflow of air. I suspect this is well known, but if so, why is it not described? Competing interests: None declared
HTA funded trial in progress for Bell’s Palsy in Scotland. 6 September 2004
Frank Sullivan, Prof of R&D in GP and Primary Care Community Health Sciences Division, Dundee, DD2 4BF Send response to journal: Re: HTA funded trial in progress for Bell’s Palsy in Scotland.	We were pleased that the BMJ published a clinical review (albeit a traditional non-systematic, opinion – based one) on the important topic of Bell’s Palsy but, like others responding to the article, we are concerned by Holland and Weiner’s assertions regarding treatment, and their conclusions are simply not supported by the current best available evidence. The most recent Cochrane reviews show that no treatment has yet been demonstrated to be more effective than another or placebo. We are aware that the more recent studies they cite have not yet been included in the systematic reviews but since they are non-randomised, suggestions that combination therapy is beneficial may not be secure. Our reading of the current situation is that there are suggestions that steroids and/or antivirals may be effective, but the evidence remains inconclusive. Since these treatments are neither cheap nor harmless and many patients have contraindications to high dose steroids, the issue is important for clinician and patient. They also seem to suggest that herpes simplex has been established as the cause, which is still a contested theory. The review by the American Academy of Neurology they cite concluded ‘Well-designed studies of the effectiveness of treatments for Bell's palsy are still needed.’ The published trials are mainly hospital based and involve small numbers, thus generating uncertain results . We are running a trial which seeks to avoid these pitfalls, and hopefully provide an answer. The Bell’s Palsy:Early acycLovir and/or prednisoLone in Scotland. (BELL’S ISRCTN 71548196) trial (which Holland and Weiner seem unaware of) is a randomised multicentre factorial trial of the early administration (within 72 hours of symptom onset) of steroids and/or antivirals for Bell’s Palsy, and is the largest trial ever planned for Bell’s palsy. Patients are randomised to receive prednisolone, aciclovir, both or neither. We have recently started recruitment, and aim to randomise 720 patients over the next 18 months. Further details are available from the trial website: http://www.dundee.ac.uk/bells/index.htm. We are concerned that the article will mislead doctors into using unproven treatments. Although no cause or therapy for Bell’s Palsy has been proven in the 183 years since the Scottish Surgeon Sir Charles Bell first described this condition we hope that our study will determine whether either of the treatments proposed by Holland and Weiner, and in common use, are actually effective, and cost-effective. We therefore urge all Scottish GPs to refer their patients with suspected Bell’s palsy to their local ENT unit for consideration of randomisation into the trial. We have been able to mount this trial because of the greatly improved research infrastructure in UK general practice in recent years. The Scottish School of Primary care (SSPC) http://www.show.scot.nhs.uk/sspc/ has developed a register of Scottish Practices and Professionals interested in Research (SPPIRe) which is working with others such as NHS24 to identify and refer patients early. The Chief Scientist Office (CSO) pays ‘Support for Science’ to funding NHS organisations including GPs who participate in studies like this. The research governance framework ensures that studies are conducted to a high standard. We hope to provide the evidence for treatment of Bell’s palsy that is currently lacking. Frank Sullivan Principal Investigator Fergus Daly Trial Co-ordinator Iain Swan Otolaryngologist Jill Morrison Prof. of GP Richard Davenport Neurologist Brian McKinstry GP Jan Clarkson Dentist Luke Vale Health Economist Peter Donnan Medical Statistician Lucy McCloughan Capacity and Capability Manager Scottish School of Primary Care References Holland NJ, Weiner GW Recent developments in Bell's palsy. BMJ 2004;329:553-557 Mulrow CD. The medical review article: state of the science. Ann Intern Med. 1987;106:485-8. Salinas RA, Alvarez G, Alvarez MI, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Oxford: Update Software. Sipe J, Dunn L. Acyclovir for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Oxford: Update Software Hato N, Matsumoto S, Kisaki H, Takahashi H, Wakisaka H, Honda N, et al. Efficacy of early treatment of Bell's palsy with oral acyclovir and prednisolone. Otol Neurotol 2003;24: 948-51. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56: 830-6.[ Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy in the UK. Eur J Neurol 2002;91:63-7 Competing interests: The respondents are engaged in an RCT in Bell’s Palsy that may be adversely affected by uncritical acceptance of Holland and Weiner’s publication.
