ARTICLE IN PRESS

Can J Diabetes xxx (2017) 1–4

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Canadian Journal of Diabetes

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Original Research

Does Type 2 Diabetes Mellitus Affect the Healing of Bell’s Palsy in

Adults?
Sultan Şevik Eliçora MD *; Duygu Erdem MD
Otorhinolaryngology Department, Zonguldak Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey

Key Messages

• There are several opinions that type 2 diabetes mellitus has a bad influence on the prognosis of Bell’s palsy. The present study
investigated effect of type 2 diabetes mellitus on Bell’s palsy healing process.
• Type 2 diabetes had no effect on Bell’s palsy prognosis.

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Bell’s palsy (BP) is defined as an acute facial weakness of unknown cause. Many factors affect-
Received 23 September 2016
ing the healing of BP have been identified; 1 factor commonly considered relevant is the presence of type 2
Received in revised form
diabetes mellitus. Our aim was to investigate the effects of diabetes on the healing of BP.
2 October 2017
Accepted 17 October 2017 Methods: Sixty patients with BP were followed up for 1 to 3 years and were divided into 2 groups, those
with and those without type 2 diabetes. All were prescribed prednisone (initially 1 mg/kg per day, with
a tapered dose reduction) and acyclovir (200 mg orally every 4 h, 5 times daily, for 5 days). Their recov-
Keywords:
Bell’s palsy ery times were compared.
diabetes mellitus Results: The healing times of the patients with and without diabetes did not differ.
facial paralysis Conclusions: Diabetes does not affect the severity, recovery rate from or healing of BP.
prognosis © 2017 Canadian Diabetes Association
healing time

r é s u m é
Mots clés :
Objectifs : La paralysie de Bell (PB) se caractérise par une faiblesse faciale soudaine dont la cause est inconnue.
paralysie de Bell
diabète sucré
Parmi les nombreux facteurs qui nuisent à la guérison de la PB, le facteur généralement jugé pertinent
paralysie faciale est la présence du diabète sucré de type 2. Notre objectif était d’examiner les répercussions du diabète
pronostic sur la guérison de la PB.
vitesse de guérison Méthodes : Nous avons suivi 60 patients atteints de PB durant 1 à 3 ans et les avons répartis en 2 groupes
: les patients atteints du diabète de type 2 et les patients non atteints. Tous se sont fait prescrire de la
prednisone (ordonnance initiale de 1 mg/kg par jour, suivie d’une réduction progressive de la dose) et
de l’acyclovir (200 mg par voie orale toutes les 4 heures, 5 fois par jour, durant 5 jours). Nous avons comparé
leur vitesse de guérison.
Résultats : La vitesse de guérison des patients diabétiques ou non diabétiques ne différait pas.
Conclusions : Le diabète n’a pas de répercussions sur la gravité, le taux de rétablissement ou la guérison
de la PB.
© 2017 Canadian Diabetes Association

Introduction

Bell’s palsy (BP) (idiopathic unilateral facial paralysis) is the most

* Address for correspondence: Sultan Şevik Eliçora, MD, Otorhinolaryngology
Department, Zonguldak Bülent Ecevit University Faculty of Medicine, Esenkoy /Kozlu
common cause of acute nontraumatic peripheral facial palsy (1).
67600, Zonguldak, Turkey. The annual incidence of BP is 15 to 30 per 100,000 subjects, and
E-mail address: drsultan@mynet.com equal numbers of males and females are affected (1,2).
1499-2671 © 2017 Canadian Diabetes Association
The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.
https://doi.org/10.1016/j.jcjd.2017.10.055
 ARTICLE IN PRESS
2 S. Şevik Eliçora, D. Erdem / Can J Diabetes xxx (2017) 1–4

Approximately 70% of patients with BP recover completely Table 2

without any treatment (3); with treatment, the rate rises to 90% Distribution of patients with and without diabetes according to degree of facial paraly-
sis before treatment
(4). Many factors have been suggested as contributors to the healing
process of BP. The most remarkable of these factors is diabetes. There Grade V Grade IV Grade III Grade II Total
is a common belief that diabetes affects the healing process of BP Diabetes, n 6 4 11 9 30
negatively. Although a relationship between diabetes and BP has 20% 13.3% 36.6% 30% 50%
been suggested, controlled studies are few in number. We explored No diabetes, n 9 3 10 8 30
30% 10% 33.3% 26.6% 50%
whether diabetes affects the healing of BP. Total 15 7 21 17 60
25% 11.6% 35% 28.3% 100%

