Monday, July 25, 2011

FACIAL PALSY (BELL'S PALSY)

FACIAL PALSY (BELL'S PALSY)

What is Bell's palsy?

Bell's palsy refers to unilateral (one side) paralysis of muscles of face.

What are the symptoms of facial palsy?

Facial palsy causes weakness of facial muscles. So, patients may face the following problems:

1. Difficulty in closing the eye, so, the eye on affected side may look bigger.
2. Difficulty in frowning, leading to absence of wrinkles over forehead on the affected side.
3. Difficulty in blowing out cheeks (air leaks out on the affected side).
4. Watering of eye on the affected side,
5. Difficulty in chewing food, food may get stuck within the mouth on the affected side
6. Facial asymmetry, face may seem to get pulled to the normal side.

Other symptoms may include:

1. Loss of taste on the affected side,
2. Faint sounds may also seem louder (hyperacusis)
3. Headache or facial pain on the affected side.

How does facial palsy start?

Symptoms of facial palsy starts suddenly over hours, so, it is very alarming for the patient. At the onset, patient may have pain behind the ear, in the neck, or the head on the side of paralysis. Symptoms are very minor in the beginning, so, they often get noticed first by others or may be noticed on looking into a mirror.

What should be done, if one suspects facial palsy?

There is no need to panic, as it is a benign condition, and often improves. One should first consult their family physician or GP and subsequently a neurologist. Care should be taken to avoid any dirt entering the eye (as it can not be properly closed) to prevent corneal (a part of eye) infection.

What are the causes of facial palsy?

Bell's falsy is idiopathic (no definite cause has been idetified). However, research has shown that it is often caused by viral infections such as herpes simplex. Facial palsy is more common in people with diabetes mellitus and in pregnant women. Patients with facial palsy often give a history of exposure to cold prior to the onset of symptoms (such as direct exposure of AC wind, going out at night or early morning, or long road journey with open windows), but their role in causing facial palsy has not been proven.

Other causes of facial palsy may include brain stroke (decreased blood supply to brain), tumors, other infections, trauma, infections of ear, etc.

What investigations would the doctor ask in facial palsy?

  • Generally, no investigations are necessary as the diagnosis of facial palsy is obvious on clinical examination.
  • However, brain scan (CT or MRI) may be done if one suspects brain stroke or tumors.
  • Blood sugar should be checked to exclude diabetes mellitus.
  • Nerve conduction studies (NCV/EMG) may be done to estimate the extent and severity of facial nerve involvement and in some cases to predict the outcome of facial palsy.
  • In patients with recurrent facial palsy, certain blood tests may be done to look for the presence of disorders like collagen vascular diseases or vasculitis.

How is facial palsy treated?

Medical management of facial palsy may include the following:

1. Anti-viral drugs: Aciclovir tablets are given for 5-7 days.

2. Corticosteroids: Role is not proven in facial palsy, but many doctors use a short course of low-dose steroid tablets,

3. Vitamins: Mecobalamin (vitamin B12), alpha lipoic acid, etc are given to speed up recovery and regeneration of the facial nerve.

4. Physiotherapy: includes facial exercises, massage, and electrical stimulation of the facial nerve.

What is the prognosis of facial palsy?

  • As earlier mentioned, facial palsy is not a serious condition and most patients recover well. Almost 60-70% patients recover in 3-4 weeks and the remainder in a few months.
  • Less than 5% patients either do not recover or recover only partially.
  • Facial palsy does not lead to death.
  • Facial palsy usually does not recur, and recurrence is seen in only 2-5% of cases.
  • Patients with residual palsy may have facial asymmetry and they may consult cosmetologist/cosmetic surgeon for correction of asymmetry.
Miscellaneous questions about facial palsy

1. Is it contagious?
No, facial palsy does not spread from one patient to another, so, isolation is not required.

2. How common is Bell's palsy?
It is quite common and I see about 5-10 new cases per month.

3. Is Bell's palsy hereditary?
No

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)
SENIOR CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD, INDIA
Phone: 040-23607777/60601066


Wednesday, July 13, 2011

ROLE OF BOTOX IN NEUROLOGICAL DISORDERS

BOTULINUM TOXIN (BOTOX) INJECTIONS IN NEUROLOGY

Botulinum toxin (popularly sold in the brand name Botox by Allergan company) is one of the commonly used treatment methods in cosmetology. Many actors and models take botox therapy to look young and hide away all facial and forehead wrinkles. Very few people know that Botox has wide applications in the field of neurology and patients with several neurological disorders can benefit from botox therapy. In this post, I would list out all the conditions where I give botox injections and would share my experiences in treating them.

