Can a facial palsy protocol improve the management of patients presenting to the ENT emergency

department with facial paralysis?

Ajith George, Emma McFarlane & Churunal HariThe Royal Shrewsbury Hospital, Shropshire, UK

Abstract

Introduction

0

10

20

30

40

50

60

70

80

90

100

Bells

Palsy

Herpes

Zoster

Oticus

Otitis

media

Other Total

Steroid & Aciclovir

Aciclovir alone

Steroid Alone

No Medication

0

10

20

30

40

50

60

70

80

90

Trau

ma

UMN/LMN

CN

Aud

io

Otosc

opy

Nec

k

Ora

l cav

ity

% D

oc

um

en

ted

2008/2009

2005/2006

References

DiscussionObjectives1.Evaluate whether a facial palsy protocol improves theclinical management of facial palsy2.Assess the efficacy of the House-Brackmann (HB) scalein prescribing ‘eye care’ for patients.

MethodsA cross sectional study of patients presenting with facialpalsy was performed in a UK Otolaryngology out-patientdepartment from January 2008 to December 2009. Aspecific Facial palsy management protocol was followed,developed using outcome assessment data from aprevious 2005-2006 analysis where no protocol was inuse. Documentation of diagnosis, side of palsy, trauma,upper or lower motor neurone lesion, cranial nerveexamination, parotid and neck examination, otoscopy,audiology, examination of the oral cavity, HB grade andtreatment with eye care, aciclovir and/or prednisolonewere recorded, analysed and compared to previousdata.Results94 case notes were included with a mean age of 43.56yrs (range 2-86) and 44/50 male to female ratio. Thepatients mean delays to initiating treatment andassessment in secondary care were 2.51 and 5.15 daysrespectively.Following the protocol introduction after 2006 therewas an improvement in documentation of assessment infacial palsy, particularly neck examination 6% to 57.4%and HB documentation from 61% to 83%. Patientsdiagnosed with a palsy of grade IV or above were 19times more likely to receive eye care (Chi2 =18.056, p=0.025) than those with grade III or less.ConclusionThe departmental facial palsy protocol for juniorinexperienced doctors improves management. Ensuringdocumentation of the HB scale significantly improveseye care prescription. `

Aeitology of facial palsy is extremely diverse. Most casespresenting to emergency ENT departments arediagnosed with Bells palsy that has an annual worldwidereported incidence of 20-32.7 per 100,00. This diagnosiscan be made only after excluding other pathologyinvolving the facial nerve along its tortuous course fromits nucleus in the brainstem to the facial muscles. Themost junior member of the ENT team is often at theforefront of emergency care. Out of hours non-ENTtrainees may now provide this cover in order to adhereto UK guidelines for working hour compliance. It isimperative to provide these doctors with easilyaccessible reliable sources of information to aid theirdiagnosis and management of emergency patients.

1. Sullivan FM, Swan IRC, Donnan PT et al. A randomised controlled trial of the use of aciclovirand/or prednisolone for the early treatment of Bell’s palsy: the BELLS study. Health Technology Assessment 2009 Vol 13, No 47

2.Almeida J et al Combined Corticosteroid and Antiviral Treatment for Bell’s Palsy: A Systematic review and metanalysis. JAMA 2009; 309(9):985-93

3.Sullivan, FM, Swan IR, Donnan PT et al. (2007) Early treatment with prednisolone or acyclovir in Bell's palsy. New England Journal of Medicine 2007; 357(16):1598-1607

4. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol. Head Neck Surg 1985; 93:146–7

5. Sweeney CJ, Gilden DH. Ramsay Hunt Syndrome. J Neurol Neurosurg Psychiatry 2001; 71:149-54

6. Stafford F W, Welch A R. The use of Acyclovir in Ramsay Hunt Syndrome. J Laryngol Otol; 100 (3):337-340

7. Images accessed at http://info.med.yale.edu/caim/cnerves/cn7/cn7_1.html

Recent studies demonstrate a lack of evidencefor the use of anti viral therapy in managingpatients diagnosed with Bells palsy. The 2009BELLs Study compared combined aciclovir andprednisolone versus prednisolone alone forearly management (within 72 hours). Therecovery after 3 months was 86.3% forprednisolone alone versus 79.7% forcombination therapy. There is howeveruncertainty as to whether anti viral therapy isbeneficial for individuals diagnosed withRamsay Hunt syndrome. Some evidencesuggests a faster resolution of symptoms whenusing Aciclovir for the management VaricellaZoster virus infection of the facial nerve and inother parts of the body and as a result it iscommonly prescribed.Inexperience may be associated withuncertainty of diagnosis between Bells Palsyand Ramsay Hunt Syndrome. To avoid the risk ofmis-managing a patient with Varicella Zosterinfection we have included the addition ofAciclovir with corticosteroid therapy on ourmanagement protocol.