STABILIZED OUTCOMES OF
IDIOPATHIC PARALYSIS OF THE FACIAL NERVE (BELL'S PARALYSIS) AND STRESS: AN
ATTEMPT OF AN ANTISTRESS DRUG THERAPY LASTING 10 MONTHS.
(Other three cases of drug treatment facial nerve paralysis outcomes)
Renato COCCHI, a neurologist and a medical
psychologist
Summary.
Results of 10 months of an antistress and
neurotrophic drug therapy on stabilized outcomes of an idiopathic paralysis of
the facial nerve to left side ( Bell's paralysis) installed two years before in
a woman of 48 years, are described.
The therapy improved 12 symptoms out of
twelve, and one of them, hypersensitiveness to noise, completely disappeared.
Six months after the woman stopped the treatment by her willing, the only
symptom that went on to improve was the ability to blow up her left cheek.
Key words: Bell's paralysis; stabilized
outcomes, GABA, antistress therapy.
Drug modulation of stress reactions
Others
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The idiopathic facial paralysis or Bell's
palsy installs abruptly or within a few hours, without any apparent cause. It
corresponds to approximately 75% of all peripheral facial palsies. There was a
predominance of cases in winter (31.38%) and autumn (30.13%), which was
statistically significant. (Gonçalvel-Cohelo et al., 1997)
According to Danielides et al, 2001, there
was instead no significant difference in the number of cases occurring during
the cold - warm half of the year, the four seasons, and in the monthly
distribution.
Campbell & Brundage, 2002 affermed again
that both climate and season were independent predictors of risk of Bell's
palsy.
The natural history of Bell's palsy is
favorable. Eight-four percent show satisfactory recovery without any treatment,
however 16% suffer moderate to severe sequelae.
The prognosis for Bell's palsy is generally
very good. With or without treatment, most patients begin to get significantly
better within 2 weeks, and about 80 percent recover completely within 3 months.
For some, however, the symptoms may last longer. In a few cases, the symptoms
may never completely disappear.
Prognosis is influenced by degree of
paresis, age of patient, and time until first signs of recovery. (Jabor &
Gianoli, 1996)
The status of facial nerve paralysis should
be monitored by repeat electrical examinations, preferably EnoG (Moore, 1990).
I did not find information on what does
happen to anyone who had an unfavourable outcome, and I concluded that the fact
that several symptoms don't disappear ever again, seems, at the moment, the
only accepted assertion.
Some elements, however (the idiopathic form,
the age of the subject (Jabor & Gianoli, 1996), female prevalence (
Gonçalvel-Cohelo and coll., 1997), possible action of the cool
(Gonçalvel-Cohelo and coll., 1997; Campbell & Brundage, 2002 ), a link with
viral illnesses of the upper respiratory tracts ( Gonçalvel-Cohelo and coll.,
1997; Campbell & Brundage, 2002 ), its recoveries in most persons without
any treatment, but not always full recoveries) led me to think that could be
some relationships with individual fragility and then with stress reactions (Cocchi,
2003 ).
The following is a first case of a subject
with stabilized outcomes of idiopathic paralysis of the facial nerve, treated
for 10 months (drug therapy stopped by the patient).
. The case.
A woman, aged 48 at first consultation. Two
years before she had a one-sided idiopathic paralysis of the facial nerve (a
Bell's paralysis) that implicated the left half-face. The paralysis came after
a drop in temperature (a possible switching factor). About her therapy in the
acute phase she remembers the corticosteroids, but perhaps she was given even
aciclovir. Since then she maintained several residual symptoms, at least
disturbing.
Currently (November 2001), she reports:
- episodes of pain beyond the left ear;
- hypersensitiveness ("internal pain
") to noise;
- wrinkling of the forehead
- left eyelid space reduced;
- difficolty to lift the eyebrows;
- pain at the exit points of the facial
nerve;
- a more deep nose-cheek line;
- light fall of the lips' line on the left
side;
- lightly reduced sense of taste of the
anterior part of the tongue (found during a previous neurologic checkup, but
not usually perceived by the patient);
- a tremor of the inferior lip;
- difficulty to blow up the left cheek.
The primary implication of the facial nerve seems
to have been under the geniculate ganglion but over the anastomosis with the
tympanic nerve.
Other anamnestic and clinical information:
Born after prolonged delivery with wound umbilical cord around the neck,
perhaps even premature delivery. Her personality was very selective, since she
was as a child, as for the relationships with the age peers. She doesn't feel
the cool, even if often has cold hands.
She was well in the mathematics. Liking for
sweet foods, but not chocolate. Hyperactive. Regular menstrual cycle every 28
days, but premenstrual syndrome. Not refractory nystagmus, with slow jerks,
beating to left. Tension headache episodes, mainly during the premenstrual
period. Intrusive thoughts. She realized she has the abit of count objects
without any need. To the Test:"Say me the opposite of the Red " she
answered: Black.
Therapy: Glutamine 250mg; pyridoxine 150mg;
biotin 5mg; amitriptyline 10mg; carbamazepine 100mg; bromazepam 0.75mg.Checkup
three months and half after therapy started: She is doing better. The
functionality of the mimic muscles improved. The tremor of the inferior lip
decreased. The wrinkling of the forehead improved, but not the same for the
lifting of her eyebrow.