1. POST-STROKE SPASTICITY

Stroke is a common disease leading to paralysis of muscles on one side of the body, due to reduced blood flow to the brain. Patients who survive stroke are left with severe disabilities. Spasticity- increased stiffness and tone of weak muscles- is a common cause of disability in stroke survivors. There are several medications (oral tablets) available for reducing the spasticity, but they have limited efficacy and significant side effects such as drowsiness. Botox injection therapy is a very effective method of treating post-stroke spasticity. Botox is injected in the spastic muscles. In the past 10 years, I have treated more than 100 patients with this condition and most of them do well. One of my recent patients was an ex-army person from Baghdad (Iraq), who was wheel-chair bound for five years due to a stroke. I gave him botox treatment, and referred him for physiotherapy. After a week, he came walking to my office. Patient and his wife were so thrilled! Reduction in spasticity also helps in doing better physiotherapy.

2. CHRONIC MIGRAINE

Migraine is the commonest cause of headache, affecting about 10-15% of women and 5-8% of men. In many cases, migraine becomes chronic and leads to frequent headaches. Frequent, severe headaches adversely affects the patients' quality of life, studies, employment and family life. Oral preventive therapies for migraine are available, but are ineffective in some and lead to adverse events in others. In these patients, botox therapy has a great role to play.

Botox is injected in scalp and neck muscles (frontalis, temporalis, occipitalis, cervical, trapezius, etc) using a very thin needle. The procedure can be done in the office, with little discomfort to the patient, and is completed within 15-20 minutes. In the past two years, I have treated about 30 patients with chronic migraine with botox. 29 of them showed good improvement in pain and quality of life. One patient who did not improve had various stressors in personal and professional life, leading to super-added tension headache. One patient, who I distinctly remember was a 35-year-old woman from Dubai, who came to me with 5 year duration of chronic migraine (20 headache days per month). She returned 3 months after botox injection therapy for review, and reported almost complete improvement in pain. However, she requested me for one more botox shot. I was surprised, as she was pain-free. Then she disclosed to me that her husband had started showing more interest in her now that she looked much younger and prettier (after botox shot to frontalis muscles) and she wanted to maintain the youthfulness of her face. I suggested to her that she consult a cosmetologist, but she insisted on me doing it. So, I along with my cosmetologist, gave her the second botox shot!

3. WRITER'S CRAMP

It is a condition, where patients find it difficult to write. They are able to perform all other activities normally, including lifting heavy weights with hands. Handwriting becomes poorer and illegible. Cheques signed by the patients start bouncing, as the signature on the cheque does not match that of bank records. Another feature of the disease is that writing becomes worse in front of others and when tensed.

Botox is very effective for treating writer's cramp. Injection is given in forearm muscles. Most patients improve very well.

4. SPASTICITY OF LIMBS IN CHILDREN WITH CEREBRAL PALSY

Cerebral palsy (CP) is a condition affecting children, characterized by developmental delay (delayed motor and speech milestones). Other features may include fits, deafness, squint, learning disability, etc. Cerebral palsy results due to a lack of oxygen or blood supply to the brain during peri-natal period (immediately before, during or immediately after birth). Many children with CP have spasticity of legs and hands. Spasticity of legs hamper in their standing and walking. Botox injections given in adducor and hamstring muscles of thighs reduce the spasticity, and improve walking. Today, I treated a 5-year old child from Bidar (Karnataka) with this condition.

5. Other dystonias- such as hemi-facial spasm, blepharospasm, cervical dystonia- are also very well treated with botox injections.

6. Hyperhidrosis- increased sweating over palms and feet, which can be embarrassing and cumbersome- responds well to botox treatment.

In general, all botox injection therapies are done on an out-patient basis. Patients can come after eating (fasting is not necessary). It is done without any anaesthesia, in the office setting. The entire procedure is completed in less than 30 minutes and patients are free to return home immediately after the procedure. No leave from work is required and they can join work the next day. Depending on the condition, 100 to 200 units (1-2 vials) of botox is required for the procedure, and the approximate cost could be Rs 25, 000- 50, 000 (USD 1000-2000). Botox treatment is safe and I have not seen any complication in more than 250 botox procedures that I have done in the past 10 years.


DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS
HYDERABAD, INDIA.
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Tuesday, July 5, 2011

RIGHTS OF A PATIENT IN A DOCTOR-PATIENT RELATIONSHIP

What are the rights of a patient, in a doctor-patient relationship?


The relationship of a patient and doctor is a very special one and is different from any other professional relationship. The patient shares a lot of personal and private details with the doctor, which at many times are not even known to close family members or relatives. The doctor is one of the most important persons in a patients’ life, as the doctor is responsible for the patients’ good health (contributing to an increased productivity at work and greater happiness in family life).

There is a need to maintain a healthy and cordial patient-doctor relationship, keeping in view the importance of this relationship. Both the patient and doctor have certain rights and responsibilities towards the success of patient-doctor relationship. In this blog, I shall focus on the rights of a patient.

1. Right to get listened to by the doctor

It may seem very basic, but several patients are not allowed to tell their complaints to the doctor. Several senior doctors spend hardly 3-4 minutes per patient, and give a prescription containing 7-10 medications to the patient! History (description of illness as given by the patient to doctor) is the most important step towards arriving at a correct diagnosis; and a patient has the right to insist that a proper history be taken. Today, several doctors over-rely on investigations (such as blood tests, X-rays, CT scan, echocardiogram, etc) to make a diagnosis (ignoring history and clinical examination of the patient). Over-reliance on investigations can lead to an error in diagnosis. For ex- epilepsy can be diagnosed only by a good history, as CT scan and EEG may be normal in true cases of epilepsy. On the other hand, 5% of normal people may have abnormal EEG.

2. Right to receive information about the illness:

Patient can ask anything about the illness to the doctor (such as why did it occur, can it spread to other family members, how long will it take to improve, any likely complications of the illness, can it recur, etc). A good doctor has enough time to answer all the illness-related queries.

3. Right to know all the possible treatment options:

A single disease may have more than one treatment options. There may be more than one medication effective for the same illness. For ex- there are several medications effective for epilepsy. The doctor selects the best anti-epileptic medication depending upon the type of epilepsy; age & sex of the patient; expected drug-related adverse events and cost. The patient has a right to understand why one medication was preferred over another. In diseases requiring surgery, patient has the right to understand different surgical options available and why a certain surgical procedure is preferred over another.

4. Right to know possible treatment-related adverse events:

Many medications may cause adverse effects, which can range from simple nausea/vomiting to liver & kidney damage. A patient has a right to know about all the possible harmful effects of the drug from the doctor. A good doctor would patiently explain them to the patient. Similarly, in patients undergoing surgery, all the possible complications of the surgery will be discussed by the surgeon with the patient.

5. Right to refuse any investigation or treatment:

A patient has the right to accept or refuse any investigation or treatment offered by the doctor. A doctor can only advise, and not force a patient to undergo an investigation or procedure. An informed consent from the patient is mandatory prior to an investigation or procedure.

6. Right to take second opinion:

The doctor’s opinion regarding the treatment is not binding on the patient and a patient can opt for a second opinion before accepting the treatment. The patient can take the second opinion from a doctor suggested by the treating doctor or any other doctor of his or her choice.

7. Right for a referral:

If the treating doctor is not competent in handing the disease, the patient has a right to be referred to another doctor who is a specialist in treating the condition. For ex- if the patient has suffered from an ischemic brain stroke (causing paralysis) and the concerned doctor is not competent in thrombolysis (clot-buster therapy), the patient can ask for referral to a stroke neurologist.

8. Right to know about any modifications in lifestyle, diet or job:

Treatment of a disease involves modification in diet, lifestyle and job. For ex- patients with kidney failure or very high blood pressure should take a low salt diet, patients with recent heart attack should avoid oily/fatty food, patients with epilepsy should avoid driving/swimming, etc. Patients have a right to know these details.

9. Right of confidentiality/privacy:

Patients details (personal or medical) can not be disclosed by the doctor to anyone else including close friends or relatives of the patient without patients’ consent.


DR SUDHIR KUMAR MD (Medicine), DM (Neurology)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com
http://members.tripod.com/sudhirkumar_5/neurologist/