HBOT an effective adjuvant therapy in the treatment of Bell’s palsy: A case series

ABSTRACT

Bell’s Palsy is characterized by sudden onset facial paralysis due to dysfunction of the facial nerve. While conventional treatments exist, the potential of Hyperbaric oxygen therapy (HBOT) in managing this condition remains underexplored. This study aims to evaluate the efficacy of HBOT as an additional intervention in Bell’s Palsy cases. Seven individuals with Bell’s Palsy were selected for this study and treated with a combination of standard therapy along with sessions of HBOT. The treatment regimen, frequency of HBOT sessions, and follow-up protocols were standardized across all cases. Following the combined therapy approach, significant improvements were observed in all seven cases. Reduction in facial paralysis, improved muscle strength, and enhanced facial mobility were notable outcomes. Furthermore, compared to historical data on Bell’s Palsy recovery rates with standard treatment alone, the addition of HBOT seemed to expedite the recovery process. This case series demonstrates promising results regarding the efficacy of HBOT as an adjunct therapy for Bell’s Palsy. The findings suggest that incorporating HBOT into the treatment protocol for Bell’s Palsy could potentially enhance facial nerve recovery and overall outcomes. Further research with larger sample sizes and controlled studies is warranted to solidify these preliminary findings and establish HBOT’s role in the management of Bell’s Palsy.

Introduction

Bell’s palsy named after Charles Bell, is the most common mononeuropathy. It is rapid unilateral facial nerve paresis. Etiology can be sporadic or infectious. Hyperbaric Oxygen Therapy (HBOT) may be useful in improving the outcome of Bell’s palsy. The people receiving HBOT get 100% oxygen at 2.4 ATA at 90 min. Limited studies have suggested the positive effect of HBOT as adjuvant therapy in moderate-to-severe palsy. HBOT has been shown to improve facial nerve function and reduce recovery time in Bell’s Palsy patients.

In this case series, we present a series of 7 cases of Bell’s palsy who were subjected to HBOT for a minimum of 10 sessions and a maximum of 20 sessions. Improvement was graded using House Brackmann’s grading. For patients, particularly those with multiple comorbidities or those resistant to standard therapy, HBOT has the potential for faster recovery and enhanced facial nerve function. The same was observed in our study too.

Our study will increase the awareness about the use of HBOT and its potential in treatment and it can guide primary care physicians and specialists in tailoring more comprehensive and patient-specific treatment plans. If proven by larger studies/RCTs it can be a boon to primary care physicians if incorporated as an adjuvant therapy which is relatively harmless and reduces the amount of steroids and their adverse effects in patients suffering from Bell’s palsy.

Awareness about this treatment modality is essential for primary care physicians as this modality is beneficial in patients with multiple co-morbidities who are not good candidates for steroid therapy. The primary care physician can thus consider referring these patients to an HBOT center in the initial week or two and follow their progress with the standard of care therapy. This study is beneficial for all practitioners as it explores HBOT, a relatively underused treatment modality, as an adjunct therapy for Bell’s Palsy. Practitioners can use these findings to broaden treatment options in patients with Bell’s palsy.

Case series

Case 1

A 28-year-old male resident of the northern part of India and a known case of severe depression on fluoxetine presented with sudden onset LMN-type facial nerve paralysis (left) for 20 days [Figure 1]. MRI was normal. He was started on Tab Prednisolone and Tab Acyclovir for 15 days from 09 to 30 Nov 23. He was given to HBOT on 21 November 23 as an adjuvant therapy, @2.4ATA for 90 min. He was diagnosed with Left Bell’s palsy House Brackmann grade IV.

Figure 1.

Showing clinical improvement in the patient condition Pre HBOT and Post 10^th session of HBOT

At discharge, lagophthalmos improved with mild forehead movement HOUSE BRACKMANN GRADE III.

Case 2

A 27-year-old male resident of the central part of India with no co-morbidities, presented with acute onset left-sided progressive LMN type of facial nerve palsy for the last 01 month [Figure 2], after 01 days of fever. MRI was normal. He was started on Tab Valcyclovir 1 gm TDS and Tab Predinisolone from 10 to 17 Oct 23. He was subjected to HBOT @2.4 ATA for 90 min from 22 NOV 23. He was diagnosed as Left Bell’s Palsy House Brackmann Grade IV.

Figure 2.

Showing clinical improvement in the patient condition Pre HBOT and Post 10^th session of HBOT

At discharge lagophthalmos has improved with mild forehead movement Left Bell’s palsy HOUSE BRACKMANN GRADE III.

Case 3

A 29-year-old male, Resident of Rajasthan, with no co-morbidities. He presented with left-sided sudden progressively increasing LMN-type palsy of the facial nerve for 08 days [Figure 3]. He had a history of fever 03 weeks back for 2–3 days associated with chills and rhinitis. MRI: NAD. The individual was started on Tab acyclovir 800 mg 5 times a day for 5–7 days. Tab Prednisolone from 20 JAN 24. HBOT as an adjuvant therapy was started on 27 Jan 24. He was diagnosed with Left Bell’s palsy House Brackmann IV.

