Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 66 Emergency (2014); 2 (2): 66-70 ORIGINAL RESEARCH Report of 121 Cases of Bell's Palsy Referred to the Emergency Department Behzad Zohrevandi, Vahid Monsef Kasmaee*, Payman Asadi, Hosna Tajik Road trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Abstract Introduction: According to the high incidence of Bell's palsy (IFP) and lack of clinical data regarding different aspects of disease, the present study investigated 121 Iranian patients with peripheral facial paralysis referred to the emergency department. Methods: In this retrospective study, all patients with peripheral facial paralysis, re- ferred to the emergency department of Poursina hospital, Rasht, Iran, from August 2012 to August 2013, were enrolled. For all patients with diagnosis of Bell's palsy variables such as age, sex, occupation, clinical symptoms, comorbid disease, grade of paralysis, and the severity of the facial palsy were reviewed and analyzed using STATA version 11.0. Results: 121 patients with peripheral facial paralysis were assessed with a mean age of 47.14±18.45 years (52.9% male). The majority of patients were observed in the summer (37.2%) and autumn (33.1%) and the recurrence rate was 22.3%. The most common grades of nerve damage were IV and V based on House-Brackman grading scale (47.1%). Also, the most frequent signs and symptoms were ear pain (43.8%), taste disturbance (38.8%), hyperacusis (15.7%) and increased tearing (11.6%). There were not significant corre- lations between the severity of palsy with age (p= 0.08), recurrence rate (p=0.18), season (p=0.9), and comorbid disease including hypertension (p=0.18), diabetes (p=0.29), and hyperlipidemia (p=0.94). The patients with any of following symptoms such as ear pain (p<0.001), taste disturbance (p<0.001), increased tearing (p=0.03), and Hyperacusis (p<0.001) have more severe palsy. Conclusion: There was equal gender and occupational distribu- tion, higher incidence in fourth decade of life, higher incidence in summer and autumn, higher grade of nerve damage (grade V and VI), and higher incidence of ear pain and taste disturbance in patients suffered from IFP. In addition, there was significant association between severity of nerve damage and presence of any simultaneous symptoms. Key words: Bell palsy; facial nerve diseases; paralysis; epidemiology; peripheral neuropathy Cite this article as: Zohrevandi B, Monsef Kasmaee V, Asadi P, Tajik H. Report of 121 cases of Bell's palsy referred to the emer- gency department. Emergency. 2014;2(2):66-70. Introduction:1 ell´s palsy, or idiopathic facial paralysis (IFP), is defined as an acute peripheral palsy of seventh cranial nerve. It is one of the most common neu- rological disorders which usually manifests with facial weakness, ear pain, taste disturbance, hyperacusis, and increased tearing (1). The worldwide incidence of IFP is 11 to 40 per 100,000 people annually (2, 3). Its preva- lence among males and females is more or less equal and its peak incidence is in the fourth decade of life (4- 6). The occurrence of familial Bell´s palsy is about 14% and its recurrent risk is about 10% (7). Unilateral pa- ralysis is the most common presentation of IFP occurs with the same frequency on the right and left sides of the face (4-6, 8). The most common causes of the abrupt onset of unilateral facial weakness are stroke and Bell´s palsy (9). Due to the close similarity between the symp- *Corresponding Author: Vahid Monsef Kasmaee; Road trauma Research Cen- ter, Guilan University of Medical Sciences, Poursina Hospital, Rasht, Iran. Phone: +989113344071. Fax: +981313238373 Email: vmonsef@yahoo.com Received: 2 March 2014; Accepted: 13 May 2014 toms of IFP and cerebrovascular accident, it is essential for emergency physicians to differentiate them (10, 11). Several risk factors can cause IFP including viral infec- tion, vascular ischemia, autoimmune inflammatory dis- orders, age, hypertension, and heredity (11, 12). Con- troversies exist regarding the incidence of IFP and its relation with potential risk factors (13-17). Reports showed an increased incidence of IFP in the third and fourth decades of life and an increased rate of disease in colder months (autumn and winter) (15, 18). Besides, the findings of another study demonstrated the in- crease in the incidence of the IFP in the spring (13). Therefore, according to the high incidence of facial pal- sy and lack of clinical data regarding different aspects of disease, the present study investigated 121 Iranian pa- tients with peripheral facial paralysis referred to the emergency department. Methods: A retrospective cross-sectional study was performed for patients with acute seventh nerve palsy referred to emergency department of Poursina Hospital, Rasht, B