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Interviewer: Bell's Palsy is a relatively uncommon condition that is typically characterized by a loss of motor function in one side of a person's face. And while it only lasts a relatively short time for most people and isn't as life-threatening as say a stroke, diagnosis and treatment are time sensitive.

And losing control of half of your face can be a serious detriment to your quality of life. Trust me, I've experienced it personally. To help us better understand Bell's Palsy, we are joined by Dr. Sarah Aina. She is an assistant professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology-Head and Neck Surgery and the director of the Facial Nerve Center at University of Utah.

Dr. Akkina: That's the main sign. That's the one that. A lot of people clue into, and of course there's recent celebrities such as Justin Bieber, who had photos out in the world of him having that facial droop on one side or just really not being able to move one side of the face.

Now, Bell's palsy can very rarely occur to both sides of the face. But that is more unusual.

Interviewer: So what exactly is going on here? It's not brain damage or a clot or something like what is it that causes this facial paralysis?

Dr. Akkina: Overall, we suspect that Bell's Palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

Interviewer: So if I understand this right, the nerves that connect half of that face to the brain are kind of pinched off. So what all do these nerves control in the face?

Dr. Akkina: The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear and tastes to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth. A change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

Interviewer: Wow. So it's not just like not being able to smile. I mean, these nerves do a lot of other things like what are some of the other symptoms that can come from this condition?

Dr. Akkina: So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye. Trouble keeping food and liquid in their mouth, nasal obstruction and overall difficulty expressing emotions so they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.

Interviewer: Typically in healing from Bells Palsy you in two to three weeks, a month or two, you should start to get your face movement back.

Dr. Akkina: That is totally correct. So for most patients who come in with facial paralysis, we say about 70% of those patients. So a big majority have Bell's Palsy, though that does mean that 30% of people who come in with a face droop may have something else going on, and that's why it is so critical if you or a loved one starts to have a strange movement in their face. They need to see a healthcare provider immediately, ideally within 72 hours.

Interviewer: Go to the ER?

Dr. Akkina: Yes. Either an emergency department, urgent care. If you can get into your family care, primary care provider's office, all of those things are great options as long as you can see a healthcare provider within 72 hours.

Part of that is because one of the main treatments of early Bell's Palsy is being able to start oral steroids. And Mitch, I know you had an experience of this, I'm curious. Were you able to see someone right away and did you start steroids?

Interviewer: Well, there's a long funny story and you can hear about it on one of our other shows.

But yes, I very quickly got to the hospital as quickly as I could. I thought I was having a stroke, et cetera. The doctors thought I was having a stroke. They went through the whole like "brain attack protocol" and then at the. Found out it was "just Bell's Palsy."

But they were expressing, it's really important that you came in. Because if it had been a stroke, there's a lot of other things we could do to help you. And then on top of that, with the Bell's Palsy, they gave me some antivirals and some some pretty intense steroids to try to get as much pressure off of that nerve as possible. As early as possible.

Dr. Akkina: And that is so critical. There are really good research studies that people have done in the past where they actually randomize people to either getting steroids, plus or minus antivirals or getting a placebo, and they really found that upwards of 10 to 20% more patients were able to get early recovery when they started the steroids. Interestingly, the antivirals did not show a very clear benefit. So in our recommendations we say you can certainly consider antiviral medicines, especially if you know there are no other contraindications for you, but we don't have great data that the antiviral medicine helps as much as we know the steroids really help.

Interviewer: Are there particular risk factors for someone to develop Bell's Palsy over, say one of these other conditions?

Dr. Akkina: There are and overall, Bell's Palsy affects 35,000 to a hundred thousand patients in the United States each year. So there are a decent number of patients, although overall rare. Patients who have diabetes, obesity, hypertension, or high blood pressure, other upper respiratory ailments and compromised immune systems are all at higher risk.

