1. Evaluation and management of Bell’s palsy Chunfu Dai Otolaryngology Department Fudan University

2. Definition Rapid onset of the facial palsy Minimal associated symptoms Spontaneous recovery (80%) The diagnosis is made after the exclusion of other possibility

3. Etiology Vascular congestion with secondary ischemia to the nerve Vasospasm would lead to ischemia, nerve edema, and secondary compression within the fallopian canal. Viral polycranioneuropathy Herpes simplex virus and herpes zoster virus

4. Clinic features Less common before the age of 15y The incidence in men and women is similar Approximately 6-9% develop recurrent Bell’s Palsy Facial paresis alone occurred in 31% Completely paralysis in 69%

5. 71% of patients with completely paralysis achieve a H-B G1 13% a H-B G2 The remaining 16% in this complete paralysis group have a fair to poor recovery (H-B 3-5)

6. Prognosis All patients with complete or partial paralysis, approximately 85% recover to normal with one year without treatment. Patient experienced delayed recovery over 3 months, all developed sequelae Return of at least some facial function was noted in all patients.

7. Evaluation of acute facial paralysis House-Brackman grade system I, Normal: Normal facial functionin all areas II, Mild dysfunction: slight weakness noticeable only on close inspection At rest: normal symmetry and tone Motion: some to normal movement of forehead Ability to close eye with minimal effort Ability to move corners of mouth with maximal effort and slight asymmetry No synkinesis, contractur, or hemifacial spasm

8. House-Brackman grade system III, moderate dysfunction: obvious but not disfiguring difference between two side No function impairment Noticeable but not severe synkinesis, contracture, and hemifacial spasm At rest: normal symmetry and tone Motion: slight to no movement of forehead Ability to close eye with maximal effort and obvious asymmetry Ability to move corners of mouth with maximal effort and obvious asymemetry Patients with obvious but not disfiguring synkinesis, contracture, and hemifcial spasm are grade 3 regardless of degree of motor activity.

9. House-Brackman grade system IV, moderate severe dysfunction: Obvious weakness and disfiguring asymmetry At rest: normal symmetry and tone motion: no movement of forehead Inability to close eye completely with maximal effort Asymmetrical movement of corners of mouth with maximal effort Patients with synkinesis, mass action, and hemifacial spasm severe enough to interfere with function are grade 4 regardless of degree of motor activity

10. House-Brackman grade system V, severe dysfunction: Only barely perceptible motion At rest: possible asymmetry with droop of corner of mouth and decreased or absent nasolabial fold Motion: No movement of forehead Incomplete closure of eye Slight movement of corner of mouth Synkinesis, contracture, and hemifacial spasm usually absent VI, total paralysis: no movement

11. Fisch grade system Rest 20, forehead movement 10, eye closure 30, smile 30, month blow 10. Each is given 0, 30%, 70% or 100%.

12. A careful history of the patients illness Sudden in onset and frequently evolve over 2-3 weeks after onset Any palsy progression over 3 weeks should be evaluated for a neoplasm Any palsy persist for 6 month without any recovery should be considered for a neoplasm.

13. Ramsay-Hunt syndrome It is manifest by a facial palsy with a vesicular eruption over a distribution of a cranial nerve Sensorineural hearing loss and vertigo may also be present in up to 20% of cases. Prognosis is poor than Bell’s palsy

14. Audiometry: to rule out any involvement of the auditory nerve CT and MRI: for patient without fully recovery, to identify the site of lesion. Electrophysiologic testing to determine prognosis.

15. Schirmer test, stapedial reflex, electrogustometry, and salivary flow has be obsolete. Serologic studies can be considered to evaluation for lyme disease, autoimmune disorders, or other central nervous system disease

16. Managements Medical treatment: Medical treatment: Steroid 1mg/kg/day Steroid 1mg/kg/day Vasodilation Vasodilation Anti-virus Anti-virus Vitamine B Vitamine B Physical therapy Physical therapy Hypobaroxygen Hypobaroxygen Protection of corner Protection of corner

17. Management Surgery Surgery Degeneration of facial nerve more than 90% indicates facial nerve decompression Degeneration of facial nerve more than 90% indicates facial nerve decompression Approach: Approach: middle fossa cranionectomy middle fossa cranionectomy Combination of middle fossa and mastoidectomy Combination of middle fossa and mastoidectomy

18. Thank you!