The Evidence for Referral 6 September 2004
Nigel S de Kare-Silver, GP Gladstone Medical Centre, 5 Dollis Hill Lane, London NW2 6JH Send response to journal: Re: The Evidence for Referral	I am intrigued by this article which so methodically and comprehensively explores diagnosis, investigation and management of Bell's palsy. The authors, with the clear support of the editors recomend referal to specialists. Why? With a dearth of neurologists in this country, to the extent that our local specialists refuse to treat or manage strokes, surely the most common neurological disease, your journal nevertheless advocates referal to a specialist services. Presumably the specialist has some sort of insider knowledge not published in your internationally esteemed journal that he is witholding from his colleagues elsewhere in medicine allowing him to provide a better service for the Bells palsy patient than a primary care doctor can manage. It is important that authors and publishers attempt to move into the 21st century. With easily accessable knowledge bases giving clear pathways for even the most rare illness management, of which Bell's palsy is not, it is time to use specialist time appropraitely and innovatively for those case that cannot be cared for elsewhere be it for reason of technical expertise (interventional procedures) or resources of time (psychiatric and pyschological cases). To lamely say 'refer to a specialist' fosters an atmosphere of historical pathways of care which this country cannot afford. My patients always ask me 'why' when i deem referral is necessary. Before i take this decision i thus need an answer in my mind which the authors fail to provide here Competing interests: None declared
Corticosteroids are Not Proven for Treatment of Bell's Palsy 7 September 2004
Michael E. Stuart, President, Delfini Group LLC, Clinical Assistant Professor, Univ. Washington, Dept. Family Medicine 98115, Sheri A. Strite Send response to journal: Re: Corticosteroids are Not Proven for Treatment of Bell's Palsy	Editor—Holland and Eisner support the use of corticosteroids for treatment of moderate to severe facial palsy based on two systematic reviews [1,2]. We believe that such a conclusion is not justified by the medical evidence presented by the authors and that the two systematic reviews are fatally flawed. In the Ramsey review, three studies met the authors’ criteria for validity [3,4,5], but in Ramsey’s analysis the study by May et al.[3]-- a valid study—-was excluded because it was an “outlier”, i.e., the results were not consistent with the other two studies included in the review. Excluding a study on the basis of results rather than methodology is inappropriate. Results from non-valid studies should not be utilized in decision-making. May et al. reported that corticosteroids resulted in poorer facial recovery than placebo. It should be noted that the quality index score of the excluded (May) study was better than one of the studies included in Ramsey’s review. If the May et al study is not excluded, the results do not support the authors’ conclusion of benefit from corticosteroid treatment. It should also be noted that a Cochrane systematic review [6]included the May study as a valid study, but excluded the Austin study because 29 percent of subjects in the Austin study were lost to follow-up. Cochrane also excluded the Shafshak study because it was a non-randomized study. As pointed out by the Cochrane group, the Grogan “practice parameter” is probably invalid because Grogan included the Shafshak and Austin studies and that if these two trials were excluded from the pooled estimate, the results were no longer in favor of steroids for the treatment of Bell’s palsy. 1. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bell's palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56: 830-6 2. Ramsey MJ, DerSimonian R, Holtel MR, Burgess LP. Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis. Laryngoscope 2000;110: 335-41 3.May M, Wette R, Hardin WB Jr, Sullivan J. The use of steroids in Bell’s palsy: a prospective controlled study. Laryngoscope 1976; 86:1111–1122 4.Austin JR, Peskind SP, Austin SG, Rice DH. Idiopathic facial nerve paralysis: a randomized double blind controlled study of placebo versus prednisone. Laryngoscope 1993; 103:1326–1333. 5. Shafshak TS, Essa AY, Bakey FA. The possible contributing factors for the success of steroid therapy in Bell’s palsy: a clinical and electrophysiological study. J Laryngol Otol 1994; 108:940–943. 6. The Cochrane Database of Systematic Reviews The Cochrane Library, Copyright 2003, The Cochrane Collaboration: Corticosteroids for Bell's palsy (idiopathic facial paralysis) [Review] Salinas, RA; Alvarez, G; Alvarez, MI; Ferreira, J Date of Most Recent Update: 26-November-2001. Date of Most Recent Substantive Update: 15- October-2001. Competing interests: None declared
Serology testing and borrelial infection 7 September 2004
Ann B Tweedie, An allied health professional with an interest in Lyme NE13 Send response to journal: Re: Serology testing and borrelial infection	Holland and Weiner give the following guidance regarding Lyme disease, “Serological tests for Lyme disease (IgM, IgG) are essential to exclude this disease in endemic areas, ..” This illustrates, I believe, a mistaken degree of trust in serological testing to detect borrelial infection. The following, web-site document, lists extracts from numerous references from a wide variety of peer-reviewed journals. The evidence casts doubt on the role of serological testing in the confident exclusion of a diagnosis of Lyme Disease. http://www.lymeinfo.net/LDSeronegativity.pdf Accurate diagnosis and reporting must surely be vital for an area to be appropriately recognised as “endemic”, such that the borrelia becomes more readily suspected as a differential diagnosis. This highlights the need for diagnosis to be made on clinical grounds and the urgent need for the introduction of a reliable test for the direct detection of borreliosis infection. Competing interests: None declared
Bell's palsy : My experience 7 September 2004
