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 Table of Contents  
Year : 2016  |  Volume : 53  |  Issue : 2  |  Page : 70-73

Incidence and clinical predictors of outcome of Bell's palsy, Al-Quseir City, Red Sea Governorate, Egypt

1 Department of Neurology, Assiut University, Assiut, Egypt
2 Department of Neurology, Al-Azhar University (Assiut Branch), Assiut, Egypt
3 Department of Neurology, Sohag University, Assiut, Egypt
4 Department of Neurology, Helwan University, Assiut, Egypt
5 Department of Neurology, Fayoum University, Assiut, Egypt

Date of Submission20-Jan-2016
Date of Acceptance02-Mar-2016
Date of Web Publication2-Jun-2016

Correspondence Address:
Ghaydaa A Shehata
MD, Neurology, Neurology and Psychiatry Department, Assiut University Hospitals, 71111 Assiut
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-1083.183405

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Bell's palsy (BP) is one of the most common causes of acute-onset unilateral facial weakness. Through this study we aimed to estimate the incidence of BP in Al-Quseir City, Red Sea Governorate, Egypt.
Patients and methods
A project was undertaken to assess the epidemiology of major neurological disorders. A total of 33 285 eligible patients were screened through a door-to-door survey (every door) by three specialists in neurology and 15 social workers. All patients were subjected to detailed history taking and a meticulous neurological examination by means of a specific questionnaire designed for this study.
Within 1 year, 27 patients were diagnosed with BP. This yielded an incidence rate of 98.9/100 000 population (aged 9 years and older). The incidence was higher in the male population than in the female population (116.4 and 81.2/100 000, respectively). Age-specific incidence of BP showed that its peak was between the ages of 18 and 60 years. About 78% of patients with BP recovered completely within 6 months after onset. There was no significant difference between male and female patients.
The incidence rate for BP was 98.9/100 000 among those aged 9 years and older. Most affected cases were older than 18 and less than 60 years.

Keywords: Bell′s palsy, clinical predictors, Egypt, facial weakness, incidence

How to cite this article:
El-Tallawy HN, Farghaly WM, Shehata GA, Badry R, Hassan M, Hamed MA, Sayed MA, Abdulghani KO, Sayed SS, Rageh TA, Metwally NA, Mohamed KO, Tohamy AM. Incidence and clinical predictors of outcome of Bell's palsy, Al-Quseir City, Red Sea Governorate, Egypt. Egypt J Neurol Psychiatry Neurosurg 2016;53:70-3

How to cite this URL:
El-Tallawy HN, Farghaly WM, Shehata GA, Badry R, Hassan M, Hamed MA, Sayed MA, Abdulghani KO, Sayed SS, Rageh TA, Metwally NA, Mohamed KO, Tohamy AM. Incidence and clinical predictors of outcome of Bell's palsy, Al-Quseir City, Red Sea Governorate, Egypt. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2023 Dec 10];53:70-3. Available from: http://www.ejnpn.eg.net/text.asp?2016/53/2/70/183405

  Introduction Top

Bell's palsy (BP) is one of the most common neurological disorders affecting the cranial nerves and is certainly the most common cause of facial paralysis worldwide [1]. BP is an abrupt, unilateral, peripheral facial paresis or paralysis without a detectable cause. This syndrome of idiopathic facial paralysis was first described more than a century ago by Sir Charles Bell; yet much controversy still surrounds its etiology and management [2]. The exact etiology of BP is unknown, but viral infection, autoimmune disease, and vascular causes have been postulated as possible pathomechanisms [3].

The incidence rate of BP varies widely worldwide. It was modest in Al-Kharga district, New Valley, Egypt (51.89/100 000) [4] and in a Sicilian survey in Italy (52.8/100 000) [5]. More recently, Monini et al. [6] found the incidence rate in Italy to be 48.157.3 per 100 000 per year, but it was lower in the UK (20.2/100 000) [7] and the USA (13-34/100 000) [8],[9].

  Aim of the work Top

The aim of this work was to determine the annual incidence rate of BP, and its fate of recovery in Al-Quseir City, Red Sea Governorate, Egypt.

  Patients and methods Top

The present work is a population-based door-to-door study among the population of Al-Quseir City, Red Sea Governorate, over a period of about 2½ years. The sample consisted of all individuals, of nuclear families or extended families, of any age, who have been living in the area of the study for at least 6 months at the time of the interview.

The study area, Al-Quseir City, was a coastal area that differed from the area studied in the previous project, Al-Kharga district, which was an oasis lying in the western Egyptian desert, with a different climate and different geography.

The total number of patients screened in Al-Quseir City was 33 816; 1.6% (N = 533) refused to participate. Patients were contacted at their locations if they were not at their homes at the time of the first visit, and revisited at a later time period (capturerecapture method).

Written informed consent was obtained from each participant (for children and incapacitated older persons through their caregivers) according to the ethics committee of Assiut University. The whole project was approved by the Ministry of Health at the Red Sea Governorate.

