Original Research—General Otolaryngology
Otolaryngology–
Cutaneous Sensibility Changes in Bell’s
Palsy Patients
Carlos Andrés Cárdenas Palacio, MS1, and
Francisco Alejandro Múnera Galarza, PhD, MS2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. Bell’s palsy is a cranial nerve VII dysfunction that ren-
ders the patient unable to control facial muscles from the
affected side. Nevertheless, some patients have reported cuta-
neous changes in the paretic area. Therefore, cutaneous sensibil-
ity changes might be possible additional symptoms within the
clinical presentation of this disorder. Accordingly, the aim of this
research was to investigate the relationship between cutaneous
sensibility and facial paralysis severity in these patients.
Study Design. Prospective longitudinal cohort study.
Settings. Tertiary care medical center.
Subjects and Methods. Twelve acute-onset Bell’s palsy patients
were enrolled from March to September 2009. In addition,
12 sex- and age-matched healthy volunteers were tested.
Cutaneous sensibility was evaluated with pressure threshold
and 2-point discrimination at 6 areas of the face. Facial paraly-
sis severity was evaluated with the House-Brackmann scale.
Results. Statistically significant correlations based on the
Spearman’s test were found between facial paralysis severity
and cutaneous sensitivity on forehead, eyelid, cheek, nose,
and lip (P \ .05). Additionally, significant differences based
on the Student’s t test were observed between both sides
of the face in 2-point discrimination on eyelid, cheek, and lip
(P \.05) in Bell’s palsy patients but not in healthy subjects.
Conclusion. Such results suggest a possible relationship between
the loss of motor control of the face and changes in facial sen-
sory information processing. Such findings are worth further
research about the neurophysiologic changes associated with
the cutaneous sensibility disturbances of these patients.
Keywords
Bell’s palsy, touch, sensory thresholds
Received June 30, 2016; revised December 19, 2016; accepted January
3, 2017.
B
ell’s palsy is an idiopathic peripheral nerve (cranial
nerve VII) dysfunction causing acute ipsilateral facial
muscle weakness.1 This disorder does not have a
Head and Neck Surgery
2017, Vol. 156(5) 828–833
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2017
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DOI: 10.1177/0194599817690107
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specific etiology2,3 but can be diagnosed from the appearance
of specific signs and symptoms, blood chemistry tests, nerve
conduction tests, cerebrospinal fluid investigations, or neuroi-
maging methods.4 Herpes simplex virus has been suggested as
its main cause,5-7 although there could be other causes, such as
ischemia,8,9 autoimmunity,10-12 and bacterial infection.13
In most of the medical literature, the disease has an inci-
dence oscillating between 11 and 40 cases per 100,000
people annually,14 mostly affecting persons between 15 and
45 years old.14,15 There is no tendency of paralysis to occur
more frequently in one side of the face than in the
other.16,17 Bilateral paralysis is unlikely to occur, since it is
evident in only 0.3% to 2.0% of facial palsy cases.18
Corticosteroids19 and antiviral agents,20 alone or in combina-
tion,21,22 have been used in the treatment of Bell’s palsy.
Additional treatments include electrical stimulation,23 surgery,24,25
physical therapy,26 and acupuncture.27 Complete recovery occurs
in .70% of cases.28 Most patients recover within 3 weeks, even
if untreated,1 although some cases demonstrate moderate or
severe sequelae following their recovery.4,28,29
Recently, some evidence emerged regarding sensory fea-
tures related with Bell’s palsy. Within this framework, cuta-
neous changes have been reported in the paretic area, such
as numbness,30 mild pain,28,31 hypoesthesia in reaction to a
pinprick,30,32 variations in temperature sensation,30 and
increases in both vibration threshold and cutaneous pressure
threshold at the same time as a reduction in static 2-point
discrimination.33 Experimental evidence in rats suggests
that the lack of active facial movements impairs facial
somatosensory information processing in the primary motor
cortex.34 Therefore, cutaneous sensibility changes are possi-
ble additional symptoms within the clinical presentation of
idiopathic facial paralysis.
Accordingly, the current study tested the hypothesis that
specific cutaneous sensitivity variations occur in patients
1
Psychology, Biology, and Neurodevelopment Group, School of Psychology,
Universidad de La Sabana, Chı́a, Colombia
2
Behavioral Neurophysiology Group, School of Medicine, Universidad
Nacional de Colombia, Bogotá, Colombia
Corresponding Author:
Carlos Andrés Cárdenas Palacio, MS, Campus Universitario del Puente del
Común, Km 7, Autopista Norte, Bogotá, Colombia.
Email: carlos.cardenas@unisabana.edu.co
Cárdenas Palacio and Múnera Galarza 829

with Bell’s palsy. To do so, the researchers tested for a cor-

relation between cutaneous sensitivity measures and clinical
characteristics, such as the time since the onset of the palsy
and the individual’s House-Brackmann score. In addition,
pressure threshold and 2-point discrimination measures in
both facial sides of Bell’s palsy patients were compared
with the same evaluations in matched healthy volunteers.