Methods
who were taking oral antidiabetic drugs were switched to insulin.
This was a retrospective case-control study approved by our ethics
A dose adjustment was made for patients using insulin. Then patients
committee (#2015-107-04/11). The study was conducted in an oto-
were placed on steroid therapy (initially, 1 mg/kg/day, reduced by
laryngology clinic between October 2012 and October 2014. We
half every day) and acyclovir (200 mg orally every 4 h, 5 times a
enrolled 60 patients who complained of facial paralysis and were
day, for 5 days). Patients without diabetes were given the same treat-
diagnosed with BP; they visited our clinic regularly during the first
ment and were also monitored for blood pressure. The groups were
week after diagnosis. Each patient underwent a complete ear, nose
compared in terms of recovery time and the severity of facial
and throat examination, a neurologic examination, routine blood
paralysis.
testing (including blood sugar and glycated hemoglobin [A1C] levels),
The effect of A1C serum levels on the severity of BP, the recov-
vital findings (including blood pressure), audiologic testing, sero-
ery rates and the durations of BP in patients with diabetes were
logic testing and magnetic resonance imaging with gadolinium
explored. The recovery times of patients with and without com-
enhancement. All patients were divided into 2 groups: those with
plications of diabetes were compared.
type 2 diabetes and and those without diabetes.
We enrolled 30 patients who were diagnosed as having type 2
Statistical analyses
diabetes according to American Diabetes Association Expert Com-
mittee criteria. Their serum A1C levels and diabetes-associated com-
Statistical analyses were performed with the aid of SPSS v. 19.0
plications were recorded. The other 30 patients had no additional
software (SPSS, Chicago, Illinois, United States). Data distributions
disease other than hypertension (HT).
were examined using the Shapiro-Wilk test. Continuous variables
Patients were routinely examined for facial-nerve motor func-
are expressed as means ± standard deviations and categorical vari-
tions: wrinkling the forehead, raising the eyebrows, closing the eyes,
ables as frequencies with percentages. Continuous variables were
opening the mouth, difference in nasolabial folds, showing the teeth,
compared using the independent samples t test or the Mann-
baring the teeth and opening the mouth, pursuing the lips, blowing
Whitney U test. Categorical variables were compared using the chi-
out the cheeks. All patients were graded using the House-Brackmann
squared test. A p value <0.05 was considered to reflect statistical
system (Table 1) (5). The pretreatment degree of facial paralysis,
significance.
according to the House-Brackmann system, are shown in Table 2.
After treatment, those of House-Brackmann grade I were regarded
as having recovered satisfactorily; House-Brackmann grades II
Results
through VI reflected unsatisfactory recovery. Patients with diabe-
tes were hospitalized and monitored for vital parameters and blood
The patients with diabetes were between 47 and 76 years of age
sugar levels. At the beginning of treatment, patients with diabetes
(mean, 62.8±8.79 years). The patients without diabetes were 25 to
70 years of age (mean, 47.5±13.11 years); the mean age differed sig-
nificantly in the 2 groups (p<0.001). The group with diabetes con-
Table 1 tained 12 (40%) women and 18 (60%) men; the group without
House-Brackmann grading system diabetes included 16 (53.3%) men and 14 (46.6%) women. The recov-
Grade Description Characteristic ery times did not differ in the 2 groups (p=0.438). We found no rela-
tionship between age and recovery time (p=0.876). The 2 groups
I Normal Normal symmetrical function
II Mild Slight weakness noticeable only on close inspection did not differ significantly in terms of the extent of facial paralysis
dysfunction Complete eye closure with minimal effort (p=0.611).
Slight asymmetry of smile with maximal effort The 2 groups were compared in terms of recovery rates. No sig-
Synkinesis barely noticeable, contracture or spasm nificant between-group differences were evident (p=0.947). The
absent
III Moderate Obvious weakness, but not disfiguring
average recovery time was 98.27±213.76 days in the group with dia-
dysfunction May not be able to lift eyebrow betes and 95.13±137.51 days in the group without diabetes. The
Complete eye closure and strong but asymmetrical median recovery time was 30 days in both groups (p>0.05).
mouth movement All patients were evaluated in terms of concomitant HT. In the
Obvious, but not disfiguring synkinesis, mass
group with diabetes, 14 patients (46.6%) had HT, as did 6 (20%) in
movement or spasm
IV Moderately Obvious disfiguring weakness the group without diabetes. The proportions did not differ between
severe Inability to lift brow the groups (p=0.055).
dysfunction Incomplete eye closure and asymmetry of mouth The A1C levels of patients with diabetes were measured to assess
with maximal effort the efficacy of long-term glucose control. The healing times were
Severe synkinesis, mass movement, spasm