Figure 3.

Showing clinical improvement in the patient condition Pre HBOT and Post 10^th session of HBOT

At discharge lagophthalmos has improved with mild forehead movement, diagnosis Left Bell’s palsy House Brackmann graded III/II.

Case 4

A 54-year-old male reported with sudden onset progressively increasing LMN of facial nerve left side since 28 Jan 24 [Figure 4]. CEMRI BRAIN: incidentally detected pineal cyst He was managed with prednisolone in tapering dose and Tab valcyclovir 800 mg 5 times for 5 days. HBOT started on 31/01/24 as an adjuvant therapy. Diagnosed as House Brackmann grade IV.

Figure 4.

Showing clinical improvement in the patient condition Pre HBOT and Post 10^th session of HBOT

At discharge, lagophthalmos improved House Brackmann grade III.

Case 5

A 30-year-old male, with no known co-morbidity, presented with LMN palsy of the right side of his face since 28/01/24 [Figure 5]. MRI: Brain NAD. He was started on tab prednisolone 40 mg OD. HBOT Started on 31/1/24 as adjuvant therapy. Diagnosis at admission HB grade III individual progressed to grade IV after 9^th session of HBOT individual started showing improvement in lagophthalmos.

Figure 5.

Showing clinical improvement in the patient condition Pre HBOT and Post 13^th session of HBOT

Case 6

A 41-year-old serving male with no co-morbidity reported with chief complaint right LMN Type facial nerve palsy [Figure 6], started on tab acyclovir 800 mg 5 times for 5 days and tab prednisolone 60 mg OD. Improvement in lagophthalmos was seen at 3^rd session. The individual could not complete 10 sessions.

Figure 6.

Showing clinical improvement in the patient condition Pre HBOT and Post 10^th session of HBOT

Case 7

A 26-year-old serving male with no co-morbidity reported with chief complaint right LMN-type facial nerve palsy [Figure 7]. Started on deflacort 75 mg, Tab acyclovir 800 mg 5 times. MRI: NAD. Individual gradually progressed to HOUSEBRACKMANN GRADE IV. The individual was given HBOT as adjuvant therapy on 4/3/24. At the end of the 6^th session, complete recovery was seen of lagophthalmos and frowning.

Figure 7.

Showing clinical improvement in the patient condition Pre HBOT and Post 10^th session of HBOT

He was discharged at Grade III/II HOUSE BRACKMANN.

Results and Discussion

Hyperbaric oxygen therapy (HBOT) has been explored for its potential role in managing Bell’s palsy. HBOT involves breathing pure oxygen in a pressurized room or chamber, which can increase oxygen levels in the body. By delivering oxygen under increased pressure, HBOT aims to enhance the amount of oxygen dissolved in the bloodstream, reaching tissues that are otherwise oxygen-deprived.[1] The rationale behind using HBOT for Bell’s palsy lies in its ability to increase oxygen levels in the body, potentially aiding in tissue repair, reducing inflammation, and improving blood flow to the affected area.[2] Proponents of HBOT suggest that the therapy may help reduce inflammation, improve blood flow, and promote tissue healing, which could potentially benefit individuals with Bell’s palsy. However, the evidence supporting the effectiveness of HBOT for Bell’s palsy is limited and conflicting. Our study uses the key distinction of emphasizing the integration of HBOT with both antiviral and corticosteroid therapies as a combined approach for faster recovery. The study offers a long-term follow-up period of up to 5 months and a detailed case-to-case tracking of clinical improvement.

The findings of our study align with previous research study Racic G et al. (1985),[3] who reported a faster recovery rate in patients treated with HBOT compared to those on steroids alone. The study by Racic G et al.[3] on the use of HBOT in the treatment of Bell’s palsy patients reported full recovery in 95.2% of patients over an average period of 22 days compared to placebo and a 94.4% recovery when compared to steroid prednisolone alone (average recovery duration 23.7 days).[4] However, our study adds new insights by focusing on a longer-term follow-up of up to 5 months and the use of HBOT as a combined treatment rather than as a standalone therapy.

A systematic review by Zhang Y et al. (2022)[1] performed on the effects of HBOT in various neurological conditions, including Bell’s Palsy showed that HBOT had a positive impact on tissue repair and nerve recovery, many studies had small sample sizes, limiting the statistical significance of the results which is also a limitation of the current case series.[5] However, our study is a detailed case-by-case analysis [Figure 8], which presents clear individual recovery trajectories and specific clinical outcomes. Unlike Zhang’s review, which often combined multiple conditions under one analysis, this study is specific to Bell’s Palsy, thus offering a more focused assessment of HBOT’s role in treating this condition.

Figure 8.

