European Journal of Neurology 2010, 17: 885–889 doi:10.1111/j.1468-1331.2010.02950.

SHORT COMMUNICATION

High-resolution ultrasound in the evaluation and prognosis of BellÕs

palsy
Y. L. Loa, S. Fook-Chongb, T.H. Leohc, Y. F. Danc, M. P. Leec, H. Y. Ganc and L. L. Chand
a
Department of Neurology, National Neuroscience Institute, Singapore General Hospital; bDepartment of Clinical Research, Singapore
General Hospital; cDepartment of Neurology, Singapore General Hospital; and dDepartment of Diagnostic Radiology, Singapore General
Hospital, Singapore, Singapore

Keywords:
Bell’s palsy, blink reflex,
diagnosis, nerve
conduction study,
prognosis, ultrasound
Received 9 October 2009
Accepted 22 December 2009
Introduction: BellÕs palsy is a commonly encountered paralysis of the facial nerve
occurring worldwide. Prognosis for BellÕs palsy is good, but the proportion of patients
with poor outcomes may reach 30%. Ultrasound (US) may provide a novel approach
for evaluating and prognosticating BellÕs palsy, in comparison with known electro-
physiological techniques.
Methods: In this study, we measured the diameter of the distal facial (VII) nerve
using US in patients with BellÕs palsy treated with prednisolone, in comparison with
healthy controls. Blink reflex and VII nerve conduction studies were also performed.
Studies were prospective and performed within 1 week of disease onset.
Results: Our results have shown that diameter of the distal VII nerve is a good
predictor of favorable (positive predictive value: 100%) and bad outcomes (negative
predictive value: 77%) in BellÕs palsy at 3 months after clinical presentation. Fur-
thermore, we also noted the lack of correlation of VII diameter with conventional VII
nerve conduction studies (NCS) and blink reflex studies. US was superior to VII nerve
conduction and blink reflex studies in outcome prediction.
Conclusions: This first study utilizing US in BellÕs palsy highlights its role in outcome
prediction and contributes to our understanding of recovery processes in this common
neurological disorder.

BellÕs palsy is a commonly encountered paralysis of the
facial nerve occurring worldwide. The etiology remains
uncertain, although preceding viral infection may play a
role. Prognosis for BellÕs palsy is good, but the pro-
portion of patients with poor outcomes may reach
30%. Recently, a large multi-center trial has shown that
early use of prednisolone significantly improved the
chances of completely recovery [1].
Marked facial nerve enhancement in the facial canal
is the characteristic MR change in BellÕs palsy [2].
However, various studies have separately documented
involvement of the mastoid, [3] tympanic, [4] and
pre-meatal portions [5]. Despite these observations,
prognostic value of MRI remains uncertain [6]. Fur-
thermore, MR scanning is expensive, time-consuming
and necessitates the use of contrast agents.
Before the advent of imaging, electrophysiological
methods have been utilized to predict outcomes in BellÕs
palsy. Tests employed included electromyography, facial
Correspondence: Dr Y. L. Lo, Outram Road, Singapore 169608,
Singapore (tel: 65 63265003; fax: 65 62203321;
e-mail: gnrlyl@sgh.com.sg).
nerve conduction, and blink reflexes. In particular,
preservation of the blink reflex and absence of sponta-
neous electromyographic activity were associated with
good outcomes [7]. Their clinical utility has not been
compared with other methods of evaluation to date.
The usage of ultrasound (US) is of proven efficacy in
carpal tunnel syndrome, ulnar neuropathy, and femoral
neuropathy [8]. It is quick safe, painless, inexpensive
and has the added capability of demonstrating struc-
tural lesions along the course of the affected nerve. We
have previously demonstrated its efficacy in the locali-
zation of peroneal and radial nerve entrapment [9,10].
To our knowledge, there are no published studies
detailing the use of US in BellÕs palsy. Previous experi-
ences have been for operative workup of parotid tumors
[11]. To this end, US may provide a novel approach for
evaluating and prognosticating BellÕs palsy, in compari-
son with known electrophysiological techniques.
Methods
This study was carried out prospectively after approval
was obtained from our institutional review board. We

Ó 2010 The Author(s)

