Bell's Palsy: Progressive Ascending Paralysis, Therapeutic Implications

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Abstract
This prospective study of 61 patients with Bell's Palsy supports the concept of a progressive ascending paralysis via the chorda tympani nerve. The severity of degeneration is directly related to the linear extent of facial nerve involvement within the fallopian canal.Reliably poor prognostic indicators are progression of paresis to complete paralysis, loss of tearing, reduced submandibular salivary flow to 25% or less, or a decreased or loss of response to maximal percutaneous electrical stimulation.Of the 61 patients selected for this study, 29 patients did not exhibit any of the above indicators and each had, without treatment, a complete or satisfactory return of facial function.However, 32 patients who exhibited one or more of the poor prognostic indicators, did not do as well. Of 12 patients operated on, four patients had complete recovery, while 3 patients had a fair return of facial function. None of the nonoperated‐on or steroid‐treated patients recovered completely. The number of patients having a poor recovery was highest among the steroid treated, lower among those who did not receive steroids, and lowest among those operated on. Decompression of the vertical and horizontal segments of the facial nerve was an effective form of treatment provided it was performed when submandibular salivary flow was 25% or less, while tearing and response to electrical stimulation were still normal. Seven of eight patients operated on with these criteria had a complete or satisfactory return of facial function.A loss of tearing was the most important prognostic sign. There were 14 patients with a loss of tearing on the involved side. Each one had a poor return of facial motor function with severe complications of faulty regeneration in spite of surgical decompression of the vertical‐horizontal segment of the facial nerve in 4 patients, steroid therapy in 7 patients, or no treatment in 3 patients. Based upon these results, a prospective study of the effectiveness of a total facial nerve decompression is justified for the few select cases with a dry eye, who would otherwise be destined to spend their lives as a facial cripple.