Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Bell'sPalsy
- Chidambaran Ganapathy, VHS,Adayar,Chennai,India (10 June 2005)
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HTA funded trial in progress for Bell’s Palsy in Scotland.
- Frank M Sullivan, Daly F, Swan I (11 June 2005)
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Rule out Lyme disease with spinal tap before giving steroids!
- Mats G Reimer (12 June 2005)
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Bell's Palsy : aetiology should include iatrogenic too
- Dr. Arunachalam Kumar (12 June 2005)
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Bell's Palsy
- Peter G Procopis (13 June 2005)
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Steroids Not Proven in Bell’s Palsy—The Legacy of Bad Science
- Michael E Stuart, Sheri A. Strite (13 June 2005)
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Acupuncture for Bell's palsy
- John P Heptonstall (14 June 2005)
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Bell's , pregnancy and diabetes
- Adam P Morton (15 June 2005)
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The importance of clinical examination in 'Bell's Palsy'
- Gavin W Watters (21 June 2005)
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Bell's palsy and aciclovir
- Akram A. Hosseini, Bridget MacDonald, FRCP (22 June 2005)
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Don't leave out the eyes and ears in facial palsy
- Dipan N Mistry, Kanchan Bhan and Siddharth Agrawal (27 June 2005)
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Bell's Palsy: A diagnosis of exclusion
- James W Moor, Andrew P. Coatesworth (27 June 2005)
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Bell's Palsy: Propagating Poor Quality Evidence
- Claire Hopkins (7 July 2005)
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Chidambaran Ganapathy, Hon.Med.Officer,VHS,Adayar,Chennai,India 600020, VHS,Adayar,Chennai,India
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Sir, Here,in this pat of the country[Chennai,India],the GP is advised to think of the following conditions apart from what is already mentioned in the article:- a) Hansen's Disease b)DiabetesMellitus c)Hepertension. d) exposure cold wind with uncovered ears espicially while travelling in high speed vehicles. Thank You, Dr.G.Chidambaran/06-10-05 Competing interests: None declared |
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Frank M Sullivan, NHSTayside Prof of R&D in 1y Care Community Health Sciences Division, University of Dundee, Kirsty Semple Way Dundee DD2 4BF, Daly F, Swan I
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The evidence for the statement in this 10 minute consultation 'recent evidence supports the use of oral prednisolone and aciclovir in patients with moderate to severe palsy, ideally within 72 hours but up to seven days from onset of symptoms' is more equivocal than stated? Recruitment to our trial http://www.dundee.ac.uk/bells/index.htm was affected adversely by a non-systematic review to which we responded and the authors accepted that a trial was still required http://bmj.bmjjournals.com/cgi/eletters/329/7465/553#73309 GPs in Scotland should conttinue to refer patients into the BELL'S trial. Competing interests: We are conducting an HTA funded trial in Bell's palsy which may be compromised by this publication |
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Mats G Reimer, Community Pediatrician Child Clinic Molnlycke SWEDEN
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I am surprised that Dr Piercy can advocate steroids and acyklovir in Bell's palsy when two recent Cochrane reviews find no solid evidence for these therapies (1,2). In the UK borreliosis is less common than i Scandinavia, but since animal studies suggest that steroids can worsen a borrelia infection (3), my view is that before steroids are tried in Bell's palsy a lumbar puncture must be done. A CSF pleocytosis would make a diagosis of neuroborreliosis probable, and treatment with tetracycline can be started while waiting for serology results. 1. Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001942 2. Allen D, Dunn L. Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2001;(4):CD001869. 3. Pachner AR et al. Lyme borreliosis in rhesus macaques: effects of corticosteroids on spirochetal load and isotype switching of anti-borrelia burgdorferi antibody. Clin Diagn Lab Immunol. 2001 Mar;8(2):225-32. Competing interests: None declared |
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Dr. Arunachalam Kumar, Professor of Anatomy Kasturba Medical College, mangalore 575001, India