This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 67 Zohrevand et al Iran, from August 2012 to August 2013. Patients with facial palsy in both upper and lower parts of the face, examined by an emergency medicine specialist and then a neurologist, were included. Patients with seventh nerve palsy without involving the upper part of the face were excluded. Data collected from patients including gender, age, employment status, season of disease, af- fected side, clinical symptoms (such as severity of facial palsy, taste disturbance, ear pain and increased tear- ing), and comorbid disease (such as diabetes, hyper- lipidemia, hypertension) were recorded in a specific datasheet. The clinical severity of the facial palsy was assessed using the House- Brackman (HB) grading scale (19, 20). The study was approved by the ethical com- mittee of Gilan University of Medical Sciences. Data were analyzed using STATA version 11.0. Mann- Whitney U and chi-square tests were used to compare the results and find a correlation between ordinal and nominal variables, respectively. Multinomial logistic regression was used to predict the probabilities of the possible differences among categories. Effects of sea- son, age, gender, comorbid disease, and clinical factors on severity of paralysis were investigated using gener- alized linear poisson model and results were expressed as adjusted rate ratio (rr) and 95% confidence interval (95% CI). P-value <0.05 was considered as significant. Results: A total number of 121 patients with Bell´s palsy were studied (52.9% cases were male). The mean age of pa- tients was 47.14±18.45 years (range: 16-81). Figure 1 shows the incidence rate of IFP in different age groups. The maximum incidence rate of IFP was in the fourth decade of patient’s life (27.3%, p<0.007). Twenty-eight patients (23.1%) were self-employed and 14 (11.6%) ones farmers. Figure 2 demonstrates the seasonal inci- dence of IFP. The seasonal incidence of disease was sig- nificantly higher in summer (37.2%, p<0.001) and au- tumn (33.1%, p=0.002). Regarding the involved side, 63 patients suffered from IFP on the left side. Ninety-four cases (77.7%) experienced IFP for the first time (22.3% recurrence rate). The most frequent simultaneous symptoms with facial palsy were ear pain (43.8%), taste disturbance (38.8%), hyperacusis (15.7%), and increased tearing (11.6%) (p<0.001) (Table 1). Figure 3 demonstrated the percentage of different grades of nerve palsy. The most frequent grade of nerve damage based on HB grading scale was V grade (28.1%, p=0.001). Six (30%) men and 14 (70%) women suf- fered from VI degree of nerve palsy. The severity of pal- sy was higher in women (p<0.001). There were not sig- nificant correlations between the severities of palsy and age (p=0.08), recurrence rate (p=0.18), season (p=0.9), and comorbid disease including hypert ension (p=0.18), diabetes (p=0.29), and hyperlipidemia (p=0.94). The patients with any of following symptoms such as ear pain (p<0.001), taste disturbance (p<0.001), increased tearing (p=0.03), and Hyperacusis (p<0.001) have more severe palsy (Table 2). Multivariate analysis showed that presence of ear pain (rr=1.31; 95%Cl: 1.07-1.61; p=0.008), taste disturbance (rr=1.38; 95% Cl: 1.13- 1.69; p=0.002), increased tearing (rr=1.39; 95%Cl: 1.07-1.80; p=0.01), and Hyperacusis (rr=1.41; 95%Cl: 1.14-1.76; p<0.001) were significantly associated with Figure 1: Percent of patient among age groups  Figure 2: Seasonal incidence of Bell's palsy  Figure 3: Incidence of Bell's palsy among severity of paralysis  This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Emergency (2014); 2 (2): 66-70 68 increase in severity of palsy (Table 3). Discussion: The main finding of the present study revealed the equal gender and occupational distribution, higher in- cidence of disease in fourth decade of life, significant higher incidence in summer and autumn, significant higher grades of nerve damage (grade V and VI), and finally significant higher incidence of ear pain and taste disturbance in IFP patients. In addition, there were sig- nificant association between the severity of nerve dam- age and presence of any simultaneous symptoms in- cluding ear pain, taste disturbance, increased tearing, and Hyperacusis. Bell´s palsy is the most common cause of facial paralysis that occurs incidentally with idiopathic etiology. It has been reported that there is a greatest incidence of IFP in Japanese and the Mexican population compared to the smallest incidence in the Swedish population (21). In a study carried out by Monini et al in Italy, it was re- ported that the age of peak incidence of IFP was 50 years and 53.7% of patients were male (22). In another study in Korea, Lee et al showed that the mean age of IFP was 47 years and 43.5% of patients