Edward Teague, Journalist 6 Albury Drive, Rochdale, Ll12 7SX Send response to journal: Re: Bell's palsy : My experience	At the age of 58, healthy with some experience of mild asthma (for which I had twice been prescribed prednisolone) I holidayed in Fuerteventura. I experienced a sore eye which was exacerbated on a bus journey by the draught from an open window. A day later, returning to the UK with a weeping, sore eye, slurred speech and some lateral facial deformity, my GP's locum prescribed a "classic case" of Bell's Palsy. After consulting practice colleagues, he prescribed daily doses of prednisolone of 60mg (BW 86Kg)- this dosage was described as high by the pharmacist, who prudently queried the prescription. I was also prescribed some lubricating eyedrops. The dose was repeated for a further week with no reduction in dosage. I was referred to a private clinic, did not see a specialist, but was provided with facial thermal treatment - which I regarded as an elabaorate - and expensive charade - and worthless as a treatment. I experienced some reaction to the steroid dose, sleeplesness, nightime urination, intense weight loss (4Kg) on the limbs, thirst and a foul tasting mouth. As Chairman and MD of a software development company the facial deformity and the apparently drunken speech were not only embarassing but made work virtually impossible by making sensible communication difficult. Therefore using the principle of Occam's razor, I went to the root of the problems I had at work and sought the services of an experienced speech therapist. It transpired after my engaging their services that they had previously treated 2 BP patients in 10 years. Intensive sessions in front of a mirror of 20 minutes every 4 hours of facial / vocal execises resulted in 3/4 weeks in almost complete reversion to normal speech and facial topography. Occasionally , 3 years later (especially when tired), my speech slurs and my eyelid droops. I do not drink alcohol. I still have a very slight but persistent facial distortion evident only to close family and friends. All BP ex patients , friends / family I met or talked to were firmly of the opinion, that draughts, wind affecting the face were the precipitating factor. I heard of transport drivers / driving instructors who left door windows open as sufferers - as well as housewives and travel shop assistants. As a consequence of tests undertaken as part of the treatment, I was diagnosed Type II diabetic (father and eldest brother previously diagnosed and died of heart attacks). I have noted references to diabetes in the literature (see e.g. NHS Direct on line). I note reference (1) to a UK study which concluded.. " results...do not support a viral aetiology". Despite the evidence (?) of PCR tests suggesting viral infection in 11 of 14 BP patients (Murakami et all quoted by Holland) my experience leaves me sceptical of a viral source of the problem. My own view ( I have undertaken considerable research in this matter) is that the palsy results from some endocrine imbalance triggered by some physical / temperature trauma to the facial area where the facial nerve emerges. Based on my own experience I would suggest immediate and intensive speech / facial exercise therapy. I note the query (and apparent scepticism) about the suggested "psychological" support. I am a fairly robust character but found the condition acutely embarassing and the public reaction to my apparent drunkeness, even amongst people I knew and worked with, difficult to deal with. The comparative rarity of the condition (20/100,000) in UK and consequent public lack of awareness helped to re-inforce the negative view of the facially distorted slurring stranger. Finally, suffering the condition, had the benefit that I was able to discover the remarkable life of Bell and his contribution to Darwin's views on the History of Man and battlefield surgery and London's hospitals. (1) Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy in the UK. Eur J Neurol 2002;9: 63-7. Competing interests: None declared
How to establish what's the "best" EBM evidence 8 September 2004
Jeffrey Mann, Retired physician Salt Lake City, UT 84103 Send response to journal: Re: How to establish what's the "best" EBM evidence	The subject of discovering the "best" scientific evidence to guide clinical action is a subject of great interest to me, and I have often pondered what is the best method of establishing the most scientifically valid evidence. In an interesting article (which is freely available online) [1], Gronseth uses the clinical problem of Bell's palsy as an example of this dilemma. He describes how two different physicians have opposing views on whether to use steroids to treat Bell's palsy and he discusses the underlying reasons for their disparate approaches. The one physician bases his clinical practice on learned behaviour, which he acquired from an "expert" while training to be a physician. This is the traditional "learning by apprenticeship" model that was commonly used in medical schools and residency training programs for many, many decades. The problem with this methodology is that it is not scientific, because the biases of the clinical teachers (so-called "clinical experts") are transferred to the trainee-clinicians, and there is no guarantee that the transferred clinical beliefs are scientifically grounded. The second physician uses the science of EBM as the foundational basis of his clinical beliefs. This system is based on a hierarchy of scientific evidence, whereby certain EBM evidence is given higher evidentiary priority than other EBM evidence (eg. RCT evidence is regarded as being more scientifically valid than the EBM evidence derived from small case studies or personal clinical experience). Because the average clinician cannot undertake the enormous task of personally reviewing the EBM literature evidence, he is dependent on systematic reviews published by organisations like the Cochrane Collaboration and/or mainstream medical journals. Can a clinican rely on systematic reviews for scientically valid EBM evidence? What is most interesting from my perspective is that a EBM-based clinician cannot really rely on systematic reviews if they are presented in a "take-it-or leave-it" manner (eg. the routine practice of the Cochrane Collaboration). Most medical medical journals publish a systematic review by a single author (or a small collection of authors) as exemplified by this review of "Recent developments in Bell's Palsy" by Holland and Weiner. The scientific validity of the authors' beliefs cannot readily be discerned by simply reading the systematic review, and most medical journals do not routinely offer an alternative point-of-view by simeultaneously publishing the alternative opinions of other systematic reviewers. The BMJ is somewhat unique in this respect because it at least offers timely (and unedited) feedback from interested readers. After reading this BMJ review, I gained the strong impression that there was substantial scientific evidence supporting the use of steroids and aciclovir in Bell's palsy, and I would have altered my clinical practice recommendations accordingly. However, I then discovered (after reading James Cave's rapid response letter) that the authors' recommendation to use anti-virals was only based on two recent studies, and that previous systematic reviews had not found unequivocal scientific evidence to suggest that anti-virals are effective. I then subsequently read the rapid response letters by Frank Sullivan and Michael Stuart, which suggests that even steroids have not being proven to be effective. I think that the BMJ's "rapid response letter" section is invaluable, because it allows me to discover the potential weaknesses/biases of published medical opinions (systematic reviews and/or original published studies). I think that all medical journals should host a "rapid response letter" section, so that journal readers can hopefully be exposed to alternative points of view. In the modern-day era of EBM, we often denigrate the scientific validity of the "learning by apprenticeship" model because it is obviously biased and non-scientific. However, I also think that the EBM model of basing one's clinical practice on systematic reviews of the EBM medical literature is also potentially biased, because of the selective (arbitrary) biases of the systematic reviewers. I think that mainstream medical journals should always simultaneously publish two (or more) systematic reviews on each subject (or at least host a "rapid response letter" section), so that interested readers can obtain a more balanced, and hopefully more scientific, view of the EBM evidence. Jeff Mann. MD. References: 1. Gary S. Gronseth From evidence to action. Neuro Rx 2004. 