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I know of a case where the most likely explanation was the full, steady blast of cold air blown by the window air conditioning unit, which had been newly installed in the patient's hospital room. In hot tropical countries like India, much is spent on privacy and personal comfort (or luxuries) by the affluent. The burgeoning numbers of polyclinics and privately operated nursing homes are evidence of the moolah in this sector of the medical world. Hospitals here, could put five star hotels to shame. The patient not only pays through his nose, but is more than willing to do so. The installation of air-conditioning units has become passe. Little rationale is applied in selection of capacity, size of room, or positioning of unit - with result a good many patients udergoing treatment for unrelated causes, could land up with unilateral facial numbness in the hospital itself: the side of face involved being the same as exposed continuously to the face of the equipment. Aetiology of Bell's could include this unusual causative factor,a factor that could be responsible for far many more cases than the one reported here. Competing interests: None declared |
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Peter G Procopis, Child Neurologist Children's Hospital, Westmead, Sydney, NSW, 2145 Australia
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Jo Piercy states in her article on this subject that in an upper motor neurone lesion affecting the facial nerve, in contrast to a lower motor nerve lesion, that eye closure is not affected. This is incorrect. The orbicularis oculus muscle has variable bilateral upper motor neurone innervation with the result that it is not at all uncommon for eye closure to be affected in an upper motor neurone lesion such as a stroke. Competing interests: None declared |
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Michael E Stuart, President Seattle, Washington 98115, Sheri A. Strite
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Editor—Piercy’s 10 minute consultation on Bell’s palsy is another example of the legacy of misleading journal articles. Piercy states that, “recent evidence supports the use of oral prednisolone and aciclovir in patients with moderate to severe palsy, ideally within 72 hours but up to seven days from onset of symptoms”[1] and cites two systematic reviews[2,3]. However, as Tonks reported in BMJ’s editorial response [4] to Holland and Weiner's flawed clinical review on recent developments in Bell's palsy,[2] numerous letters-to-the-editor were critical of the review because it recommended early treatment with steroids. The editor went on to state that, “The authors were wrong to recommend early treatment with steroids or antiviral agents, or both, because the supporting evidence they offered was inconclusive and flawed…” The editor also pointed out, as did several letter writers, that there was “an obvious inconsistency between Clinical Evidence—the BMJ Publishing Group's most systematic and evidence-based publication—which says that steroids are an unproved treatment for Bell's palsy; they ignored the best evidence (two systematic reviews) and selected other trials to support their own opinion; neither treatment is harmless, and antiviral agents are expensive.” We agree with Tonks and believe that the best available evidence supports the Cochrane Collaboration’s conclusion that corticosteroids have not been demonstrated to be effective in Bell’s palsy.[5] 1 Piercy J. 10-minute consultation: Bell's palsy. BMJ 2005:1374, doi:10.1136/bmj.330.7504.1374. 2 Holland NJ,Weiner GM. Recent developments in Bell’s palsy. BMJ 2004;329:553-7. 3 Salinas R. Bell’s palsy. In: Clinical evidence concise. Issue 11. London: BMJ Publishing, 2004: 311. 4 Summary of Responses. Recent developments in Bell's palsy. BMJ 2004;329:1104 (6 November), doi:10.1136/bmj.329.7474.1104-a. 5 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. Michael E Stuart, M.D. President, Delfini Group LLC Seattle, WA 98115 mstuart@delfini.org Sheri A Strite Principal & Managing Partner, Delfini Group, LLC Competing interests: None declared |
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John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