This study was conducted in three stages. Phase 1 (screening phase): A door-to-door survey was conducted for all inhabitants of Al-Quseir City (33 283) by three specialists of neurology to assess the epidemiology of major neurological disorders. In addition, 15 female social workers helped in screening by taking the social data of all patients, and facilitating contact with families. The study was conducted over 2½ years. Screening of all eligible individuals was carried out to identify all suspected cases of neurological disorders including BP, using a standardized Arabic screening questionnaire [4].

Phase II (case verification): All individuals who were suspected to have BP were invited to attend Al-Quseir General Hospital where they were fully evaluated by three neurology specialists as well as by another nine neurology staff members to confirm diagnosis. BP cases were diagnosed according to the definition proposed by Katusic et al. (1986) [9], who defined BP as peripheral monosymptomatic facial paralysis of acute onset with clear-cut symptoms and a benign course and without detectable causes.

Phase III: All data on each patient were registered in a specialized sheet prepared specifically for this study. Data regarding age at onset, sex, seasonal onset of symptoms based on the month in which BP was first diagnosed, specific treatment received (oral steroids and/or transcranial magnetic stimulation), as well as the duration of illness, outcome, recovery time, and family history of BP were collected in this specific sheet. Comorbid conditions such as diabetes mellitus, hypertension, pregnancy at the time of onset, and past history of herpetic infections or stroke were also recorded. Neuroimaging (computed tomography and/or MRI) was performed for selected cases when necessary to exclude symptomatic facial nerve lesions. Reassessment of the severity of BP was done 6 months after onset to verify the fate of the illness.

Grading of the severity of BP was performed on the basis of the House-Brackmann grading scale [10]. Grades of dysfunction are as follows: I, normal; II, slight; III, moderate; IV, moderatesevere; V, severe; and VI, total paralysis.

Statistical analysis

Data were managed by two specialists in data entry and by three medical statisticians using SPSS software (v 16; IBM Corporation, Armonk, New York, USA), Excel (Microsoft Corporation, Redmond, Washington, USA), and EpiCalc 2000 (Microsoft Corporation). Statistical analysis was conducted with analysis of variance. The χ2 -test was used to illustrate the relations or comparisons in nominal data. P-values less than 0.05 were considered significant.

  Results Top

No cases of BP were detected before 9 years of age. There was no statistically significant difference in sex-specific and age-specific incidence of BP within 1 year, as seen in [Table 1] and [Table 2]. All patients were followed up for 6 months. Among the predictors of outcome of BP (fate of recovery) illustrated in [Table 3] and [Table 4], postauricular pain, severe cases, and complete paralysis were found to be statistically significant predictors for poor prognosis. Other predictors are illustrated in [Table 3]. The House-Brackmann grading scale scored most of the cases as being between grades 3 and 4 [Table 4]. Twenty-one cases (78%) recovered completely, but six cases graded 5/6 on the scale had incomplete recovery.
Table 1: Sex-specific incidence rate of Bell's palsy (≥ 9 years) in Al-Quseir City, Egypt

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Table 2: Age-specific incidence rate of Bell's palsy (≥ 9 years) in Al-Quseir City, Egypt

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Table 3: Predictors for outcome of Bell's palsy (fate of recovery)

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Table 4: Classification of patients with Bell's palsy according to House - Brackmann grading scale

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  Discussion Top

The incidence rate of BP in a population aged 9 years and older was 98.9/100 000. These results were higher than those recorded worldwide, including other areas in Egypt. For example, in Al-Kharga district, New Valley, Egypt, the incidence rate of BP was 51.89/100 000 [4], and in the Sicilian survey in Italy the incidence was 52.8/100 000 [5]. In the UK study it was 20.2/100 000 [7], and in the USA it was 13-34/100 000 [8]. The overall incidence across Italy was 53.3 per 100 000 [6]. This discrepancy in the recorded rates across studies can be attributed to the differences in survey methods, study design (whether door-to door or hospital based), demographic characteristics, and genetic predisposition of the studied populations. As regards the two studies carried out in Egypt (the present study and the one conducted in Al-Kharga), although both were door-to-door studies, the Al-Quseir study calculated the age-specific incidence rate among individuals older than 9 years and the Al-Kharga study calculated the incidence among those over 8 years. In addition, the difference could be attributed to the climatic differences, with Al-Kharga representing an oasis in the western desert with extremes of temperature and Al-Quseir representing a coastal area with better climate.

The present study showed that BP was higher in the male population (59%) than in the female population (41%), with no significant difference in incidence rate. These results were in agreement with those of Monini et al. (2010) [6] in their Italian study, which reported that BP was slightly more in the male population (53.7%) compared with the female population (46.3%); however, Peitersen (2002) [11] reported that the incidence of BP was slightly higher in the female population (51.9%) than in the male population (48.1%). In contrast, Gillman et al. (2002) [12] reported that females and males are equally affected.