Importantly, patients who are pregnant are actually also at higher risk. Partly related to that compromised immune system. But yes, interestingly we do see a higher number of Bell's palsy in pregnant patients. They can also have a little bit more of a struggle with their recovery sometimes.

Interviewer: Talk me through recovery. So the person experiences facial group, ideally they go in, they get some pretty intense anti-inflammatories as fast as possible. What, a week or so?

Dr. Akkina: About 10 days. Seven to 10 days.

Interviewer: And then what's'the next thing? Like what happens after that?

Dr. Akkina: Yes. So overall, most patients show some sort of recovery within two to three weeks after their weakness starts. With a majority having complete recovery in three to four months. So it does take some time in patients who continue to have some movement at the time of their face droop, about 94% of those will completely recover in six months.

And that's one of the key things that we establish when we first see someone with facial paralysis is, "Do they have a complete paralysis or do they have partial weakness?" Because the recovery can be different for each of those patients. And again, for those with a little bit of weakness, but having some movement, the recovery is better and overall prognosis is better.

For patients who have complete paralysis and weakness. About 70% of those will recover completely in six months. So alternatively, 30% of those patients who start with complete weakness will continue to have some weakness in the long term or other disabilities.

Interviewer: Wow. And so during those times, during the recovery, what are some of the things that a patient can do to minimize some of the potential side effects that can come from having facial paralysis?I know that, myself included, I could not blink on that side of my face, could not keep food in the side of my mouth, et cetera. What are some of the things that can be done to minimize that?

Dr. Akkina: The number one thing we always wanna make sure for all of our patients who have facial nerve weakness is we're taking care of the eye.

And you even said that first, right? It's so important for us to make sure that the eye is protected, that it's getting enough lubrication and moisture. Otherwise, people can have permanent issues with either scratches of the eye or other disorders. So, number one, we always wanna make sure that patients with face weakness are taking care of the eye.

Number two is actually something that a lot of research is being done on because we don't have great evidence to say that some alternative therapies actually help in recovery. Overall, as we reviewed, most patients do recover, but things that have been tried, including physical therapy, acupuncture, and even electrical stimulation. We're still learning about. Currently we don't have enough evidence to recommend things like immediate physical therapy or acupuncture. But you know, we're still conducting studies on those aspects. So hopefully in the next five to 10 years we'll have more information on that. But at this time, I can't recommend those other aspects because of that.

Interviewer: So for a patient that recovers in six months or however long it takes. Is there a likelihood of recurrence?

Dr. Akkina: So there is a possibility of recurrence, and this is where it's really critical for us to make sure we know that a patient either does have Bell's Palsy or if they have any other factors that they come in with. We've identified that.

Because having a recurrent paralysis makes me more concerned that there might be another reason that that patient has facial paralysis. In other words, that maybe they were diagnosed with Bell's palsy for their initial paralysis, but it turns out they might actually have something like a skull-based tumor or a vascular reason to have other issues causing facial weakness.

So it is possible for patients to have recurrent Bells Palsy, but it does make us want to really carefully examine that patient on a physical exam and get a great history so that we can make sure we're not missing these other factors.

Interviewer: So say a patient who has been diagnosed with Bell's Palsy has experienced that facial droop, that facial paralysis it is now seven months. Eight months. We are past that six month ideal window of recovery. What kind of treatment options are available to them?

Dr. Akkina: And that's a great question because even as early as three months, if a patient is not fully recovered from what's been diagnosed as Bell's Palsy, they need to see a facial nerve specialist. Because there are, again, other reasons that might be causing that. Bell's Palsy as an overall phenomenon, part of the definition is that you recover. So if you don't recover, we need to evaluate other reasons why that might be.

So things that you should definitely be referred to a facial nerve specialist for if you have Bells Palsy are: one, if you have incomplete recovery three months after. Two, if you have any new or worsening neurologic findings at any point.

And three, if you have ocular symptoms.