1:331- 340. http://www.neurorx.org/cgi/content/full/1/3/331 Competing interests: None declared
More research evidence for facial retraining 9 September 2004
Todd C. Henkelmann, Instructor, University of Pittsburgh Department of Physical Therapy Facial Nerve Center, UPMC Montefiore Hosp., 3459 Fifth Ave., 6th Fl. NE-653, Pittsburgh, PA 15213 Send response to journal: Re: More research evidence for facial retraining	An excellent review. However, only one reference for facial retraining, aka facial neuromuscular reeducation (NMR), was cited and it had to do with mime therapy alone. Included below are other research studies that are rigorous enough to withstand scrutiny for treating post- acute cases of Bell's palsy or other forms of facial palsy, when there is incomplete recovery and synkinesis development. These should not have been overlooked. One of the key components of this approach is surface electomyographic (EMG) biofeedback training. 1) Brach JS, Vanswearingen JM, Lenert J, et al: Facial neuromuscular retraining for oral synkinesis. Plast Reconstruc Surg 99:1922-1933, 1997. 2) Cronin GW, Steenerson RL: The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. Otol-Head Neck Surg 128:534-538, 2003. 3) Diels J: New concepts in nonsurgical facial nerve rehabilitation, in Meyers EN, Bluestone CD, Brackmann DE, et al (eds.) Advances in Otolaryngol-Head Neck Surg, vol. 9, Chicago, Mosby-Year Book, 1995. 4) Ross B, Nedzelski JM, McLean JA: Efficacy of feedback training in long- standing facial nerve paresis. Laryngoscope 101:744-750, 1991. 5) Segal B, Zompa I, Danys I, et al: Symmetry and synkinesis during rehabilitation of unilateral facial paralysis. J of Otolaryngol 24:143- 148, 1995. 6) VanSwearingen JM, Brach JS: Changes in facial movement and synkinesis with facial neuromuscular reeducation. Plast Reconstruc Surg 111(7):2370- 2375, 2003. By the way, there is an excellent resource in England for these techniques in the person of Dame Diana J. Farragher, a physiotherapist who runs a facial rehabilitation centre. However, she does use electrical stimulation also in her approach, which is not as well supported in the literature. Competing interests: I do provide physiotherapy services that utilize neuromuscular reeducation to this population
Should BMJ be more 'Evidence-Based' in publishing 'Clinical Reviews' ? 10 September 2004
Kumara Mendis, Senior Lecturer Department of Community and Family Medicine, Faculty of Medicine. University of Kelaniya, Sri Lanka Send response to journal: Re: Should BMJ be more 'Evidence-Based' in publishing 'Clinical Reviews' ?	Editor, Can one more research paper be better than methodologically sound systematic reviews published by the BMJ group Clinical Evidence in 2002? Current recommendations (Key Messages) from Clinical Evidence http://www.clinicalevidence.com is given below: (accessed on 10-08-2004) Clinical Evidence - Search date November 2002, Rodrigo Salinas Antiviral treatment - Two systematic reviews found no RCTs of aciclovir versus placebo. One RCT found limited evidence that aciclovir plus prednisone improved facial function compared with prednisone alone after 4 months. Corticosteroids - One systematic review found no clear evidence that corticosteroid improved the recovery of facial motor function or cosmetically disabling sequelae compared with placebo after 6 months. As a practicing GP from a developing country like Sri Lanka, we have little time to assess the methodological validity of systematic reviews and tend to increasingly depend on Clinical Evidence, Cochrane Reviews and of course electronic BMJ. What really confuses me is what is given inside the box ‘Recent Advances’ is directly contradictory to the Clinical Evidence summary findings. The only sensible information in this box is - ‘Treatment of partial Bell's palsy is controversial’ To put it bluntly, BMJ should be more ‘Evidence Based’ in publishing Clinical Reviews. Competing interests: None declared
Making claims in the face of the evidence 12 September 2004
Martin J Burton, Co-ordinating Editor Cochrane Ear, Nose & Throat Disorders Group The Radcliffe Infirmary, Oxford, OX2 6HE, Richard Hughes Send response to journal: Re: Making claims in the face of the evidence	The BMJ has a strong tradition of publishing high quality evidence. We were therefore surprised it should publish so prominently and without qualification an article making inadequately substantiated claims about the effectiveness of treatment for Bell’s palsy (1). The authors cite two Cochrane reviews (2,3) which examined evidence for the efficacy of corticosteroids and acyclovir but concluded that there was no evidence for either drug being significantly better than placebo. Holland and Weiner ignore these conclusions and express their personal opinion based on a non -randomised retrospective study. Before reaching any conclusion it would be appropriate to wait for the results of the randomised “Bell’s Palsy: Early aciclovir and/or prednisolone in Scotland” trial under the auspices of the NHS Health Technology Assessment Programme which plans to recruit 960 patients. Randomised trials are particularly important in diseases which have a very high rate of spontaneous recovery. In the meantime there is uncertainty about whether these drugs are effective or not. Martin Burton Cochrane Ear, Nose & Throat Disorders Group Department of Otolaryngology – Head & Neck Surgery The Radcliffe Infirmary Oxford Richard Hughes Cochrane Neuromuscular Disease Group Department of Clinical Neurosciences King’s College London 1. Holland NJ, Weiner GW Recent developments in Bell's palsy. BMJ 2004;329:553-557 2. Salinas RA, Alvarez G, Alvarez MI, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd. 3. Allen D, Dunn L Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis) (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd. Competing interests: None declared
Patients Agree 12 September 2004
