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doi: 10.3122/jabfm.2012.06.120084
Diabetes, hypertension, and hypercholesterolemia all have been correlated with microangiopathy, which, according to the theory of microcirculatory failure of the vasa nervosum, is a potential
causative and poor prognostic factor in Bell palsy.
To date, the respective literature reports are quite
controversial.4 7 The facial nerve represents a
unique case where a cranial nerve is conned within
a bony canal, known as the fallopian canal, and Bell
palsy represents a unique case of nerve entrapment
in a bony canal. Therefore, the study of the factors
affecting the clinical presentation and prognosis of
Bell palsy constitutes a challenge in the pathophysiology of peripheral nerves.
The aim of this study was to demonstrate any
correlation between diabetes, hypertension, or hypercholesterolemia and the severity of Bell palsy at
its onset and after a 6-month interval. Contrary to
previous reports, the correlation between diabetes
and Bell palsy was not investigated by the use of
fasting plasma glucose (FPG) but through serum
glycosylated hemoglobin (HbA1c) levels, which are
thought to state a brief history of the patients
819
glycemic control over the last 2 to 3 months unaffected by diet, insulin, other hypoglycemic drugs or
exercise.8,9 The possible pathophysiologic mechanisms explaining the results of this study as well as the
clinical implications of the ndings are discussed.
820
glyceride levels have been reported to have an independent, additive, and durable effect on restoration of nerve function in patients with mild to
moderate diabetic sensorimotor polyneuropathy.12
Statistical Analysis
Statistical analysis was conducted with SPSS software version 17.0 (SPSS, Inc, Chicago, IL). Statistical comparisons between patient and control
groups for string values (diabetic or nondiabetic, with
or without a history of hypertension or hypercholesterolemia) were performed using Pearson 2 test. Colinearity diagnostics for numerical values (HbA1c, cholesterol, low-density lipoproteins [LDL], high-density
lipoproteins [HDL], and triglycerides) were performed
using a variation inltration factor. Correlations between numerical values and H-B scores at admission
and the 6-month follow-up visit were calculated using
the Kruskal-Wallis nonparametric test for k independent variables (the Monte Carlo technique). Signicance was attributed at P .05.
Ethical Considerations
The study was performed in accordance with the
Declaration of Helsinki and was approved by the
institutional ethical committee.
Results
In the population of this study, HbA1c ranged
3.3% to 9.8% (mean SD, 5.8 1.4), the values
of serum cholesterol ranged from 11 to 395 mg/dL
(216.3 60.6), the values of LDLs ranged from
57.8 to 270.6 mg/dL (150.4 43.5), the values of
HDLs ranged from 31 to 92 mg/dL (53.7 12),
and the values of triglycerides ranged from 42 to
609 mg/dL (165 87.4).
Among the 56 patients in this study, 20 patients
presented with abnormal values of HbA1c, 26 with
a history of hypertension, and 16 with a history of
hypercholesterolemia. The distribution of H-B
classication of these groups of patients at admission is presented in Table 1. After statistical analysis (Pearson 2 test, cross-tabulation), it was demonstrated that severe Bell palsy of grade V and VI
was signicantly more frequent among patients
with abnormal HbA1c values (P .008). Among
the 20 patients who presented with abnormal
HbA1c values, 14 patients were diagnosed with Bell
palsy of grade V and VI, whereas only 6 were
diagnosed with grade IV or less. The possibility of
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Table 1. Correlation of the Severity of Bell Palsy (House-Brackmann Classification) with the Patients History of
Hypertension and Hypercholesterolemia and with Abnormal Values of Glycosylated Hemoglobin (HbA1c)
House-Brackmann Classication
Total
HbA1c
Hypertension
Hypercholesterolemia
3
4
5
6
total
P*
3
27
7
19
56
6
3
11
20
.045
1
10
4
11
26
.5
1
6
2
7
16
.7
Discussion
The frequency of Bell palsy in diabetic patients is a
matter of controversy. According to most authors,
the percentage of diabetics among patients with
Bell palsy is not higher than in the general population,7,1315 although there are some reports that
refer to Bell palsy as occurring more commonly in
Table 2. Correlation of the Severity of Bell Palsy (House-Brackmann Classification) with the Patients History of
Hypertension and Hypercholesterolemia and with Abnormal Values of Glycosylated Hemoglobin (HbA1c)
House-Brackmann Classication
56
4
Total
P*
Odds ratio (95% condence interval)
HbA1c
Hyper-tension
Hyper-cholesterolemia
Total
14
6
20
.008
4.7 (1.415.2)
15
11
26
.1
2.3 (0.86.9)
9
7
16
.4
1.7 (0.55.6)
26
30
56
doi: 10.3122/jabfm.2012.06.120084
821
Table 3. Correlation of the Severity of Bell Palsy (House-Brackmann Classification) with the Patients History of
Hypertension and Hypercholesterolemia and with Abnormal Values of Glycosylated Hemoglobin (HbA1c) at
Follow-up Visit, 6 Months Later
House-Brackmann Classication
Total
HbA1c
Hypertension
Hypercholesterolemia
1
2
3
46
Total
P*
48
5
3
0
56
17
1
2
0
20
.4
22
2
2
0
26
.7
13
2
1
0
16
.8
Pearson 2 test.