Interviewer: So if someone is out there listening or reading along with the transcript for this piece, there's a good chance that either they or a loved one are suffering from some of the side effects of Bell's Palsy. Maybe they're dealing with facial drooping. Maybe they're dealing with facial paralysis.What is something that you can tell them to give them a bit of hope? To give them a bit of understanding about their condition.

Dr. Akkina: I would focus on the prognosis and that's the most important part about Bell's Palsy. Most patients will recover, so hopefully there's always some comfort in knowing that for any patient who comes in with Bell's Palsy, the majority will get better.

It just takes some time and that timeframe is on the order of weeks to months. In the meantime, it's so important to take care of their eye and make sure they're getting enough, both moisture to the eye and protection of the eye, especially when they're sleeping. Wearing things like an eye patch or taping the eye is incredibly important for that.

Other things to know are that should you be in that small category of patients that have ongoing issues, we have a specialized facial nerve center that is built to take care of you and your loved one. We would love to see you at any stage at your disease to talk about prognosis, ensure that you've gotten the right diagnosis and that there's nothing else we need to look into. And be with you as you recover from this process.

We also, again, would love to eventually identify ways that we can help patients recover faster. So being plugged into our facial nerve center is our first step in us being able to track outcomes for people and make things better overall.

Dr. Miller: Spinal stenosis. Do you have that, and what do you about it if you do have it? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Darrel Brodke and I'm Dr. Tom Miller, and Darrel is a professor of orthopedic surgery at the University of Utah. Darrel, what is spinal stenosis?

Dr. Brodke: Well, spinal stenosis, Tom, is a narrowing of the spinal canal. The spinal canal is where the nerve roots coming off of the spinal cord come down through the remainder of your spine and then out to form nerves that go down your leg. This can also happen in the cervical spine, by the way, or the neck, but classically it's in the lumbar spine. So spinal stenosis is a narrowing in the space, like a pipe that had sediment built up so that the space is now so narrow that it's compressing the nerves.

Dr. Miller: So the spinal cord, the main nerve, is compressed. Now does this happen because of trauma, does it happen in younger patients or older folks? What causes it?

Dr: Brodke: Spinal stenosis is largely a disease of older folks, although we can see congenital stenosis in younger folks. Classically it would be an older person who started having problems with pain radiating from their buttocks down their legs, particularly when they walk.

Dr. Miller: And does it come on suddenly? What kind of a pain is it? Is it burning, is it sharp, is it lancinating? I mean, is there a type of pain that one typically experiences when they have spinal stenosis?

Dr. Brodke: Sure. So the pain, it can vary in nature from person to person, but it's common, most commonly, a pain that feels like pressure or a pain that feels fairly sharp and searing down the legs. It can also take the form of fatigue in the legs rather than actually frank pain and it commonly limits the distance that a person can walk or a time that they can stand.

Dr. Miller: So when they stop walking the pain gets better, then they start walking again and it recurs.

Dr. Brodke: Often they have to sit down or bend over for the pain to actually get better because that posture of flexion allows for increased space for the nerves and therefore better blood flow, better nutrients, and the nerves start feeling better. As soon as they stand up again, they start getting that compression of the nerves and then after a short period of time the nerves start responding by hurting.

Dr. Miller: Darrel, is there a particular place in the spine that is more common to see spinal stenosis?

Dr. Brodke: Yeah, most commonly we see spinal stenosis in the lumbar spine, that is the low back, and therefore it most commonly affects the buttocks and legs. We can see spinal stenosis in the cervical spine as well where it's actually pressing on the spinal cord causing problems with balance or stability or fine motor dexterity in the hands, but most commonly we see it in the low back.

Dr. Miller: How does one treat this? Are there conservative ways to treat it? Do you go to surgery?

Dr. Brodke: So we will often try to treat spinal stenosis, particularly in the lumbar spine, conservatively first. That means physical therapy, anti-inflammatory medications, changing . . .

Dr. Miller: Things like ibuprofen, Motrin?