Alessandro B. Osvaldt, Surgeon 90035-170, Brazil Send response to journal: Re: Patients Agree	Dear Editor, I'm a general surgeon that had his practice affected by a Bell's palsy sixty days ago. I really agree with the letters sent to this section. After reading this article that sounds good to me as a author's view, their beliefs about the topic. But it is not the EBM that we really want to read and support our clinical practice. In fact, even Bell's palsy being a commom disease we don't have good clinical research and evidences to prescribe corticosteroids plus aciclovir. These two drugs have severe side effects and the benefits are unknown because the most of the patients affected have well recovering after time. As a patient and physician, I think that the most important is to develop a multicenter trial with placebo, predinisone, acyclovir, and prednisone plus acyclcovir. Alessandro Osvaldt Competing interests: None declared
Authors Response 12 September 2004
Graeme M Weiner, Consultant Otolaryngologist Royal Devon and Exeter Hospital, N Julian Holland Send response to journal: Re: Authors Response	We are pleased to see that our paper has excited so much interest. To quote from the website of the Oxford centre for evidence based Medicine” What are we to do when the irresistible force of the need to offer clinical advice meets with the immovable object of flawed evidence? All we can do is our best: give the advice, but alert the advisees to the flaws in the evidence on which it is based”. It is clear that the overwhelming majority of patients with Bells palsy do well with or without treatment. Outside certain patient subgroups it remains impossible to identify who will fair well and who won’t. Therefore if treatment is to be given, all who are eligible for treatment must be treated for the benefit of the few. Although systematic reviews do not show statistically significant benefits, they are at least suggestive of benefit. We accept that the differences are small but would assert that for a disorder with much disability and cosmetic blight associated with it, the difference between treatment and non treatment may be clinically very significant. Our remit was to provide a summary of the current evidence, define from it, with a degree of pragmatism, what advice to give, and to inform discussions with patients. The uncertainties in the current evidence base, and possible solutions to it are clearly discussed in the paper. Our wording was carefully chosen to allow for these uncertainties, providing “support” ( level B or C advice) rather than “recommendations” ( level A advice), all that is possible given the current level of evidence. We feel that our advice is compatible with the current evidence given the uncertainties within it. We are also certain that further studies are indicated because of those uncertainties, including placebo controlled studies such as the Scottish one.We look forward to the results of such large and robust studies. With regard to referral of patients, we accept that there is no evidence that this will lead to better outcomes, but would suggest that any patient is best cared for by a practitioner with an interest, who may treat, investigate or refer onward for further management as appropriate. The fact that a sizable proportion of patients have an alternate diagnosis justifies this approach. As the facial nerve is a corner stone in otological practice we feel well placed to manage facial palsy, and are pleased to see that this is the starting point for the Scottish study. Graeme M Weiner Consultant Otolaryngologist N Julian Holland Specialist Registrar Otolaryngology Competing interests: None declared
Acute facial palsies: seasonal variations and a cultural myth? 13 September 2004
Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Director, CME&R POBox.2292, Buraidah Ment. Halth. Hosp., Saudi Arabia., Dr.Ibrahim A. Al-Hoqail, Dean, College of Medicine, MOH, Riyadh, Saudi Arabia. Send response to journal: Re: Acute facial palsies: seasonal variations and a cultural myth?	Sir: Holland and Weiner have provided an excellent clinical review on Bell's palsy [1]. However, they have not touched on certain aspects of acute facial palsies. For example, is the prevalence of Bell's palsy more common during winter than the summer season? Likewise, do herpes simplex virus-1 and herpes zoster virus reactivate more commonly among immunosuppressed patients than the healthy subjects? Or certain individuals like pregnant women, older people, and children have known or unknown higher risk factors for developing Bell's palsy. The answers to these questions may guide that there may be some prophylactic strategies such as dietary supplements and vaccinations in preventing the occurrence of Bell's palsy, which were not highlighted by the authors, but we know that the prevention is better than cure. It is just a cultural myth or belief or scientific fact that those who get up during the cold winter nights and move out face uncovered also tend to develop fasial palsy. Besides reported etiological factors of acute facial palsies, LIPOSUCTION for correcting facial lipodystrophy may also cause facial palsy, which is a known complication. Reference: 1. N Julian Holland and Graeme M Weiner. Recent developments in Bell's palsy. BMJ 2004; 329: 553-557 Competing interests: None declared
Surgical efficacy in Bell's Palsy 14 September 2004
Jay T Rubinstein, MD, PhD, Virginia Merrill Bloedel Professor and Director, Professor of Otolaryngology University of Washington, Box 357923, Seattle, WA 98195-7923 USA Send response to journal: Re: Surgical efficacy in Bell's Palsy	It is remarkable to me that a Journal of the stature and caliber of the British Medical Journal would allow publication of a review of Bells Palsy that completely writes off surgical intervention with the single citation of a paper over twenty years old. Indeed in that paper, Fisch (1981) makes the case that the benefit of middle fossa decompression far outweighs the risk. I bring the authors and reviewers attention to a more recent and statistically valid study: Gantz, BJ, Rubinstein JT, Gidley P, Woodworth G. Surgical management of Bell’s Palsy. Laryngoscope 109:1177-1188,1999. While middle fossa decompression indeed carries risk, when performed by a surgeon skilled in the approach, this risk is minimal in comparison to a lifetime of facial disfigurement and potential career devastation in some fields. Thus the critical question is not whether decompression “is not routinely offered in the United Kingdom”, or anywhere else, but whether it offers benefit in appropriately selected cases. Our data suggests strongly that it does when performed early in the population most at risk for a poor outcome. While the authors and reviewers may take issue with our findings, ignoring them does no service to enhance the care given to patients with Bell’s Palsy. Competing interests: The author is a surgeon who performs middle fossa decompression for Bell’s Palsy following the criteria outlined in the reference above.
