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- Page navigation anchor for RE: "Bell palsy" article by Patel et alRE: "Bell palsy" article by Patel et al
Dear Editor,
We read an article by Patel et al entitled “Bell palsy” with great interest. We acknowledge the substantial efforts of the involved authors and reviewers. With this letter, we would like to clarify a few inaccuracies that may have been overlooked.
Firstly, we agree with the authors that commonest cause of peripheral facial paralysis is Bell’s palsy, but it always the diagnosis of exclusion.(1-3) Acute Bell’s palsy should be treated with high dose steroids, while high dose antivirals must be added if Ramsay-Hunt is suspected.(2,3)
We would like to acknowledge Dr. Sjonnesen comment, who was first to identify that ptosis was erroneously mentioned as a symptom of acute flaccid facial paralysis. If present, this should trigger further investigations, specifically imaging, because the diagnosis is no longer “Bell’s palsy” when facial paralysis co-exists with oculomotor findings.(1)
Please note that the House-Brackman scale is an outdated tool to measure facial nerve recovery. A major disadvantage of using the House-Brackman scale is the under-characterization of patients with chronic dysfunction, specifically synkinesis.(4) Synkinesis refers to unwanted facial movements and tightness, which are the hallmark of incomplete facial nerve recovery.(4,5) Patients with “Grade 2” facial function could still have significant synkinesis and chronic facial dysfunction, yet are labelled as “recovered” in older studies. Scales like Sunnybrook are ea...
Show MoreCompeting Interests: None declared.References
- 1. Hohman MH, Hadlock TA. Etiology, diagnosis and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope 2014; 124:E283-93.
- 2. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell’s palsy. Otolaryngol Head Neck Surg 2013;149(3 Suppl):S1–27.
- 3. de Almeida JR, Guyatt GH, Sud S, et al. Management of Bell palsy: clinical practice guidelines. CMAJ 2014;186(12): 917-22.
- 4. Fattah AY, Gurusinghe ADR, Gavilan J, et al. Facial nerve grading instruments: systematic review of the literature and suggestion for uniformity. Plast Reconstr Surg. 2015;135(2):569-579.
- 5. Miller MQ, Hadlock TA. Beyond Botox: Contemporary Management of Nonflaccid Facial Palsy. Facial Plast Surg Aesthet Med. 2020;22(2):65-70.
- Page navigation anchor for Authors' reply to letter responseAuthors' reply to letter response
Dr. Sjonnesen correctly points out that Bell Palsy does not cause ptosis, but causes incomplete eyelid closure which can appear as ptosis but is more accurately described as lower eyelid sagging or drooping. (1, 2). We apologize for the error.
Sincerely,
Drs. Matthew Patel, Ameen Patel, Shijie ZhouCompeting Interests: None declared.References
- 1) Tiemstra JD, Khatkhate N. Bell’s Palsy: Diagnosis and Management. AFP. 2007 Oct 1;76(7):997–1002.
- 2) Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R, et al. Clinical Practice Guideline: Bell’s Palsy. Otolaryngol Head Neck Surg. 2013 Nov 1;149(3_suppl):S1–27.
- Page navigation anchor for RE: ptosis mentioned as core clinical featureRE: ptosis mentioned as core clinical feature
Elevation of the upper eyelid is controlled by levator palpebrae (oculomotor nerve) and Mueller muscle (long ciliary nerve from superior cervical ganglion). Ptosis, generally referring to upper eyelid droop, would not be considered a core feature of Bell palsy, as facial nerve is responsible for eye closure, not opening. This leads to incomplete eye closure in Bell palsy. Some sources describe "eyelid drooping" in Bell palsy, but specifically refer to "widening of the palpebral fissure with sagging of the lower eyelid" (Uptodate) in keeping with orbicularis oris involvement.
Competing Interests: None declared.References
- . https://webeye.ophth.uiowa.edu/eyeforum/cases/215-facial-nerve.htm
- Bell's palsy; pathogenesis, clinical features and diagnosis in adults. Uptodate.