Dr. Brodke: Exactly. We'll also have them change the way they do activities. In physical therapy we do exercises, for example, bent over inflexion because that opens the space for the nerves. So it's a specific kind of physical therapy.

Dr. Miller: So the conservative therapy is something that you would prescribe for a patient. They would generally go to a physical therapist who would then carry out the type of exercise and treatment that you had recommended?

Dr. Brodke: Yes.

Dr. Miller: Now how often is that effective?

Dr. Brodke: That's effective quite a fair amount of time. It's hard for me to estimate but I can quote you statistics from the literature in which maybe half the patients really feel like that was very effective, another third of patients feel like it was somewhat effective, and then there are a fair number of patients where that didn't work at all and we end up talking about surgery.

Dr. Miller: And what percentage of patients would maybe need to go on to surgery, and if that is the case, tell me a little bit about that.

Dr. Brodke: That's a number that's a little hard to get to because the total number of patients with spinal stenosis is not well identified, but if we look at studies in which only spinal stenosis patients are enrolled and we look at operative and non-operative treatment options, somewhat under half of the patients end up in surgery, and those patients that end up in surgery do extremely well. In fact, they do better than the non-operative patients do.

Dr. Miller: So what's important is to go to someone who is a particular specialist in spine surgery so that they could actually select the patient for surgical procedure after having gone through rather conservative therapy.

Dr. Brodke: Exactly. We'll often try conservative therapy whether you're seeing the surgeon first, or your primary care physician, or a physiatrist. All of those types of physicians are certainly well-capable of prescribing the physical therapy and anti-inflammatory medications, ibuprofen for example, that are the beginning of treatment for spinal stenosis. But as the disease progresses and for those patients that that actually doesn't work on, the next step would be to see a surgeon whose specialty is treatment of lumbar spinal disease.

Dr. Miller: So for our listeners, if you're having burning pain radiating down from your buttocks down the sides of your legs that causes you to stop, you rest, it goes away, it starts again when you walk any distance, it's relieved when you're bending forward, you might have spinal stenosis. You'd probably see your primary care provider who can then refer you on to a spine specialist who might start with conservative therapy, likely would start with conservative therapy and that would generally do the trick in a number of patients, and if not, they would best advise you on what the next steps are and that might include surgery.

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Dr. Miller: What is spinal stenosis? Could you have that as a problem? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists with Dr. Tom Miller" is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an Orthopedic Surgeon and a Professor of Orthopedics here at the University of Utah. Ryan, what is spinal stenosis and who gets that?

Dr. Spiker: It's a great question. Spinal stenosis is very common, especially as we age. So in the elderly population, what happens is you get some reason for compression of the nerves in the low back. This is often from arthritis, degenerative changes, and slowly that compression can lead to pinching of the nerves in the low back, which leads to weakness and pain in the legs.

Dr. Miller: So the anatomy is . . . tell me about that. The spinal cord goes down through the vertebrae, which are the bones of the spine and they travel through a tunnel. And what happens? That tunnel becomes narrow, is that what happens?

Ryan. Absolutely. So at the bottom of the spinal cord, there are still nerve roots and all those nerve roots end up innervating our legs, providing sensation and strength to our legs. And in that bottom part of the spine, just above the pelvis, it's common for arthritis to lead to hypertrophy or thickening of the ligaments, thickening of the disk and then compression of those nerve roots. And that compression leads to the pain that often shoots down into the legs.

Dr. Miller: So is spinal stenosis then a condition that someone who is a farmer or a laborer would get more commonly than somebody who was maybe working at a desk, or does it matter?

Dr. Spiker: So it does matter. There's some effect of environment so what we do. Sitting is actually very bad for our backs and so that can be a risk factor in and of itself.

Dr. Miller: So a clerk or a professional who's sitting a lot might be at greater risk than even somebody who is out working all day?

Dr. Spiker: Absolutely. Depending on the type of the work and there are also some genetic risk factors that we've studied here at the U that have been shown to impact how often family members will get spinal stenosis.