The present study shows that the incidence of BP was higher on the left side (59%) than on the right side (41%), with no significant difference. These results are in agreement with those of Peitersen (2002) [11], who recorded 48.7% right-sided and 51.3% left-sided palsies with no significant difference in localization. Although Katusic et al. [9] in their definition of BP reported that the disease may occur at any age, the present study showed that the peak age for occurrence of BP was 1860 years, with low incidence at the extremes of age and no cases recorded before the age of 9 years. There was a general agreement among previous studies that the incidence of BP peaks in middle age (maximum incidence between the ages of 15 and 45 years [13] and between 20 and 40 years [11],[14]).

Sex has no impact as a predictor of recovery from BP, as in our study there was no statistically significant difference between male (81%) and female (72%) patients who experienced full recovery within 6 months of follow-up. This was in agreement with the results of Peitersen (2002) [11], who reported that there was no statistically significant difference between male (69%) and female (72%) patients who attained full recovery in his study.

Follow-up of patients with BP for 6 months revealed that 78% of patients had complete recovery and the remaining 22% had incomplete recovery (varying degrees of residue). This is higher than the results of Peitersen (2002) [11], who found that 71% of patients regained normal function of their facial muscles after an idiopathic paresis. However, our results were lower than those of Sridharan et al. [15] (1988, Benghazi, Libya) and Savettieri et al. [5] (1996, Sicily, Italy), who reported incomplete recovery in 12 and 15% of patients with BP, respectively. Also Tang et al. (2009) [16] in Malaysia found after 6 months of follow-up that 83.3% of patients had full recovery from facial nerve paralysis, 15.4% of patients had partial recovery, and one patient (1.2%) with House-Brackmann grade V facial nerve paralysis did not recover at all during the period of follow-up. This discrepancy in outcome could be attributed to the severity of affection depending on the grading system and treatment given by different caretakers (grading system) at the time of onset and the lines of treatment used. The finding that all six cases who did not regain full recovery had severe degree of facial weakness grade 5 and 6 supports this assumption.

The present study showed that postauricular pain was a potential predictor of poor outcome (incomplete recovery) for BP. This is in agreement with the result of Peitersen (2002) [11], who reported that 78% of patients with no postauricular pain regained normal function.

The present study showed significant correlation between the degree of paralysis, according to House-Brackmann grading scale, and outcome of BP, where severe degrees of weakness (grade 5 and 6) were associated with poor outcome (incomplete recovery). These results are in agreement with those of Sathirapanya and Sathirapanya (2008) [17], who reported that severe facial paralysis (scores > 4) was correlated with unfavorable outcome. In contrast, Sαnchez-Chapul et al. (2011) [18] found that House-Brackmann grade did not represent a significant prognostic value for recovery.

  Conclusion Top

The incidence rate for BP in Al-Quseir City, Red Sea Governorate, Egypt, is 98.9/100 000 population aged 9 years and older. The incidence rate is higher among male patients than among female patients (116.4 and 81.2/100 000, respectively), with no significant difference between the two sexes. The present study showed the peak age for occurrence of BP is between 18 and 60 years, with low incidence at extremes of age. We also concluded that postauricular pain and severe facial weakness (House-Brackmann grade 5 and 6) at onset are predictors of unfavorable outcome.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Savettieri G, Salemi G, Rocca WA, Meneghini F, Santangelo R, Morgante L, et al. Incidence and lifetime prevalence of Bell′s palsy in two Sicilian municipalities. Sicilian Neuro-Epidemiologic Study (SNES) Group. Acta Neurol Scand 1996; 94 :71-75.  Back to cited text no. 5
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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 :622-627.  Back to cited text no. 9
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985; 93 :146-147.  Back to cited text no. 10
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.  Back to cited text no. 11
Gillman GS, Schaitkin BM, May M, Klein SR. Bell′s palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Neck Surg 2002; 126 :26-30.  Back to cited text no. 12
Gordon SC. Bell′s palsy in children: role of the school nurse in early recognition and referral. J Sch Nurs 2008; 24 :398-406.  Back to cited text no. 13
Prescott CA. Idiopathic facial nerve palsy (the effect of treatment with steroids). J Laryngol Otol 1988; 102 :403-407.  Back to cited text no. 14
Sridharan R, Radhakrishnan K, Ashok PP, Mousa ME. Clinical and epidemiological study of Bell′s palsy in Benghazi, Libya. Afr J Med Med Sci 1988; 17 :141-144.  Back to cited text no. 15
Tang IP, Lee SC, Shashinder S, Raman R. Outcome of patients presenting with idiopathic facial nerve paralysis (Bell′s palsy) in a tertiary centre - a five year experience. Med J Malaysia 2009; 64 :155-158.  Back to cited text no. 16
Sathirapanya P, Sathirapanya C. Clinical prognostic factors for treatment outcome in Bell′s palsy: a prospective study. J Med Assoc Thai 2008; 91 :1182-1188.  Back to cited text no. 17
Sánchez-Chapul L, Reyes-Cadena S, Andrade-Cabrera JL, Carrillo-Soto IA, León-Hernández SR , Paniagua-Pérez R, et al. Bell′s palsy. A prospective, longitudinal, descriptive, and observational analysis of prognosis factors for recovery in Mexican patients. Rev Invest Clin 2011; 6:361-369.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4]

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