|Year : 2013 | Volume
| Issue : 2 | Page : 165-167
Simultaneous Bilateral Bell's palsy in a Nigerian man
Lukman F Owolabi1, Farouq Zayyad2
1 Department of Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Ophthalmology, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
|Date of Web Publication||24-Dec-2013|
Lukman F Owolabi
Department of Medicine, Aminu Kano Teaching Hospital, Bayero University, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Bilateral Bell's palsy occurring simultaneously is exceedingly rare. We report a case of a 27-year-old Nigerian man with bilateral Bell's palsy, that occurred simultaneously, who had remarkable response to steroid and physiotherapy. We emphasized the importance of considering Bell's palsy and the various differential diagnoses in all cases presenting with bilateral facial muscle paralysis.
Keywords: Bilateral, Bell′s palsy, simultaneous
|How to cite this article:|
Owolabi LF, Zayyad F. Simultaneous Bilateral Bell's palsy in a Nigerian man. J Med Trop 2013;15:165-7
| Introduction|| |
Bell's palsy otherwise known as idiopathic facial paralysis is the most common cause of unilateral facial paralysis accounting for about 60-75% of cases of acute unilateral facial paralysis.  It has an average annual incidence rate of 23 to 25 patients per 100,000 population. , The right side is often more affected as it is the case in 63% of the time. ,
Bell's palsy can also be recurrent, with a reported recurrence range of 4-14%.  Recurrent facial weakness is more of a curiosity, occurring in 7% of patients with Bell's palsy. 
However, bilateral Bell's palsy occurring simultaneously is exceedingly rare with a frequency of 1 in 5,000,000 people.  It is decidedly uncommon as it constitutes less than 1% as frequent as unilateral paralysis. 
We present the case report of a Nigerian Hausa man with bilateral Bell's palsy that occurred simultaneously with a view to drawing attention of clinicians to this rare entity and the need for cautious evaluation of patients presenting with bilateral facial paralysis. This, to the best of our knowledge, is the first case to be reported from Nigeria.
| Case Report|| |
A 27-year-old Nigerian was seen in neurology clinic of Murtala Muhammad Specialist Hospital, Kano, with a 2-day history of difficulty with closing of both eyes, difficulty with smiling, and dripping of fluid out of his mouth while performing ablution. The symptoms were first noticed on awakening from sleep early in the morning. Before retiring to bed the previous night, the patient noted numbness and paraesthesia on his face. There was no similar sensation or weakness in the limbs. There was no history of recent head trauma, ear discharge, ear pain, hearing difficulty, toothache, or cold sores. However, 10 days prior to the onset of the symptoms he had flu-like illness that resolved a week later on loratidine and vitamin C. He neither smoked nor consumed alcohol and there was no history of illicit drug use. There was no family history of the illness.
On examination, the patient was conscious and alert and oriented. He had demonstrable bilateral lower motor neuron facial nerve palsy as evident by inability to close his eyelid as well as bilateral facial weakness [Figure 1]. However, the other cranial nerves were intact. His pupils were 3 mm, equal and reactive to light. Fundoscopy did not reveal any abnormality. There were no cerebellar or extrapyramidal signs. Skin examination did not reveal any abnormality. No vesicular rashes were found on his external ears. The remainder of his examination including respiratory, cardiovascular, and abdominal assessment was grossly unremarkable.
His fasting blood sugar (FBS), on two occasions, was within normal limits. The other biochemical parameters including electrolyte and urea were all normal. His full blood count (total and differentials), erythrocyte sedimentation rate (ESR), serological screening for HIV, syphilis, hepatitis B and C were not reactive. Brain computerized tomography scan did not show abnormal findings. Electromyography and nerve conduction study showed reduced amplitude, distal latencies, and conduction velocities bilateral. Both R 1 and R 2 responses were delayed on blink reflex.
The patient was diagnosed to have simultaneous bilateral Bell's palsy and was placed on prednisolone, omeprazole, acyclovir, moisturizing eye drops, and eye patch. He also had regular physiotherapy. After 6 months of treatment, he had full resolution of his symptoms and regained full function of the facial muscles with the exception of occasional excessive tearing in the right eye on eating [Figure 2]. A measuring instrument, House-Brackmann grading scale,  was used for objective assessment by viewing and assessing the photographs taken during the patient visits. The instrument showed improvement from grade V at presentation to I after treatment [Figure 1], [Figure 2] and [Figure 3] respectively].
| Discussion|| |
Unilateral Bell's palsy is not uncommon, however, simultaneous bilateral facial nerve palsy is a rarity and hence presents a diagnostic challenge.
Generally, Bell's palsy is an acute, unilateral, peripheral, lower motor-neuron facial nerve paralysis that gradually resolves over time in 80-90% of cases.  As exemplified by the index patients, it occurs more commonly in adults with the peak ages between 20 and 40 years. The lowest incidence is reported in patients younger than 10 years and the highest incidence is in patients aged 60 years or older. 
The patient presented within the first 36 hours of onset of the symptoms, this was rather unusual in our setting where majority of the patients with Bell's palsy often presented late. Early presentation seen in this patient could be ascribed to the extent or severity of the facial paralysis which was rather unusual when compared to unilateral Bell's palsy.