When she is smiling, the line between the
lips is less asymmetric.
There is still a difference in opening her
eyelids.
Still pain: At the left nose-wing and cheek
angle, at the internal angle of the eyebrow, but reduced at the chinned point.
The nystagmus beating to the left is unchanged. Unchanged the sense of taste.
She can blow up some more the left cheek, but always a few. Still pain beyond
the ear, but it happens less frequent. Her head is always full of intrusive
thoughts. Objects counting, as usual. Unchanged premenstrual syndrome, as well
as the related tension headache. She restarted to do bad dreams with impotence
themes.
Therapy variation:Pyridoxine stopped; I
prescribed thiamine 125mg + pyridoxine 125mg + cyanocobalamin 500mcg.
A telephone checkup after 16 months from the
first visit. She has stopped the drug therapy after 10 months because worried
from having to take drugs.
She thinks of having improved the facial
motility of about 15%. The pain went down, but it varies following the weather,
the work tiredness and stress.
Checked symptoms and their variations are
summarized in Table 1.
Tab. 1 Symptoms evaluation at the stop of
the therapy and six months later.
|
Symtom |
Evalaluation at the stop of the therapy |
Evaluation 6 months after the drug stop |
|
Episodes of pain beyond the left ear |
Reduced |
Not changed |
|
Hypersensitiveness to noise |
Desappeared |
Not changed |
|
Wrinkling of the forehead |
Improved |
Not changed |
|
Difficolty to lift the eyebrows |
Improved |
Not changed |
|
Left eyelid space reduced |
More open |
Not changed |
|
Pain at left eyebrow point |
Reduced |
Not changed |
|
Pain at the nose-cheek point |
Reduced |
Not changed |
|
Pain at the chin point |
Reduced |
Not changed |
|
Deep nose-cheek line |
Less evident |
Not changed |
|
Line between lips sliht falling at left |
Improved |
Not changed |
|
Reduced sense of taste at 1/3 of the tongue |
She cannot evaluate it |
She cannot evaluate it |
|
Tremor of the lower lip |
Decreased |
Not changed |
|
Difficolty to blow up the left cheek |
Improved |
Improved (*) |
(*) now she can whistle
again
Discussion.
First we note that the affected subject is a
woman, in the fifth decade her life, and the switching factor was a lowering of
the temperature. Then we are facing with a very typical situation.
As traits of personal fragility we find
again a birth following prolonged and complicated delivery, a not-refractory
nystagmus, and a personality with relationship difficulty with age peers, since
she was a child. At the first consultation were symptoms of reduced ability to cope
with stress: The premenstrual syndrome and the relative tension headache, the
intrusive thoughts, and the habit of counting objects, without any apparent
need.
Black as her answer to the test: Say me the
opposite of red leads to think to a basic masked depression.
The therapy prescribed, primarily as
antistress therapy, acted mainly on the GABA, either by improving its synthesis
(glutamine and pyridoxine), either by inhibiting its B receptors
(carbamazepine) either by activating its A receptors (benzodiazepine).
Biotin, thiamine, and cyanocobalamin,
besides the pyridoxine, were used as neurotrophic drugs, the amitriptyline as
an antidepressant and as an antipain drug (favouring descending pain inhibition
from the raphe).
The course of the symptoms as reported in
the Tab. 1 points out that the therapy had undoubtedly got some results on 12
symptoms out of 13 (the patient was unable to answer about one symptom) The
clinical frame improved of 15%, as said by the patient herself.
Six months after stopping the drug therapy,
only the ability to blow up the left cheek, till the point of she can recover
to whistle, is even improved.
The ten symptoms remaining did no more vary.
The improvement during the drug therapy appears probably contingent upon the
same, since it did not go on, in ten on the eleven symptoms surely present,
after its stop.
As every antistress therapy requires, even
this one was individually tailored, because the reaction answers to the stress
depend from individual, both genetic and acquired, factors.
Undoubtedly a single case, for its nature,
is always anecdotal, but we need to remember that the patient zero always
exists. I hope that this patient could be the patient zero of the relationship
between stabilized outcomes (or, the so presumed ones) of the idiopathic
paralysis of the facial nerve and antistress therapies.
(An other case of drug treatment facial nerve paralysis outcomes)
References
Campbell KE; Brundage JF. Effects of climate,
latitude, and season on the incidence of Bell's palsy in the US Armed Forces,
October 1997 to September 1999. Am J Epidemiol 2002, 156: 32-39.
Cocchi R. Need we recover the clinical idea
of an individual resistance to illnesses? August 2003 <www.stress-cocchi.net/Speculation4.htm>.
Danielides V; Nousia C-S; Patrikakos G;
Katsaraki A; Skevas A. Seasonal Distribution and Epidemiology of Bell's Palsy.
Oto-Rhino-Laryngologia-Nova 2001, 11:151-156
Goncalves-Coelho TD; Pinheiro CN; Ferraz EV;
Alonso-Nieto JL. Clusters of Bell's palsy. Arq Neuropsiquiatr 1997,55: 722-727
Jabor MA; Gianoli G. Management of Bell's
palsy. J La State Med Soc 1996, 148: 279-283
Moore GF. Facial nerve paralysis. Prim Care
1990, 17: 437-460.
First published on Internet on March 2003. Copyright by Renato Cocchi,
2003.
Author's address: Dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it