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Sir Traditionally, in China, acupuncture is well known as a first line treatment for Bell's palsy. I have used this technique on numerous occasions to great effect in treating, and dramatically recovering patients from, the condition. It is known as a "wind" disease (eg. viral/bacterial) in Trad. Chinese medicine and is often seen during a "windy season" - autumn, amongst field workers. I note that a large proportion of my own patients who presented with the condition had concurrently been working outdoors during a windy period when the condition developed. Regards John H. Competing interests: Practitioner of TCM acupuncture & moxibustion |
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Adam P Morton, Physician Brisbane Australia 4101
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The related article by Holland and Weiner published last year mentions pregnancy as an indicator of poor prognosis in Bell’s palsy.1 Indeed one study showed that only 52% of women with Bell’s palsy of pregnancy whose facial palsy progressed to complete paralysis within 10 days of onset recovered to a satisfactory level compared to 77% to 88% of comparison patients.2 During pregnancy or the puerperium , women are three times more likely to develop Bell’s palsy than their non-pregnant, age-matched counterparts. An important association of Bell’s palsy is with hypertensive disorders of pregnancy, gestational hypertension or preeclampsia being present in 22% of pregnant women developing Bell’s palsy in a Medline review of the literature from January 1966 to October 1998.3 Thus any pregnant woman presenting with Bell’s palsy in second or third trimester should be observed closely for the development of preeclampsia. An additional consideration for future studies on the treatment of Bell’s palsy should be to compare the efficacy of antivirals and glucocorticoids in those with diabetes mellitus. A possible reason for the poor response to treatment in this group may be that glucocorticoid- exacerbated hyperglycaemia may impair nerve healing. 1. Holland NJ, Weiner GM. Recent developments in Bell's palsy. Bmj 2004;329(7465):553-7. 2. Gillman GS, Schaitkin BM, May M, Klein SR. Bell's palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Neck Surg 2002;126(1):26-30. 3. Shapiro JL, Yudin MH, Ray JG. Bell's palsy and tinnitus during pregnancy: predictors of pre-eclampsia? Three cases and a detailed review of the literature. Acta Otolaryngol 1999;119(6):647-51. Competing interests: None declared |
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Gavin W Watters, ENT Consultant Southend Hospital NHS Trust SS0 0RY
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Editor, The article on Bell's palsy by Jo Piercy(10-minute consultation, 11 june 2005) has some serious omissions with regard to clinical examination of patients presenting with a lower motor neurone facial nerve palsy. A Bell's palsy is an idiopathic lower motor neurone facial palsy, so to make the diagnosis of Bell's palsy other causes of facial nerve palsy need to be excluded. The author makes no mention of examination of the ear or the parotid gland though facial palsy can be secondary to pathology in both sites. Ear disease in particular is a relatively common cause of a facial nerve palsy, though in the past 18 months I have also be referred 2 cases of 'Bell's palsy' where the facial nerve weakness was actually due to a parotid tumour. It is particularly important not to miss disease in the middle ear or boney ear canal, as such ear pathology warrants urgent treatment to preserve remaining facial nerve function and maximise the chance of a full recovery. Often this will require surgery and such cases should be referred urgently to an ENT department, not after initiating treatment for 'Bell's Palsy', as implied in this article. As an educational article aimed at primary care physicians, it is a serious omission not to stress the importance of ear examination and also palpation of the parotid gland. Yours sincerely Gavin Watters FRCS FRCS(ORL) Competing interests: None declared |
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Akram A. Hosseini, Neurology SHO St. George's Hospital, London, Bridget MacDonald, FRCP