with IFP were male (23). Savadi Oskouei et al showed the high inci- dence of IFP in 20-30 years patients and in cold seasons (18). The seasonal incidence of IFP has been discussed for many years. Previous studies have found higher in- cidence of Bell's palsy in autumn and winter, related to high prevalence of viral infection in the cold seasons (17, 24). Movahedian et al stated that the high incidence of IFP occurs in autumn and winter (15). Despite vari- ous studies on seasonal effects on IFP (16, 17, 25), the severity of seasonal effects of IFP in different areas and climate conditions are not well studied. In the present study, the most incidence of IFP has been observed in summer (37.2%) and autumn (33.1%) and fourth dec- ade of life (30-44 years). Previous studies demonstrat- ed that activation of the latent herpes viruses by ultra- violet could cause IFP. People, who are more suscepti- ble to ultraviolet, including farmers, are at the higher risk of IFP. This hypothesis is supported by a study per- formed by Savadi Oskooi et al showed that 90% of pa- tients referred at midsummer were farmer (18). This study showed that the most patients were self- employed (23.1%) and 18.2% farmers. Recurrent IFP has been reported in different studies (26-30). Soltanzadeh et al estimated that 9% of patients Table 2: Baseline characteristics of patients with Bell’s palsy who had referred to the ED  Variable N (%) P Gender Male 64 (52.9) ref Female 57 (47.1) 0.525 Occupational status Self-employed 28 (23.1) ref Housekeeper 26 (21.5) 0.79 Employee 15(12.4) 0.05 Farmer 22 (18.2) 0.40 Construction worker 16 (13.2) 0.07 Other 14(11.6) 0.06 Comorbidity Hypertension 27 (22.3) ref Diabetes mellitus 23 (19.0) 0.57 Hyperlipidemia 25 (20.7) 0.78 Symptoms Ear pain 53 (43.8) Ref Taste disturbance 47 (38.8) 0.55 Increased tearing 14 (11.6) <0.001 Hyperacusis 19 (15.7) <0.001 Table 3: Relationship between demographic and clinical factors with severity of palsy (Univariate analysis)  Variable Severity of paresis P 1-4 4-6 Age (years) 15-29 10 (34.5) 19 (56.5) 0.08 30-44 22 (66.7) 11 (33.3) 45-59 15 (53.6) 13 (46.4) 60-74 10 (58.8) 7 (41.2) >=70 10 (71.4) 4 (28.6) Gender Male 45 (70.3) 19 (29.7) <0.001 female 22 (38.6) 35 (61.4) Times of refer First 49 (52.1) 45 (47.9) 0.18 Second 18 (66.7) 9 (33.3) Season Spring 8 (50.0) 8 (50.0) 0.9 Summer 26 (57.8) 19 (42.2) Autumn 23 (57.5) 17 (42.5) Winter 10 (50.0) 10 (50.0) Comorbidity Hypertension 18 (66.7) 9 (33.3) 0.18 Diabetes mellitus 15 (65.2) 8 (34.78) 0.29 Hyperlipidemia 14 (56.0) 11 (44.0) 0.94 Symptoms Ear pain 16 (30.2) 37 (69.8) <0.001 Taste disturbance 13 (27.7) 34 (72.3) <0.001 Increased tearing 4 (28.6) 10 (71.4) 0.03 Hyperacusis 2 (10.5) 17 (89.5) <0.001 Table 1: Association between demographic and clin- ical factors with severity of palsy (Multivariate anal- ysis)  Variable rra 95% CIb P Age 1.01 0.94-1.09 0.70 Gender 1.16 0.96-1.38 0.12 Ear pain 1.31 1.07-1.61 0.000 Taste disturbance 1.38 1.13-1.69 <0.001 Increased tearing 1.39 1.07-1.8 0.01 Hyperacusis 1.41 1.14-1.76 <0.001 a: Adjusted risk ratio b: Confidence interval This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 69 Zohrevand et al with IFP experienced the recurrence (31). In this study, recurrent IFP was observed in 22.3% of patients. In contrast to other studies, the higher recurrence rate observed in this study may be related to the lack of the patients’ follow-up after the first recovery. In a research performed by Lee et al on IFP patients, it was shown that 63.3% of patients had a higher severity of nerve involvement (HB grade>IV) (23). According to the pre- vious studies, it was found that 44.6% of IFP patients belonged to IV and V HB grades and only 21.5% of them had I and II grades. The limitations of this investigation are that patients could not follow-up and the number of them was too small. This study recommends to design a greater pro- spective or case- control studies to recognize the relat- ed factors of IFP and confirm the data with a larger sample size. Conclusion: There was equal gender and occupational distribution, higher incidence in fourth decade of life, higher inci- dence in summer and autumn, higher grades of nerve damage (grade V and VI), and higher incidence of ear pain and taste disturbance in patients suffered from IFP. In addition, there was significant association be- tween the severity of nerve damage and the presence of any simultaneous symptom. Acknowledgments: The authors appreciate the insightful cooperation of Medical Sciences and the staffs of the Emergency De- partment of Poursina Hospital in Rasht. We thank the patients and their families participated in this study. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Lee CD, Carnahan RM, McPheeters ML. 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