Beware preeclampsia with Bell's palsy in pregnancy 15 September 2004
Adam P Morton, Physician Mater Hospital, Raymond Tce, South Brisbane, QLD 4101 , Australia Send response to journal: Re: Beware preeclampsia with Bell's palsy in pregnancy	In their excellent review on Bell's palsy, Holland and Weiner note the increased incidence of this disorder in pregnancy, and the worse outcome with only 52% of pregnant women who progressed to complete facial paralysis within ten days of onset having a satisfactory outcome, compared with 77% to 88% of comparison patients.[1] Importantly there is also likely to be an association between Bell's palsy and hypertensive disorders of pregnancy, with one study reporting 22% of mothers with Bell's palsy onset during the index pregnancy developing preeclampsia, and 7.3 % developing gestational hypertension.[2] These rates were approximately five times that expected. Thus clinicians should heighten surveillance for hypertensive disorders in women developing Bell's palsy during pregnancy. 1. Gillman GS, Schaitkin BM, May M, Klein SR. Bell's palsy in pregnancy: A study of recovery outcomes. Otolaryngol Head Neck Surg 2002;126:26-30. 2. Shmorgun D, Chan WS, Ray JG. Association between Bell's palsy in pregnancy and pre-eclampsia. QJM 2002;95:359-62. Competing interests: None declared
I think I can't add...... 20 September 2004
Declan P Fox, Freelance physican Home base 6 Ballymullarty Road, Newtownstewart, Co Tyrone BT784NP Send response to journal: Re: I think I can't add......	Am I thick or did anyone else have problems with Table 1? The figures don't seem to add up. Declan Fox Competing interests: None declared
Re: I think I can't add...... 21 September 2004
Peter Flegg, Physician Blackpool, UK Send response to journal: Re: Re: I think I can't add......	The table is unclear. They have subdivided classical Bell's palsy into HSV-1 and HZV (zoster sine herpete), but have left Ramsay Hunt syndrome as a separate entity. Competing interests: None declared
Coeliac disease and recurrent Bell's palsy 8 October 2004
john m hedley, consultant physician Blenheim, NZ Send response to journal: Re: Coeliac disease and recurrent Bell's palsy	Bell's palsy is infrequently recurrent. A 36 year old otherwise healthy man presented with his third episode of Bell's palsy over a 10 year period, and had undergone neurological investigations at a specialist unit with negative findings including CT,csf and evoked potentials 15 years before.Endomysial antibodies were positive, the duodenal biopsy was of partial villous atrophy indicative of coeliac disease. His brother was screened and found to have coeliac. The patient has had no further episodes of Bell's palsy on a gluten free diet.Coeliac disease can be associated with neurological symptoms and recurrent Bell's palsy should be added to the list. Competing interests: None declared Editorial note The patient whose case is described has given his signed informed consent to publication.
Bell's Palsy - another cause? 20 October 2004
Alastair G Smith, Consultant Haematologist Haematology Department, Southampton General Hospital, SOUTHAMPTON, SO16 6YD Send response to journal: Re: Bell's Palsy - another cause?	I read with interest the review on Bell’s palsy by Holland and Weiner. A recent clinical encounter suggests I may have identified a further causal factor not listed by the authors. A 76-year old Scottish male patient presented with a combination of autoimmune thrombocytopenic purpura and classic Bell’s palsy. In counselling him about the diagnoses I explained to him that the facial paralysis was a condition called Bell’s palsy. He paused and looked at me before replying: - “I’ve been drinking it all my life!” His facial paralysis has fully recovered and he has abstained from Bell’s whisky since with no recurrence. Holland J N, Weiner G M Recent Developments in Bell’s palsy BMJ 329 553-7 2004 Alastair G Smith Consultant Haematologist Southampton General Hospital, Tremona Road, Southampton SO16 6YD Competing interests: None declared Editorial note The patient whose case is described has given his signed informed consent to publication.