V Severe Motion barely perceptible
not significantly influenced by these levels (p=0.666).
dysfunction Incomplete eye closure, slight movement corner The complications in patients with diabetes are shown in Table 3;
mouth 10 patients had 1 complication, and 6 patients had more than 1.
Synkinesis, contracture and spasm usually absent We asked whether these complications affected the healing times.
VI Total paralysis No movement
Neuropathy did not affect the healing times (p=0.666); neither did
 ARTICLE IN PRESS
S. Şevik Eliçora, D. Erdem / Can J Diabetes xxx (2017) 1–4
Table 3
Distribution of diabetes-related complications
Complication N Total
One Neuropathy 2 10
complication Retinopathy 1
Nephropathy 0
Microvascular complications 1 with diabetic facial paralysis to 83 patients with diabetes but no
Cardiovascular complications 6 facial paralysis; the peripheral facial paralysis was not a compo-
Multiple Neuropathy+Microvascular complication 1 6
complications Neuropathy+Cardiovascular complication 2 tes (20). We found no significant difference in the recovery times
Neuropathy+Retinopathy+Nephropathy 1 of patients with and without neuropathy.
Neuropathy+Retinopathy+Cardiovascular 1
complication
Nephropathy+Cardiovascular 1
complication+Mikrovasküler complication
Total 16
cardiovascular complications (p=0.307). We could not examine any
possible effects of nephropathy, retinopathy or microvascular com-
plications because patients with such complications were few in
number.
Discussion
A number of factors supposedly affecting the prognosis of BP have
been studied; they include age, sex, the side affected, hypertension,
hypercholesterolemia and diabetes. The most controversial of these
factors is diabetes. Takemoto et al found an association between dia-
betes and lack of recovery (6). Kanazawa et al found that although
the healing process of patients with diabetes was similar to that
of those without diabetes for the first month, healing was notably
slower in patients with diabetes at months 3 and 6 (7). We found
no difference in lack of recovery rates between patients with and
without diabetes, in agreement with other reports (8–10). We also
found that age did not affect recovery time, and others have come
to the same conclusion (8–11). Recent studies have found no rela-
tionship between age and the severity of facial paralysis (7,8).
Some studies have explored the combination of HT and BP. Kudoh
et al found that diabetes was not associated with the extent of
paralysis, but that both HT and diabetes slowed healing (12). In con-
trast, when we studied 13 patients with diabetes and HT and
6 patients without diabetes but with HT, we found no significant
differences in recovery times of BP. The frequency of HT was higher
among patients with diabetes because they were older than the
patients without diabetes.
Viral infections play an important role in the pathogenesis of BP.
Esaki et al showed, in an animal model of drug-related diabetes,
that herpes simplex virus type 1 caused severe facial paralysis (13).
Herpes zoster (shingles) is the second most common viral infec-
tion associated with facial palsy. A study analyzing 1,701 cases of
BP identified the herpes simplex virus as a causative factor in 7%
of the cases (3). In our study, 1 patient who did not recover from
facial palsy had both diabetes and shingles.
We investigated the effects of long-term diabetes control on the
severity and healing times of facial paralysis. We found no corre-
lation between serum A1C levels and either parameter. One study
found a correlation between serum A1C levels and severity of BP
(14); another reported that there is no relationship between serum
A1C levels and severity of BP (7).
Kiziltan et al found no relationship between the severity of facial
paralysis and the duration of diabetes (8). The longer the duration
of diabetes, and the poorer the control of blood glucose levels, the
greater the risk for complications, but we found no difference in the
healing times of patients with diabetes and without complications.
3
Some studies have reported that BP is more common in patients
with diabetes, while others have found no difference in its occur-
rence between healthy populations and patients with diabetes
(15–19). Thus, peripheral facial paralysis may be a form of dia-
betic peripheral neuropathy if, indeed, such paralysis is more
common in patients with diabetes. One study compared 49 patients
nent of the multifocal neuropathy evident in patients with diabe-
Results
Our study had certain limitations. Our patient numbers were low,
and the 2 groups differed in terms of mean age. To minimize this
imbalance, we included only the oldest patients without diabetes.
However, further work with more patients and groups that are better
balanced in terms of age is required.
Conclusions
Diabetes did not significantly affect the severity or healing rate
of BP or the recovery rate. A possible influence of steroid therapy
on BP development in patients with diabetes should be consid-
ered; such patients should be closely monitored.
Author Disclosures
Conflicts of interest: None.
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