Graph representing the recovery of seven patients post-HBOT over time. X-axis represents the number of days since the start of the HBOT sessions and the Y-axis shows the House-Brackmann grade (where lower values represent better recovery)

The study by Collettini et al. (2024) explored the potential of HBOT in otorhinolaryngology and specifically included Bell’s Palsy in their analysis. This study suggested that HBOT could help manage nerve inflammation and enhance tissue healing. However, the authors noted that the evidence was mixed, with some trials showing minimal benefit compared to conventional treatments. Our study shows a more consistent improvement across all patients. One unique finding is that patients with more severe grades of Bell’s Palsy (House-Brackmann Grade IV) showed notable progress to Grade III or even II within 10 to 15 days, reinforcing the notion that HBOT may be more beneficial when combined with conventional therapy [Table 1]. The current study is also distinct because it incorporates a follow-up period (up to 5 months) for long-term recovery evaluation, providing a more comprehensive assessment of sustained improvements.

Table 1.

Listing the available treatment modalities for Bell’s palsy

Pharmacological

- Corticosteroids (e.g., prednisone)

- Antivirals (e.g., acyclovir)

- Analgesics for pain management and artificial tears and lubricants for eye protection

Non-Pharmacological

- Physical therapy for facial exercises

- Eye patching for eye protection

- Massage therapy for muscle relaxation

- Acupuncture for symptom management

Newer Modalities

- Hyperbaric Oxygen Therapy (HBOT)

- Nerve stimulation techniques (e.g., TENS)

- Biofeedback for muscle re-education

- Regenerative therapies (e.g., stem cell therapy)

Our study provides a more comprehensive insight into long-term benefits of HBOT. Several patients showed near-complete recovery at the 5-month mark, suggesting that the effects of HBOT are not just temporary but contribute to sustained nerve function recovery [Table 2].

Table 2.

Summarizing the cases clinical details of the various cases in the case series

Name	Age/sex	Onset of Bell’s palsy	Addn Rx	Co-morbidities	HBOT	HB grade@ admission	HB grade @ discharge	Remarks
Chandan Yadav	28/M	18/10/23	Fluoxetine, prednisolone, acyclovir, Physiotherapy, facial exercise	Severe depression	2.4 ATA for 90 min for 15 days	Grade 4	Grade 2	After 6th session of HBOT, lagophthalmos improved followed by frowning. The angle of deviation of the mouth persisted. 5 month follow-up up a 90% improvement
Santosh Kumar	27/M	09/10/23	Prednisolone, acyclovir, physiotherapy, facial exercise	Nil	2.4 ATA for 90 min for 15 days	Grade 4	Grade 2	After 6th session of HBOT, lagophthalmos improved followed by frowning. The angle of deviation of mouth persisted. 5 months followed 90% improvement
Ravindernath mandal	29/M	19/01/24	Prednisolone, acyclovir, physiotherapy, facial exercise	Nil	2.4 ATA for 90 min for 15 days	Grade 4	Grade 2	After 6th session of HBOT, lagophthalmos improved followed by frowning. The angle of deviation of the mouth persisted.
Sadasiba palauar	52/M	28/01/24	Prednisolone, acyclovir, physiotherapy, facial exercise	Nil	2.4 ATA for 90 min for 15 days	Grade 4	Grade 3	After 6th session of HBOT, lagophthalmos improved. Frowning & Angle of deviation of mouth persisted.
Shaktivel S	30/M	28/01/24	Prednisolone, acyclovir, physiotherapy, facial exercise	Nil	2.4 ATA for 90 min for 15 days	Grade 3	Grade 3	Individual progressed from grade 3 to 4 then from 9th session lagophthalmos started decreasing, complete recovery with maximal force after 13th session
Navdeer singh	41/M	11/02/24	Prednisolone, acyclovir, physiotherapy, facial exercise	Nil	2.4 ATA for 90 min for 15 days	Grade 4	Grade 3	Individual progressed from grade 3 to 4, HBOT started after 6th session complete recovery in lagophthalmos, and frowning appeared.
Pawan	26/M	24/2/23	Prednisolone 60 mg, acyclovir 800mg	Nil	2.4 ATA for 90 min for 15 days	Grade 4	Grade 3	Individual lagophthalmos recovered completely after 6th session.

This study utilizes the House-Brackmann grading system extensively to track improvements. By quantifying the recovery process and correlating it with the number of HBOT sessions, this study provides a more nuanced understanding of the treatment’s efficacy, which many previous studies lack.

Conclusion

Hyperbaric oxygen therapy is an effective adjunct in the treatment of Bell’s Palsy with significantly improved outcomes. Combining these treatment modalities decreases the recovery time of the nerve from the injury. Many other studies have also reported positive outcomes, suggesting that HBOT may lead to quicker recovery, improved facial function, and reduced long-term complications. HBOT shows promise as a potential adjunctive therapy for Bell’s palsy due to its anti-inflammatory and tissue-healing properties, more high-quality research is needed to establish its true effectiveness and optimal role in managing this condition. Healthcare providers should carefully consider individual patient characteristics, disease severity, and available treatment options when deciding whether to incorporate HBOT into the treatment plan for Bell’s palsy.

Conflict of interest

Nil.

Funding Statement

Nil.