Journal compilation Ó 2010 EFNS 885
886 Y. L. Lo et al.
included patients with acute onset of unilateral BellÕs
palsy, all seen within a 1-week period from onset of
symptoms. We excluded patients with diabetes mellitus,
traumatic facial palsy, or other causes of polyneuro-
pathy that may confound the diagnosis.
Each patient was seen initially by an experienced
neurologist who confirmed the diagnosis and classified
severity according to the House-Brackmann grading of
I to VI [12]. All patients were treated with predniso-
lone 50 mg a day for a period of 10 days [1]. Patients
were followed up by the same neurologist blinded to
US findings when a final grading at 3 months was
obtained.
US examination was conducted with a General
Electric Logiq 7 Pro (GE Company, New York, USA)
machine, employing a 5 to 10 MHz linear array trans-
ducer by an experienced staff. With the subject in a
supine left or right lateral position, the facial nerve in
the longitudinal view can be identified at the mastoid
region as it emerges from the stylomastoid foramen. At
this site, it is visualized to traverse anteriorly into the
parotid gland substance before dividing into five bran-
ches. Using color Doppler, the facial artery can be
identified deep to the facial nerve.
We obtained the diameter of the facial nerve from an
average diameter at the most proximal and distal
visualized portions, as well as midway between these
two points. The normal nerve in this plane has a
relatively hyperechoic neurilemoma compared to
Journal compilation Ó 2010 EFNS European Journal of Neurology 17, 885–889
Figure 1 Ultrasound (US) of the right
(top row) and left (bottom row) VII nerve
in a patient. The right VII nerve shows
abnormally increased VII diameter of
0.26 cm, indicated by arrows. The left VII
nerve shows a normal diameter of
0.11 cm. The flow duplex shows the facial
artery related deep to the VII nerve which
terminates into branches in the parotid
substance. The patients had an unfavor-
able outcome at 3 months after clinical
presentation.
surrounding muscle and exhibits a linear fascicular
appearance. In contrast, the abnormal facial nerve is
often swollen, with loss of hyperechoic appearance and
fascicular pattern. Each study was performed within the
first week of clinical presentation. US images were
stored and analyzed offline by a separate blinded
examiner. Figure 1 shows an actual example of US
examination in a patient.
In addition, blink reflex studies were performed by
stimulating the facial nerve at the pre-auricular region,
and recordings were made at the orbicularis oculi
muscles. We recorded both early (R1) and late (R2)
components, and results were considered abnormal if
corresponding to the pathological side showed either
prolonged latency (R1: >12 ms; R2: >35 ms) or
absent response.
We also obtained direct facial nerve conduction
studies (VII NCS) recording supramaximal compound
muscle action potentials from the nasalis bilaterally.
Data from patients consisting of distal latency and
baseline to peak amplitude were compared with those
from 25 healthy controls, as were US findings. All
electrophysiological studies were performed with a
Medtronic Keypoint system (Medtronic, Skovlunde,
Denmark), where amplifier filter settings were 5 to
5000 Hz.
Data analysis was performed using SPSS for
Windows package. In healthy controls, normality of
parameters was regarded as a value within two standard
Ó 2010 The Author(s)