Methods
From March to September 2009, 52 patients affected with
facial paralysis who reached the Fundación Cardioinfantil
Instituto de Cardiologı́a, the Hospital San José, or the
Clı́nica Universidad de La Sabana in Bogotá, Colombia,
were evaluated. Forty patients were excluded because their
facial paralysis was associated with tumors, traumatic brain
injury, central nervous system lesions, or other cranial nerve
lesions. So, the experimental group included 12 acute-onset
Bell’s palsy patients (\2 weeks since diagnosis; 7 women
and 5 men; mean age = 33.42 years, SD = 17.85). Twelve
sex- and age-matched healthy volunteers (mean age = 31.75
years, SD = 19.04) formed the control group. In the experi-
mental group, 5 participants were prescribed with physical
therapy in association with an oral pharmacologic treatment Figure 1. Facial areas where cutaneous sensitivity was evaluated.
(prednisone, 50 mg/d; valacyclovir, 2000 mg/d) within 10 Open circles indicate the places used for evaluation: forehead,
days of symptom onset; the remaining 7 received only phys- eyelid, cheek, nose, lip, and jaw. Ó Sara Suzunaga.
ical therapy treatment during the same period. Control
group participants did not receive any treatment.
All procedures agreed with the Declaration of Helsinki’s Table 1. Nominal Weight Value for Each Filament in the Von Frey
ethical principles. The Ethics Committee of the School of Esthesiometer: Lafayette Instruments, Model 16013.
Medicine, Universidad Nacional de Colombia, approved the Filament Nominal Weight, g
study. The participants provided informed consent, in agree-
ment with Colombian state law 008430. 1 0.05
Patients’ sensitivity was evaluated weekly for 5 consecu- 2 0.15
tive weeks, beginning at each patient’s recruitment. Healthy 3 0.4
volunteers’ sensitivity was evaluated once. Cutaneous sensi- 4 0.8
tivity was measured in 6 facial areas: forehead, eyelid, 5 1.2
cheek, nose, lips, and jaw (Figure 1). 6 3.2
Facial paralysis severity was also assessed weekly with 7 4.5
the House-Brackmann scale. This scale, recommended by 8 6.5
the American Academy of Otolaryngology,35 classifies the 9 10.2
facial motor function into 6 grades, from normal symmetri-
cal function in all areas (grade I) to total paralysis (grade
VI).36 In addition, this scale can monitor facial function
status over time and assess the course of recovery and the
effects of treatment.37 procedure was based on the method of limits for determin-
Pressure threshold evaluation was conducted with a Von ing absolute thresholds proposed by Fechner (as cited in
Frey esthesiometer (model 16013; Lafayette Instruments, Goldstein38).
Lafayette, Indiana). This esthesiometer includes 9 filaments A 2-point esthesiometer (model 16011; Lafayette Instruments)
that apply a nominal weight over the skin. The specific was used to assess 2-point discrimination. For this evaluation, a
values for each filament can be seen in Table 1. similar procedure was performed, also based on the above-
Pressure threshold was evaluated in 2 successive trials mentioned method of limits. Ascending and descending trials
with filaments of either ascending or descending nominal were done with 3-mm increments or decrements in a range from
weight. The score for each trial was the middle value 0 to 24 mm. A middle value between the 2-point distances was
between the nominal weights of the filaments used when used as each trial score when point perception shifted from 1 to 2
pressure perception appeared (ascending) or disappeared (or vice versa). An average of the ascending and descending trial
(descending). An average of these 2 scores was used as the scores was used as a patient’s score for a facial area in a given
patient’s score for a facial area in a given week. This week.
830 Otolaryngology–Head and Neck Surgery 156(5)