diabetic patients or subjects at a high risk of diabetes.20 However, the oral glucose tolerance test is
not common in clinical practice because it is time
consuming, costly, and less reproducible than measurement of FPG.21 The importance of HbA1c
levels lies in the fact that it states a brief history of
the patients glycemic control over the last 2 to 3
months because an erythrocytes life span averages
120 days. FPG alone is not a sufcient test to
diagnose a patient as diabetic because there is a
possibility of giving false results. However, once
glycosylation occurs, the concentration of HbA1c
does not vary day to day and is unaffected by diet,
insulin, other hypoglycemic drugs, or exercise on
the day of investigation contrary to the estimation
of blood glucose.8,11 HbA1c is correlated with FPG
and 2-hour plasma glucose. HbA1c is more reproducible than FPG, and within-subject coefcients
of variation are 1.7 and 5.7%, respectively.2226
The use of abnormal HbA1c values as the criterion
for diagnosing diabetic patients and including them
in our diabetic group may explain the different
results reported by this study, which seem to point
Table 4. Correlation of the Severity of Bells Palsy (House-Brackmann Classification) with the Patients History of
Hypertension and Hypercholesterolemia and with Abnormal Values of Glycosylated Haemoglobin (HbA1c) at
Follow-up Visit, 6 Months Later
House-Brackmann Classication
1
2
Total
P*
Odds ratio (95% condence interval)
HbA1c
Hypertension
Hypercholesterolemia
Total
17
3
20
.9
1.1 (0.25.1)
22
4
26
.8
1.2 (0.35.3)
13
3
16
.5
1.6 (0.37.7)
48
8
Pearson 2 test.
822
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Sex
H-B Admission
(Grade)
H-B Follow-up
(Grade)
HbA1c (%)
Cholesterol
(mg/dL)
LDL
(mg/dL)
HDL
(mg/dL)
Triglycerides
(mg/dL)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
1
0
1
1
0
1
0
0
0
0
0
1
0
0
0
0
0
1
1
0
1
0
1
1
0
1
0
0
1
0
0
1
1
1
1
0
1
1
1
1
0
0
0
1
0
0
1
1
0
5
6
4
6
4
5
4
6
4
5
4
6
4
3
4
5
6
4
4
3
6
6
5
4
4
4
6
4
4
4
4
4
6
4
6
6
5
4
4
4
4
6
5
4
6
6
4
6
3
1
2
1
1
1
1
1
2
1
1
1
3
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
1
1
1
4.9
6.8
5.5
7.9
6.1
5.3
4.5
4.6
4.1
6.8
6.9
4.8
5.5
3.5
8.9
4.4
7.4
6.1
4.3
4.6
7.1
5.6
6.8
4.6
6.5
4.5
5.24
9.5
5.5
3.28
4.3
5.5
7.5
5.6
5
6.3
7.8
4.6
5.5
4.8
6.8
4.8
4.8
4.5
7.2
6.8
5.3
9.8
6.1
246
282
220
289
177
220
275
268
222
197
181
296
169
175
258
151
190
209
199
253
268
245
327
174
241
150
199
252
242
234
215
245
235
185
118
193
201
224
207
154
246
219
178
208
182
11
35
395
288
145
202
135
203
98.6
133.4
200.8
199
149
123.8
114.2
205.2
73.4
104.8
147
57.8
128.8
122.8
165
133.4
187
186
216.8
100
176
123
128.2
99.2
156.4
155.8
138
167
163
97.8
76
137.71
178
146
131.2
83.2
158
167
126.8
156
127.6
151.2
179
270.6
242
56
67
52
35
43
63
58
49
45
58
47
60
54
54
68
74
43
61
56
59
55
56
71
92
63
65
38
31
62
66
55
56
67
65
36
55
32
65
49
45
59
59
34
52
46
39
45
65
45
185
65
165
199
177
118
81
155
155
76
99
154
208
81
215
96
91
126
156
303
185
155
196
196
319
120
134
609
118
155.8
110
145
150
111
200
145
291
65
134
129
145
119.8
86
85
42
219
199
297
205
Continued
doi: 10.3122/jabfm.2012.06.120084
823
Table 5. Continued
Patient
Sex
H-B Admission
H-B Follow-up
HbA1c (%)
Cholesterol
(mg/dL)
LDL
(mg/dL)
HDL
(mg/dL)
Triglycerides
(mg/dL)
50
51
52
53
54
55
56
0
1
1
1
1
1
0
4
4
6
6
6
4
6
1
1
3
1
3
1
1
4.8
5.6
7.1
8.4
6.9
6
5.9
192
202
216
286
235
225
212
147
102.2
135.8
233
206
178
156
34
55
36
52
53
65
45
55
224
221
250
183
175
165
0, male; 1, female; H-B, House-Brackmann classication; HbA1c, glycosylated hemoglobin; LDL, low-density lipoprotein; HDL,
high-density lipoprotein.
824
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References
1. Bibas T, Jiang D, Gleeson J. Disorders of the facial
nerve. In: Gleeson M (ed). Scott-Browns Otorhinolaryngology Head and Neck Surgery. 7th ed. London: Edward Arnold Ltd; 2008: 3883 6.
2. Engstrom M, Thuomas K-, Naeser P, Stelberg E,
Jonsson L. Facial nerve enhancement in Bells palsy
demonstrated by different gadolinium-enhanced
magnetic resonance imaging techniques. Arch Otolaryngol Head Neck Surg 1993;119:2215.
3. Gilden DH. Bells palsy. N Engl J Med 2004;351:
132331.
4. Smith IM, Heath JP, Murray JA, Cull RE. Idiopathic facial (Bells) palsy: a clinical survey of
doi: 10.3122/jabfm.2012.06.120084
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