deviations from the mean. A P value of less than 0.05
was considered statistically significant.
Results
We studied 37 patients (mean age: 46; range: 25–69; 18
men) and 25 healthy controls (mean age: 45; range:
24–71; 9 men) whose normal values are depicted in
Table 1. Table 2 summarizes results in all patients.
Abnormalities in US diameter were 35% compared
with VII NCS latency (32%), VII NCS amplitude
(46%), and blink reflex (73%).
No significant correlations were found for severity
grading at examination with US diameter, VII latency,
amplitude, or blink reflex findings. Neither was there
significant correlation of US diameter with VII latency,
amplitude, or blink reflex findings (PearsonÕs correla-
tion, P > 0.05 all). We did not find any significant
correlation of initial severity grading with patients with
abnormal US diameter (r = 0.32, P = 0.29), VII
latency (r = 0.05, P = 0.88), and VII amplitude
(r = 0.33, P = 0.19). Using logistic regression, we did
not find any significant correlation of timing (mean:
5.14 days, standard deviation: 1.69 days, range:
2–7 days) with US examination (P = 0.46), VII latency
(P = 0.94), VII amplitude (P = 0.36), or blink reflex
(P = 0.1) with outcome prediction. For cases with
poor outcome, similar negative findings were obtained
(P = 0.33) with US examination. Overall, 27 of the 37
patients (73%) had good recovery (Grade I) at
3 months.
Chi-squared tests were utilized to test the association
of clinical grade outcomes with US, VII latency, VII
amplitude, and blink reflex. US was highly correlated
with clinical grade outcomes (v2 = 25.3, df = 1,
Table 1 US and VII nerve conduction studies in controls
Parameter Mean SD Mean + or )2SD
US diameter (cm) 0.14 0.02 0.18
VII latency (ms) 2.95 0.33 3.61
VII amplitude (mV) 2.39 0.74 0.91
Total number for each parameter = 50 (pool left- and right-sided
values).
US, ultrasound; VII, facial nerve; SD, standard deviation.
Table 2 US and VII nerve conduction studies in patients
Parameter Mean SD
US diameter (cm) 0.17 0.2
VII latency (ms) 3.22 0.6
VII amplitude (mV) 1.63 0.84
US, ultrasound; VII, facial nerve; SD, standard deviation.
Ó 2010 The Author(s)
Journal compilation Ó 2010 EFNS European Journal of Neurology 17, 885–889
Ultrasound and Bell’s palsy 887
P < 0.0005). Normal US accurately predicted all
patients (positive predictive value = 100%) having a
good outcome of Grade I at 3 monthsÕ review. This was
higher than the accurate prediction of good outcome of
72% for VII latency, 80% for VII amplitude, and 90%
for blink reflex.
Additionally, abnormal US accurately predicted for
77% (negative predictive value = 77%) of patients
with poor outcome at 3 months (Grade II and above),
but only 25% for VII latency, 35% for VII amplitude,
and 33% for blink reflex.
Discussion
Our results have shown that US diameter of the distal
VII nerve is a good predictor of good and bad outcomes
in BellÕs palsy at 3 months after clinical presentation.
Furthermore, we also noted the lack of correlation of
US diameter with conventional VII NCS and blink
reflex studies. US was superior to these other electro-
physiological tests in predicting good and poor recovery
at 3 months. We have chosen the 3-month review per-
iod after steroid treatment so as to be in line with the
largest trial of BellÕs palsy treatment to date [1]. Finally,
US also suggested that distal abnormality of the nerve,
if present, can be visualized early.
From the superficial attachments to the brain, the
two roots of the VII nerve travel forward with the
acoustic nerve into the internal auditory meatus. At the
bottom of the meatus, it enters the facial canal where it
travels forward to exit the skull at the stylomastoid
foramen. Distally, it enters the parotid substance where
it divides into distinct branches. Specifically, US in our
study had visualized the region between the stylomas-
toid foramen exit and the parotid gland. Overall, US
was painless, quick, and technically easy to perform.
Our experience with the blink reflex was similar to
previous experiences, suggesting its high sensitivity in
predicting a favorable outcome [13–15]. Contrarily, this
test was much less accurate in predicting a poor out-
come when performed within the first 10 days of onset
[16]. This may be related to the indirect way of inter-
preting the blink reflex for VII neuropathy itself.
Whereas the blink reflex pathway traverses the brain-
stem and would be ideal for screening abnormalities
from the brainstem, and distally, it would not be ade-
quately specific for addressing dysfunction involving
the VII nerve alone.
For VII NCS, other authors have previously utilized
Range
VII motor conduction velocity and evoked electro-
0.09 to 0.35 myography to highlight their value in prognosis [17,18].
2 to 5.1
However, theses patents were not treated with steroids,
0.2 to 3.8
and the differences in methodology made each study
not directly comparable with the present. It should be
888 Y. L. Lo et al.
noted that VII NCS here have addressed compound
muscle action potentials from the nasalis only and
recording from additional muscles like the orbicularis
would be technically more demanding. The study by
Olsen [19] had compared VII amplitude of the affected
and unaffected side as a predictor of outcome but
suggested that prediction was more accurate for good
rather than for bad outcomes. This is corroborated by
our study. Notably, this study has shown that US
examination performed at 2–7 days after onset was
efficacious for outcome prediction, but the clinical
utility beyond 7 days remains to be determined. How-
ever, in this context, early outcome prediction within
the disease-onset period might prove most relevant
clinically.
As previously noted, MRI studies have been utilized
to investigate the site of lesion in BellÕs palsy. Based on
the main finding of nerve enhancement alone, abnor-
malities in the distal nerve segment appeared to be the
less common abnormality compared to enhancement in
the more proximal segments in the labyrinthine portion
and geniculate ganglion [5,20]. Separately, Murphy [4]
reported 10 cases of BellÕs palsy whereby enhancement
of the facial nerve in the mastoid segment correlated
with incomplete recovery compared with enhancement
limited more proximal sites at the labyrinthine and
geniculate ganglion segments. These results are cor-
roborated by our findings using US examination of the
distal facial nerve. It should also be highlighted that
MRI findings are usually described as contrast
enhancement rather than physical nerve swelling.
Therefore, MRI may actually demonstrate vascular
rather than structural changes seen with US.
What are the possible reasons which can explain our
findings? First, the lack of correlation of US with VII
NCS and blink reflex suggests that US measurement of
nerve diameter may not specifically point to demyelin-
ation or axon loss processes independently The patho-
physiology of nerve swelling and thickening is complex
and may involve endoneural edema, demyelination,
axonal degeneration, and fibrosis [21,22]. Rather, US
structural changes may be a surrogate indicator of a
combination of these processes, or other yet unknown
factors. Secondly, the efficacy of US in clinical outcome
prediction could be explained by both anatomic and
physiologic factors. It is possible that the affected and
swollen distal VII segment is too distant to receive cell
body nutrients in BellÕs palsy and involvement of this
segment would thus delay recovery as seen in cases with
poor recovery at 3 months. Additionally, even if
regeneration has been complete in the un-visualized
proximal nerve segments, abnormality in the visualized
distal segments would impede efficient conduction to
the facial muscles receiving innervation [23–26]. These
Journal compilation Ó 2010 EFNS European Journal of Neurology 17, 885–889
are certainly intriguing areas, and the answers may be
apparent with future research.
In conclusion, this is the first study utilizing US in the
evaluation and prognosis of BellÕs palsy. The findings
also contribute to our understanding of the recovery
processes in this common neurological disorder.
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