To assess the level of cutaneous sensitivity disturbance Table 2. Profile of the Patients with Bell’s Palsy.
in Bell’s palsy patients, pressure threshold and 2-point dis- Facial Score
crimination in the affected side were each expressed as a
percentage change with respect to the value obtained in the Case No. Age, y Sex Side Second Week Sixth Week
nonaffected side. Thus, with the cutaneous sensibility mea-
sure in each facial region of the nonaffected side as a refer- 1 34 Female Left 2 2
ence (ie, 100%), the corresponding magnitude of the region 2 40 Male Left 3 2
in the affected side was expressed as a percentage of it. A 3 39 Female Left 5 3
value .100% should be interpreted as an increase in the 4 53 Female Left 4 3
sensory measure in the affected side and, consequently, as a 5 26 Female Right 2 1
lesser level of cutaneous sensitivity. 6 13 Male Left 3 2
Spearman’s rank correlation coefficient between facial 7 23 Male Left 2 1
paralysis severity and the time elapsed since the onset of the 8 36 Female Left 4 3
illness or the level of cutaneous sensitivity disturbance was 9 13 Female Left 2 1
determined to assess relationships between such variables. 10 76 Female Left 2 1
Rank correlation took into account the ordinal scale of 11 19 Male Right 2 1
paralysis severity. 12 29 Male Right 2 1
The differences in cutaneous sensitivity between both
sides of the face in Bell’s palsy patients were analyzed with
a Student’s t test; however, pressure threshold in both fore-
head and nose was compared with a Wilcoxon signed-rank
test due to uneven variances, as evidenced by Levene’s test
(P = .022 and .003, respectively). In healthy controls, such
analysis was conducted with a Wilcoxon signed-rank test
for pressure threshold in jaw (P = .004, Levene’s test) and
for 2-point discrimination in lips (P = .018, Levene’s test);
for the remainder of the cutaneous sensibility assessments in
this group, Student’s t test was used.
The statistical analyses were performed with the corre-
sponding modules of SPSS 21.0 (IBM Corp, Chicago,
Illinois), with a significance level set at P  .05.

Results
Demographic data are summarized in Table 2. Nine patients
had left-sided Bell’s palsy, and 3 presented a right-sided palsy.
Seven patients were female, and 5 were male. At the begin-
ning of the study, facial paralysis evaluation showed 7 patients
scoring II (slight paralysis) on the House-Brackmann scale; 2
patients, III (moderate paralysis); 2 patients, IV (moderately
severe paralysis); and 1 patient, V (severe paralysis). The
healthy control group consisted of 12 sex- and age-matched
participants.
Based on Spearman’s rank correlation coefficient, a sig-
nificant decrease in the House-Brackmann score was
observed along the 5 weeks following the onset of the
paralysis (r = 20.361, P = .005; Figure 2).
There were statistically significant correlations between
House-Brackmann score and pressure threshold disturbance
at the eyelid (r = 0.396, P = .002), cheek (r = 0.454, P \
.001), and nose (r = 0.310, P = .016). There were also sig-
nificant correlations between House-Brackmann score and
2-point discrimination impairment at the forehead (r =
0.368, P = .004), eyelid (r = 0.284, P = .028), cheek (r =
0.360, P = .005), and lip (r = 0.255, P = .049). The more
severe the facial paralysis, the more intense the alteration in
sensorial measurements (Table 3).
Figure 2. Facial paralysis severity as a function of Bell’s palsy evo-
lution time, based on Spearman’s rank correlation test. Diamonds
represent the data for each patient; the solid line represents the
best linear regression fit for the whole data.
Globally, there were no significant side-to-side differ-
ences in pressure threshold for either Bell’s palsy patients
(affected vs unaffected) or healthy controls (left vs right).
However, with respect to 2-point discrimination, there was
statistically significant impairment in the affected side of
Bell’s patients at the eyelid (t = 2.543, P = .014), cheek (t =
2.060, P = .044), and lip (t = 2.696, P = .009); in contrast,
there were no significant side-to-side differences in any of
the evaluated facial areas in healthy volunteers (Table 4).
Discussion
The main aim of this study was to investigate the relationship
between cutaneous sensibility and facial paralysis severity in
Bell’s palsy patients. In this regard, pressure thresholds and 2-
point discrimination measures were obtained in both facial
sides of Bell’s palsy patients and later correlated with the
Cárdenas Palacio and Múnera Galarza 831