Another Possible Cause? My Experience 10 November 2004
Darvin W. Dwyer, Business Manager United States of America Send response to journal: Re: Another Possible Cause? My Experience	I wanted to share another possible cause, not mentioned in "Recent Developments in Bells Palsy", while everything was fresh on my mind. I have had partial facial paralysis for 6 days and am in day 3 of treatment.The night before I experienced the initial symptoms, I hyper extended my jaw while biting into an apple. I remember my left jaw hurting as this had never happened before. The pain of this injury went away in a few seconds. That evening, my wife mentioned that my eyes looked different and we assumed I was tired after a long day at work. Early the following morning, I noticed numbness on the left side of my face as if I had just received a deadening injection from a dentist. The left side of my tongue was numb while the right side was fine. Very quickly, the movement of the left eyebrow; the ability to blink my left eye; and the movement of the left side of my lip was gone. I also began to slur my speech. Treatment is a combination of Valtrex (3 – 500 mg tablets per day) and Prednisone (an 12 day regiment that decreases from 60 mg per day to 30 mg per day). No immediate improvement of my symptoms. I am a 45 year old male. Competing interests: None declared
Tretment of Bell's palsy with hyperbaric oxygen 7 December 2004
Gojko Gosovic, MD Private Clinic for Hypebaric Medicine, Domovinskog rata 1, Split, Croatia., Dr. Goran Račić, professor. MD, PhD, NTE Department, Clinical Hospital, Split, Croatia. Send response to journal: Re: Tretment of Bell's palsy with hyperbaric oxygen	We have some remarks to the very interesting and actual paper “Recent development in Bell’s palsy” (1) published in BMJ volume 329: 553-557, because authors neglected the positive effects of Hyperbaric oxygen in the treatment of Bell’s palsy. Please, be very kind as to publish our remarks, as additional information, to above cited paper. The antioedematous effect and additional oxygenation of hypoxic cranial nerve VII with dissolved oxygen was main reason that we started hyperbaric oxygenation (HBO2) in the treatment of Bell’s palsy. In 1985, we full had recovery in 94.7% from 19 Bell’s palsy patient (3) treated two times daily with HBO2 under 2.8 ATA at the average interval of 19.5 days. In the double blind study, Račić at al. in 95.2% cases had full recovery in the average period of 22 days at experimental group of 42 patients treated only with HBO2 under 2.8 ATA and placebo tablets. At the contrary, in the control group of 37 patients treated with Pronison tablets and exposed to hyperbaric mixture (7%O2:93% N2 at 2.8 ATA) full recovery in the average period of 34 days was reached by 75.7% of treated patients. This difference was statistically significant (3). In addition Gošović G, and Gošović S, in 2000 treated 18 Bell’s palsy patients with HBO2 among which 77.5% was with total and 11,1% with severe paralyses. Full recovery was reached by 94.4 % of Bell’s palsy patients in 23.7 days at the average (4). All cited results were attained in patients who had Bell’s palsy not longer than 8 days (1-3). Later, some other authors also presented good experience after applying HBO2 to Bell’s palsy patients (5,6). To our opinion those results should be attributed to antioedematous effect and additional oxygenation with HBO to the facial nerve where the fundamental causes for obtaining a paralysis are mutual effects of swelling and acute lack of oxygen of facial nerve. REFERENCES 1. Holland NJ, Weiner GW Recent developments in Bell’s palsy. BMJ 2004; 329: 553-7. 2. Račić G, Denoble P, Gošović S, Kovačević H. The Hyperbaric Oxygen in the Treatment of Bell’s Palsy. In: Orhagen H, editor. Proceedings of the 11th Annual Scientific Meeting of the European Underwater and Baromedical Society - EUBS, Göteborg, 1985: 139-46. 3. Račić G, Denoble P, Sprem N, Bojić L, Bota B. Hyperbaric Oxygen as therapy of Bell,s palsy. Undersea Hyperb Med 1997; 24(1):35-8. 4. Gošović G, Gošović G. Hyperbaric oxygen (HBO2) in the treatment of Bell,s palsy. In: Germonpré P, Balestra C, editors. Proceedings of the 28th Annual Scientific Meeting of the European Underwater and Baromedical Society - EUBS, Brugge 2002:107-9. 5. Latavin AP, Platonova GB, Gribanov VY. Hyperbaric oxygenation in the treatment for facial neuritis. Zh Nevropat Psukhijat 1985; 85:528-31. 6. Makishima K, Masafumi Y, Yoshiki K, Nobuhide K, Eiji I. Hyperbaric oxygen as a treatment for facial palsies. In: Hyperbaric oxygen therapy in otorhinolaringology (Advances in Oto-Rhino- Laryngology Vol. 54) Janagita N, Nakashima T., editors, Karger, Basel, Paris, London, New York, 1998; 110-118. Competing interests: hyperbaric practice
Re: Beware preeclampsia with Bell's palsy in pregnancy 20 December 2004
Mark A Kent, GP Registrar Friarage DL6 2RH Send response to journal: Re: Re: Beware preeclampsia with Bell's palsy in pregnancy	Any personal experience of Pre-eclamsia and pregnancy induced hypertension occuring with Bell's Palsy in pregnancy. Should we treat these patients' Palsy any differently to the general population? i.e more aggressively with high dose steroids. How regularly would you advise BP monitoring also? - Thakyou for your response Competing interests: none
Managing Bells Palsy -My experience 6 January 2005
Nirmal Surya, Consultant Neurologist and Neurorehab specialist Surya Neuro Centre, 310 lotus House, 33-A, New Marine Lines,Mumbai 400020, India Send response to journal: Re: Managing Bells Palsy -My experience	I see almost 4-5 patients with Bell's palsy in a month in my practice which increases in some seasons like after rain fall suggesting that viral infection could be an aetiological factor and i firmly believe though no scientific data that it could be polio like or entero viruses at least in india, as many of these patient respond extremely well to a short course of steroids. In the same season we also see many cases of Guillian Baree syndrome and its possible that the etiology in both could be the same. The second commonest cause in our practice in India is Diabetes and these patients respond poorly as they are not given steroids and ( we can compare the two groups one treated with steroid who are nondiabetic and other treated without steoid those who are diabetic ) and the recovery is slow and takes longer in diabetic patients; hence steroid is an important drug in the treatment of Bell's palsy. We also see a few cases of sarcoidosis presenting as Bell's Palsy in perticular with recurrent Bells Palsy. Therefore any patient with recurrent Bell's palsy or bilateral Bell's palsy must be investigated for sarcoidosis. In my practice EMG is only done to see the pattern of recovery in non-responsive patients and some of these patients who have poor recovery do develop complications like crocodile tears and hemifacial spasm. Post Bell's palsy hemifacial spasm respond well to a very small dose of Botulinum toxin and the effect also lasts for longer duration. Competing interests: None declared