The patient had a preceding upper respiratory tract infection. Bell's palsy has been repeatedly shown to follow recent upper respiratory infection. , To some extent, controversy still surrounds the etiology of Bell's palsy, many authors strongly believe that it is commonly caused by Herpes Simplex Virus (HSV). Nonetheless, in view of the ubiquitous nature of HSV, a definitive causal relationship of HSV to Bell's palsy may be difficult to establish. In a landmark study, Murakami et al. using polymerase chain reaction reported HSV in the endoneural fluid of the facial nerve in 11 out of 14 patients who had surgery for Bell's palsy. 
In patients with presumptive diagnosis of bilateral Bell's palsy which happens to be a diagnosis of exclusion, but much less so in unilateral presentation, effort should be geared toward excluding diabetes mellitus, human immunodeficiency virus (HIV) infection, syphilis, infectious mononucleosis, malformations as Mobius syndrome, vasculitis, or bilateral neurofibromas, intrapontine and prepontine tumor, Guillain-Barre syndrome (GBS), multiple idiopathic cranial neuropathies, Lyme disease, meningitis, brain stem encephalitis, benign intracranial hypertension, leukemia, Melkersson-Rosenthal syndrome More Details. , Clinical, laboratory, and radiological investigation results were not suggestive of any of these differentials in the patient in question. However, other viral causes such as Herpes viruses were excluded on clinical ground. Having excluded a number of the other possible causes of this disorder after extensive evaluation, we assumed that the most likely cause of facial diplegia in the case being reported was Bell's palsy.
Our patient presented early and possibly benefited from early steroid therapy. Treatment of bilateral Bell's palsy does not differ from that of unilateral Bell's palsy. However, the use of steroid and or acyclovir is shrouded in controversy. A randomized double-blind control trial showed that in patients with Bell's palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone.  Other studies, including systematic review, have shown that that there is insufficient evidence to recommend an antiviral agent in addition to prednisolone in the treatment of Bell's palsy.  It was based on this evidence that the patient was given only prednisolone.
However, the recent report of the Guideline Development Subcommittee of the American Academy of Neurology on treatment of Bell's palsy stipulated that for patients with new-onset Bell's palsy, steroids are highly likely to be effective and should be offered to increase the probability of recovery of facial nerve function. Antiviral agents in combination with steroids do not increase the probability of facial functional recovery by 7%. Because of the possibility of a modest increase in recovery, patients might be offered antivirals. Patients offered antivirals, however, should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is likely that it is modest at best. 
In conclusion, we reported a 27-year-old man with simultaneous bilateral Bell's palsy following upper respiratory infection which responded favorably to steroid and physiotherapy. The practitioner should be aware of the diagnostic possibilities of this very rare condition.
| References|| |
|1.||Pothiawala S, Lateef F. Bilateral facial nerve palsy: A diagnostic dilemma. Case Rep Emerg Med 2012;2012:458371. |
|2.||Hauser WA, Karnes WE, Annis J, Kurland LT. Incidence and prognosis of Bell's palsy in the population of Rochester, Minnesota. Mayo Clin Proc 1971;46:258-64. |
|3.||Katusic SK, Beard CM, Wiederholt WC, Bergstralh EJ, Kurland LT. Incidence, clinical features, and prognosis in Bell's palsy, Rochester, Minnesota, 1968-1982. Ann Neurol 1986;20:622-7. |
|4.||Peitersen E. Bell's palsy: The spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002;549:4-30. |
|5.||Pitts DB, Adour KK, Hilsinger RL. Recurrent Bell's palsy: Analysis of 140 patients. Laryngoscope 1988;98:535-40. |
|6.||Teller DC, Murphy TP. Bilateral facial paralysis: A case presentation and literature review. J Otolaryngol 1992;21:44-7. |
|7.||Keane JR. Bilateral seventh nerve palsy: Analysis of 43 cases and review of the literature. Neurology 1994;44:1198-202. |
|8.||House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7. |
|9.||Peitersen E. The natural history of Bell's palsy. Am J Otol 1982;4:107-11. |
|10.||Owolabi LF, Ibrahim A. Recurrent Bell's palsy in a Nigerian patient with Human Immunodeficiency virus (HIV) infection: Case report. Jos J Med 2010;5:43-5. |
|11.||Vrabec JT, Backous DD, Djalilian HR, Gidley PW, Leonetti JP, Marzo SJ, et al. Facial Nerve Grading System 2.0. Otolaryngol Head Neck Surg 2009;140:445-50. |
|12.||Liu J, Li Y, Yuan X, Lin Z. Bell's palsy may have relations to bacterial infection. Med Hypotheses 2009;72:169-70. |
|13.||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;124:27-30. |
|14.||May M, Klein SR. Differential diagnosis of facial nerve palsy. Otolaryngol Clin North Am 1991;24:613-45. |
|15.||Serrano P, Hern×andez N, Arroyo JA, de Llobet JM, Domingo P. Bilateral Bell palsy and acute HIV type 1 infection: Report of 2 cases and review. Clin Infect Dis 2007;44:57-61. |
|16.||Sullivan FM, Swan IR, Donnan PT. Early Treatment with Prednisolone or Acyclovir in Bell's Palsy. N Engl J Med 2007;357:1598-607. |
|17.||Shahidullah M, Haque A, Islam MR, Rizvi AN, Sultana N, Mia BA, et al. Comparative study between combination of famciclovir and prednisolone with prednisolone alone in acute Bell's Palsy. Mymensingh Med J 2011;20:605-13. |
|18.||Gronseth GS, Paduga R; American Academy of Neurology. Evidence-based guideline update: Steroids and antivirals for Bell palsy. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2012;79:2209-13. |
[Figure 1], [Figure 2], [Figure 3]