Table 3. Spearman’s Correlation Values between Cutaneous diminished significantly along the observation interval. As a
Sensitivity and Facial Paralysis Severity. result, a significant recovery occurred between the second
Cutaneous Sensitivity Measure: Facial Region r P and fifth weeks since the onset of symptoms. This result is
consistent with descriptions of the duration of this illness,
Pressure threshold which estimate that time of recovery should be between 2
Forehead 0.200 .125 and 6 weeks in most cases.39
Eyelid 0.396 .002a A later analysis showed statistically significant correla-
Cheek 0.454 \.001a tions between pressure threshold disturbance and House-
Nose 0.310 .016b Brackmann assessment of the eyelid, cheek, and nose and
Lip 0.250 .054 between 2-point discrimination and House-Brackmann score
Jaw 0.158 .227 on the forehead, eyelid, cheek, and lip. Thus, these sensory
Two-point discrimination perturbations’ reduction paralleled the decrease in facial
Forehead 0.368 .004a paralysis severity. This can be due to the close relationship
Eyelid 0.284 .028b between facial movement and somatosensory information
Cheek 0.360 .005a processing mentioned above. However, since the above-
Nose 0.190 .147 mentioned correlations are not strong enough, it should be
Lip 0.255 .049b inferred that there are additional factors determining cuta-
Jaw –0.132 .316 neous sensibility disturbances other than the motor impair-
a
ment. In addition, there were no significant differences in
P  .01.
b cutaneous pressure threshold identified across both sides of
P  .05.
the face among Bell’s palsy patients and the healthy control
group. Since this latter finding runs contrary to the changes
described for this measure in patients with unilateral facial
Table 4. Side-to-side Comparison in 2-Point Discrimination: Bell’s paresis,33 this issue deserves further research.
Palsy Patients and Healthy Volunteers. Moreover, 2-point discrimination threshold impairment
Two-Point Discrimination: Mean 6 SD, mm occurred on the affected side of Bell’s palsy patients in the
eyelid, cheek, and lip. This finding is consistent with other
Participants: Facial Area Affected Side Nonaffected Side observations in such patients,33 which suggests an impair-
ment in the processing of this threshold associated with a
Bell’s palsy patients decrease in facial movement. Nevertheless, similar to the
Forehead 12.08 6 0.90 11.13 6 0.64 homologous pressure threshold analysis, there was no similar
Eyelida 10.20 6 0.71 8.52 6 0.47 reduction in the remainder of the evaluated facial regions,
Cheeka 10.57 6 0.73 8.97 6 0.49 which also justifies further research on the tactile changes
Nose 9.74 6 0.65 9.22 6 0.60 occurring alongside diminished motor control of the face.
Lipb 6.70 6 0.51 5.47 6 0.29 In this vein, changes in sensory information processing
Jaw 7.98 6 0.56 7.18 6 0.43 in the contralateral vibrissal primary motor cortex occurred
after peripheral facial nerve lesions in animal models; such dis-
Left Side Right Side turbance may be due to vibrissal paralysis–induced changes in
somatosensory input. Thus, the variation in this sensory input
Healthy controls would produce a reorganization of the dendritic trees in the
Forehead 9.67 6 1.25 8.92 6 1.00 vibrissal primary motor cortex and the other cortical areas; this
Eyelid 8.25 6 1.12 8.08 6 1.07 sensory unbalance may also occur in patients with facial nerve
Cheek 8.42 6 0.80 6.67 6 0.80 paralysis irrespective of the underlying etiology.34 Such
Nose 7.92 6 1.18 8.08 6 1.12 paralysis-induced reorganization has to be studied in other sen-
Lip 3.92 6 0.40 3.92 6 0.63 sorimotor cortical and subcortical regions to understand the
Jaw 5.83 6 1.04 6.42 6 0.96 underpinnings of the correlation between cutaneous sensibility
a
P  .05.
changes and facial paralysis severity and its inhomogeneous
b
P  .01. distribution in the present sample. However, the observed
changes would be a possible explanation for some functional
sequelae in these patients.40

House-Brackmann score. These sensorial data were also com- Conclusion

pared with the same values from matched healthy volunteers.
Nine patients had the left side of the face affected, while
only 3 had the right side affected, which does not corre-
spond with the equal distribution described in some studies.4
Severity of facial paralysis with the House-Brackmann scale
Statistically significant correlations were found between
facial paralysis severity and cutaneous sensitivity on fore-
head, eyelid, cheek, nose, and lip. Additionally, changes in
2-point discrimination among Bell’s palsy patients were
observed on the eyelid, cheek, and lip. These findings may
832
be due, at least partially, to a defective processing of facial
somatosensory information associated with impaired facial
movement. There was also no significant correlation between
facial paralysis severity and cutaneous sensitivity on the jaw;
in addition, statistically significant differences in pressure
threshold between affected and nonaffected sides of Bell’s
palsy patients were not observed.
Although some changes in sensory information process-
ing were observed in the vibrissal primary motor cortex
after contralateral peripheral facial nerve lesion in rats, the
neurophysiologic changes underlying the cutaneous sensibil-
ity disturbances of Bell’s palsy patients are not yet com-
pletely understood. Therefore, further research is needed on
this subject.
Acknowledgments
We thank the staff at the Fundación Cardioinfantil Instituto de
Cardiologı́a, Hospital San José, and the Clı́nica Universidad de La
Sabana for their assistance with the recruitment of participants for
the study. We also thank Dr Jorge Herrera Ariza, Dr José Carreño,
Dr Mónica Rincón, Dr Yisel Estrada, Fabio Motta, Aura
Hernández, Sandra Farı́as, Henry Ayala, and Katherine Andrade
for their assistance with the recruitment and scheduling of partici-
pants. Additionally, we acknowledge the contribution of Sara
Suzunaga, who designed 1 of the figures used in this study.
Author Contributions
Carlos Andrés Cárdenas Palacio, collected data, analyzed data,
wrote article; Francisco Alejandro Múnera Galarza, designed
study, revised article.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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