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To the editor- Jo Piercy in her 10 minute consultation article on Bell’s palsy states that “recent evidence supports the use of oral prednisolone and aciclovir in patients with moderate to severe Bell’s palsy”[1]. However, the use of steroids and aciclovir in the treatment of Bell’s palsy has been addressed in two recent Cochrane reviews[2] [3]. These found no proven benefit from aciclovir, early treatment with corticosteroids may be more effective than aciclovir or valaciclovir, but concluded that available studies were insufficiently powered or had insufficient clinical follow up to detect treatment effect. Omitted from this article were two systematic reviews and the selected supporting evidence was Holland and Weiner’s review article[4] which is inconclusive and was criticized in numerous letters-to-the- editor. It is stated that “antivirals inhibit viral replication” [1] but cause-and-effect conclusions cannot be drawn from observational studies nor there is the aetiology of Bell’s palsy. The dangers of advocating an unproven treatment are: 1. Dictating treatment leads to the treatment being “normal practice” and compromising current or future studies such as the Bell’s trial currently being run[5]. 2. Treatments are not harmless; many patients have contraindications to high dose steroids or need an adjusted dose for antivirals. 3. Antiviral agents are expensive. 4. This non-evidence-based practice of medicine can expose practitioners to complaints from patients, in particular those suffered from complications of treatment or who fail to have perfect outcomes. In conclusion, current evidence does not support the use of antiviral alone or in combination for Bell’s palsy. Corticosteroids seem to have a small benefit in the final functional recovery. We await the results of the ongoing Scottish trial[5] (aciclovir vs. prednisolone vs. aciclovir and prednisolone vs. placebo) and hope it will be conclusive. 1. Piercy J. 10-minute consultation on Bell’s palsy. BMJ 2005; 330:1374. 2. Allen D, Dunn L. Aciclovir for Bell’s palsy (idiopathic facial paralysis). The Cochrane Database of Systematic Reviews 2005 Issue 2. 3. Sipe J, Dunn L. Aciclovir for Bell’s palsy (idiopathic facial paralysis). The Cochrane Database of Systematic Reviews 2004 Issue 2. 4. Holland NJ, Weiner GM. Clinical review. Recent developments in Bell’s palsy. BMJ 2004; 329: 553-557. 5. Sullivan F. Bell’s trial. University of Glasgow. www.dundee.ac.uk/bells Competing interests: None declared |
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Dipan N Mistry, Specialist Registrar Hull Royal Infirmary, HU3 2JZ, Kanchan Bhan and Siddharth Agrawal
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Editor We feel that there are some key aspects of assessing the patient with facial palsy that need to be addressed.[1] When examining a patient with facial palsy, it is helpful to think about the course of the facial nerve from the brainstem, through the temporal bone and middle ear, exiting the skull at the stylomastoid foramen and dividing into terminal branches as it passes through the parotid gland. It is therefore essential that the ipsilateral ear is examined with an auroscope to assess the ear canal, eardrum and middle ear. Middle ear infection, cholesteatoma and malignant otitis externa can all cause facial palsy. The parotid gland should be examined for masses, as malignant tumours can also cause facial palsy. Risk factors for and the presence of exposure keratopathy should be assessed. Risk factors include persistently poor orbicularis oculi function, a poor Bell’s phenomenon (the protective reflex upward rotation of the eyeball on attempted lid closure) and diminished corneal sensation. Bell’s phenomenon and corneal sensation, unlike orbicularis function, are factors independent of the severity and persistence of facial palsy. Incomplete recovery of facial nerve function is not the only indication for referral to an ophthalmologist. Symptoms and signs of exposure keratopathy are probably a more common cause for referral to the eye clinic. Symptoms might include pain or irritation of the eye, blurred vision, photophobia and epiphora. Clinical signs include decreased visual acuity, redness of the conjunctiva, corneal haze and fluourescein staining of a disrupted corneal epithelium. 1. Piercy J. 10 minute consultation Bell’s palsy. BMJ 2005; 330: 1374 Competing interests: None declared |
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James W Moor, SpR Otolaryngology York Hospital, YO31 8HE, Andrew P. Coatesworth