Dr. Miller: Well, tell me a little bit about what the symptoms are.

Dr. Spiker: The most common symptoms are pain or weakness or heaviness of the legs and it's usually worse when people are standing up and walking and improved when they bend forward. So if they're using a shopping cart or if they're using a walker, it feels much better. But again, it's worse when they attempt to stand up straight or extend their back.

Dr. Miller: What kind of pain is it? Is it a burning pain in both legs generally, if they're walking more than a block, I mean if it's severe?

Dr. Spiker: Often, people will describe some burning sensation. Commonly, it's a heaviness. It's a feeling that their legs are disconnected from their body. It can be a sharp pain that shoots down the spine. There's some variation with nerve pain, but invariably, it's worse with walking and usually goes down the back of the legs and can go all the way down into the feet.

Dr. Miller: What age groups are most susceptible to spinal stenosis?

Dr. Spiker: So, for most patients, it's as they get older so usually in patients that are 50 or 60 or above. Certainly, there are causes of spinal stenosis such as fractures or really large disc herniations that can occur in a younger population, but the vast majority of patients are a little older.

Dr. Miller: In a previous talk, we talked about sciatica and how that's caused by disc herniations mostly. Would spinal stenosis be more common or less common than disc herniation-related sciatica?

Dr. Spiker: So similar in different groups. So at a national level, certainly more common to have spinal stenosis than disc herniations that would cause somebody to see a spine surgeon like me. Most spinal stenosis patients will have some progression over time or continue to have symptoms, whereas most patients with disc herniations will get better on their own and this won't require to come in to see a spine surgeon.

Dr. Miller: So tell me about the therapies, treatments, for spinal stenosis. Obviously, it depends on the severity of the problem.

Dr. Spiker: Absolutely. So our first line treatments are anti-inflammatory medications, non-steroidal anti-inflammatories.

Dr. Miller: Ibuprofen, naproxen, aspirin, things like that.

Dr. Spiker: Exactly. They help calm down some of the inflammation from the area of compression. And then getting people into physical therapy to help strengthen their core, take some of the stress off the bones and the nerves of the back.

Dr. Miller: Would you say that physical therapy is kind of an underused and underappreciated modality?

Dr. Spiker: Absolutely, absolutely. And often, I would say 60, 70, 80% of patients that I see in my clinic have not yet undergone physical therapy and anti-inflammatories. And sometimes, these simple interventions can really change the quality of their life.

Dr. Miller: How long would it take before someone would know if physical therapy was actually working?

Dr. Spiker: It's a great point that it does take time so often the first few weeks can be frustrating because it's difficult and it can cause some pain, but usually, within six to eight weeks, people start to see the fruits of their labor.

Dr. Miller: In your experience, when then do you start talking about a surgical solution to the problem?

Dr. Spiker: So surgery is always the last option, it's never the first option. And fortunately, we can usually get people better with the anti-inflammatories, the physical therapy, some nerve medications, neuromodulatory medications like gabapentin, sometimes even injections. If all of these fail and the symptoms are progressive and really causing a change in their quality of life, that's when we talk about surgery.

Dr. Miller: And surgical outcomes, how well does it work?

Dr. Spiker: So surgical outcomes are excellent in well-selected patients. So in patients that have gone through the right preoperative therapies and interventions, it ends up about 80-85% of people are much better after surgery than they were before.

Dr. Miller: That's a great outcome.

Dr. Spiker: Yes.

Dr. Miller: And over time, does that hold?

Dr. Spiker: It does. So we have great data up to about eight years now showing that people have continued benefit with surgical intervention for at least eight years and we certainly think longer.

Dr. Miller: Well, thanks, Ryan. So for our audience, basically surgery is the last option, but it has an excellent outcome. But prior to surgery you want to think about a good trial of physical therapy and the use of over-the-counter non-steroidals like ibuprofen and naproxen just to try to control the pain while you're testing physical therapy and working with your therapist.

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