Underrecongnized use of oral B-12 for Bell's palsy 21 February 2005
Irwin Abraham MD, Physician private practice 520 White Spruce Blvd.,Rochester Ny USA 14623 Send response to journal: Re: Underrecongnized use of oral B-12 for Bell's palsy	The article, "Recent development in Bell's Palsy" did not mention the use of oral B-12 for Bell's palsy. I thought to now bring this to wider attention. I discovered this treatment when about 6 years ago a patient called me describing symptoms of Bell's Palsy. Since to my understanding the efficacy of prednisone was slow and uncertain, I went to look at the available research on PubMed. I found this article,in Methods Find Exp Clin Pharmacol. Oct;17(8):539-44.1995,Methylcobalamin treatment of Bell's palsy by MA Jalaludin. A daily 5 milligram dose of oral methylcobalamin was shown to be useful in a controlled trial. I suggested that this use, as compared with the results of the recent therapy studies using prednosisone &/or acyclovir, seemed superior. Symptoms were gone by the end of a week. Subsequently we have used oral B-12 with about 6 other paitents. Only one failed to resolve guickly and completely on this regimen. I urge others to consider this easy, cheap, non-toxic rememdy, and for researchers to investigate this further. Competing interests: None declared
Location of vesicular eruption in Ramsay Hunt syndrome 8 July 2006
Hui Liu, Vice Director, PhD Neurological Department of 210 Hospital,Dalian,PR China(116021) Send response to journal: Re: Location of vesicular eruption in Ramsay Hunt syndrome	Recently I treated a young male patient of Bell's palsy (right) accompanied with vesicles on the right soft palate, the ipsilateral anterior two thirds of the tongue and right gum. These vesicles disappeared within one week after anti-virus treatment. As a matter of my experience, vesicular eruption in Ramsay Hunt syndrome usually appears in the external auditory canal and other parts of the cranial integumentis, not common on the mucous membrane of the oropharynx.The above is the first case I met during more than 15 years. The authors of this review provide me a determinate elucidation that the vesicles may presnt to not only "outside", but also "inside". Competing interests: None declared
Re: Undescribed symptom of Bell's palsy? More unaddressed symptoms: 11 November 2006
L Gill, recovering patient 80579 Send response to journal: Re: Re: Undescribed symptom of Bell's palsy? More unaddressed symptoms:	The symptom described, inhaling with difficulty through one of the nasal passages, has affected me since Aug. 1995 when first diagnosed with Bell's Palsy (right facial). This was one of the few minor residual signs that persisted after a three-month recovery period. Worse: changes in the soft palate and throat which resulted in sleep apnea and snoring, tinnitus, a reduced sense of balance, and kinesis. I subsequently gave up the sports of scuba diving, repeling, and even skiing. Otherwise, the following ten years were problem free. These developments seem minor compared to the ongoing residuals I have today after two recurrences in May of 2005 and again in Jan. 2006. I consider myself fortunate that, with three onsets of facial paralysis to the same (right) side, no outbreak of vesicules occured. Thus, my case is thought to be Ramsay Hunt sine zoster. However, unaddressed concerns remain: myoclonic jerking at night, difficulty swallowing, a sense that the paralysis extends down the right esophagal passage and perhaps lower into kidney or bladder (notable diminished awareness of need to vacuate), arm and leg tingling, painful left hand and foot cramps, heart palpitations, motor and gait changes, and significant pain in the left shoulder, arm, elbow (ulnar nerve?), knee, and foot, and continuing changes in vision in both eyes. (Not to mention the multi-types and locations of post-herpetic neuralgia(PHN) extending far beyond the cranium. I was seen this summer at the Anschutz Neurological Outpatient Clinic, Denver, Colorado. The symptoms described above were dismissed as probable onset of arthritis and unrelated complaints. (Bloodwork is negative for HIV, Lyme's, and diabetes; MRI okay.) Hours of intense internet research has finally paid off. Today I found a definition of Ramsay Hunt Type3 (RH-3) involving the ulnar nerve. I am also going to request testing for wheat gluten sensitivity. My vital data is that I am (or was) a healthy, active 49-yr. old caucasian female with no family history of cancer, diabetes, heart disease, NO arthritis, or anything notable. Competing interests: None declared
Recent Development in Bell's Palsy 19 January 2007
Carol Blackbird, Teacher R1N 3Y4 Send response to journal: Re: Recent Development in Bell's Palsy	The research article was not at all helpful. It provided no new information or anything helpful whatsoever for people suffering from long term Bell's Palsy. What exactly did this research accomplish? All of the information contained in the article was exactly the same as the information in the majority of Bell's Palsy information sites on the internet. Serious and on-going research as to the actual cause(s) and successful treatment for those who suffer from long term Bell's Palsy needs to be undertaken. Just because it is not a terminal illness does not mean it is not devastating to those people who suffer from it. I am not referring to the people who make a full or nearly full recovery but those who have only partial or limited recovery. With all the medical advances that have been made in recent years it is unbelievable that there has been absolutely no advances in the treatment (or cause)of this "devastating medical illness/disease/problem." Competing interests: None declared
Re: Undescribed symptom of Bell's palsy? 20 January 2007
John R Cherry, Honorary Consultant Otolaryngologist Royal Blackburn Hospital, Blackburn, Lancs, BB2 3HH Send response to journal: Re: Re: Undescribed symptom of Bell's palsy?	Yes, it is well recognised, and is known in ENT as alar collapse. It results (in BP) from paralysis of the levator labii superioris alaeque nasi, and perhaps the dilator naris. These, of course, are muscles of facial expression supplied by the facial nerve. It also occurs from structural causes, especially after nasal trauma, when it can be corrected by inserting a batten of autologous cartilage either between the alar cartilage and the overlying skin, or between the alar cartilage and the underlying mucosa, with overlap of the upper lateral cartilage in either case. John R. Cherry, F.R.C.S. Competing interests: None declared