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Editor, Re: Piercy, Jo. 10 minute consultation, Bell's palsy. BMJ 2005 (June);330:1374 The term Bell’s palsy should be reserved for cases of facial paralysis that have signs and symptoms consistent with the disease in which a diligent search for another cause is negative (1). This is the cause in 60-75% of acute facial palsies, with traumatic, neoplastic, infectious, metabolic and congenital aetiologies accounting for the remainder (2). It is important to have arrived at the diagnosis of Bell’s palsy by excluding other common causes of acute facial palsy and examination of the patient must include visualisation of the auditory canal and tympanic membrane (looking for vesicles in Ramsay Hunt syndrome or acute otitis media) and palpation of the parotid gland (neoplasia, associated cervical lymphadenopathy). Both these points were omitted by Piercy (3). A variety of grading systems exist to enable reliable documentation of facial palsy the most widely used in clinical practice is the House- Brackmann scale which assigns patients to one of six categories depending on the degree of facial function (4,5). Grade I is normal function, grade VI is complete paralysis with grades II to V pertaining to increasing severity of facial weakness, full details are available in ETN texts and in the medical literature (2,5). Routine use of such a grading system allows objective assessment at initial presentation and also at subsequent review visits which may or may not be by the doctor making the original diagnosis. It is reassuring to be able to provide a diagnosis of Bell’s palsy to the patient as prognosis is good, but the use of this diagnosis must be judicious. References 1. Cummings WC, Fredrickson JM, Harker, LA, Krause CJ, Richardson MA, Schuller DE. Otolaryngology Head and Neck Surgery, London, Mosby 1998. Ch 142, p2767 2. Jackler RK, Brackmann DE. Neurotology, London, Mosby, 1994.Ch 73 pp1292-98 3. Piercy, J. Bell’s palsy. BMJ 2005;330:1374 (11 June) 4. Evans RA, Harries DM, Baguley DM, et al. Reliability of the House and Brackmann grading system for facial palsy. J Laryngol Otol 1989;103:1045-6. 5. Couson SE, Croxon GR, Adams RD, O’Dwyer NJ. Reliability of the “Sydney,” “Sunnybrook,” and “House Brackmann” facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis. Otolaryngol Head Neck Surg 2005;132: 543-549 Competing interests: None declared |
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Claire Hopkins, ENT SpR Lewisham Hospital University Hospital Lewisham
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Editor, The 10-minute consultation published on Bell's Palsy not only propagates poor quality evidence, but also contains many inaccurate statements. Incidence: Bell's occurs more commonly in patients older than 65 (59 per 100,000) than the general population (20 - 30 per 100,000)(1). Examination: Sparing of the frontalis muscle in upper motor neurone palsy does not imply that eye closure will be preserved in every case. Bell's palsy is not a priori a seventh nerve palsy in isolation, as careful examination will reveal other CN weaknesses in more than 50% of patients with Bell's (1). Examination must include inspection of the tympanic membrane to exclude middle ear pathology, and palpation of the parotid gland to exclude malignancy, both of which are omitted in the paper. Bell's is a diagnosis of exclusion, to be made only after a meticulous search for other causes. Treatment: This article propagates the 'systematic' review of Holland and Weiner (2), which chose to ignore two Cochrane reviews on the use of steroids and aciclovir in Bell's Palsy (3,4). These concluded that there is not good evidence currently to support their use in every case of suspected Bell's. Publication of articles such as this one by Piercy will compromise entry into studies such as the trial underway in Scotland (5), which may provide us with a robust answer to the optimum management of this common condition. Eye care is an essential part of treatment. However, use of an eye patch over an insensate cornea may increase the risk of abrasion; if the eye opens under the patch during sleep the applied patch will abrade the cornea. It preferable to tape the lid closed directly, after applying a protective ointment such as lacrilube. Symptoms or signs of exposure keratopathy warrant urgent referral to an ophthalmologist. I agree that it is important to reassure a patient with Bell's palsy that the prognosis is favourable. However, it is equally important to make a correct diagnosis, and commence appropriate management based on best current evidence. References 1.Cummings WC, Fredrickson JM, Harker, LA, Krause CJ, Richardson MA, Schuller DE. Otolaryngology Head and Neck Surgery, London, Mosby 1998. Ch 142, p2767 2.N Julian Holland and Graeme M Weiner. Recent developments in Bell's palsy BMJ 2004 329: 553-557 3. Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001942 4. Allen D, Dunn L. Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2001;(4):CD001869 5.Sullivan F. Bell’s trial. University of Glasgow. www.dundee.ac.uk/bells Competing interests: None declared |
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