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Association of Overweight and Obesity with Bell`s palsy in Children

  • Vivian Kaps
    Correspondence
    Corresponding Author: Vivian Kaps, MD, Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Strasse 40, 37075 Göttingen, Germany. ()
    Affiliations
    Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen Germany
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  • Andreas Leha
    Affiliations
    Department of Medical Statistics, University Medical Center Göttingen, Göttingen Germany
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  • Stina Schiller
    Affiliations
    Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen Germany
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  • Marie Kruizenga
    Affiliations
    Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen Germany

    Department of Internal Medicine and Gastroenterology, Ev. Amalie Sieveking-Krankenhaus, Hamburg Germany
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  • Author Footnotes
    † These authors contributed equally
    Jutta Gärtner
    Footnotes
    † These authors contributed equally
    Affiliations
    Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen Germany
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  • Author Footnotes
    † These authors contributed equally
    Hendrik Rosewich
    Footnotes
    † These authors contributed equally
    Affiliations
    Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen Germany
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  • Author Footnotes
    † These authors contributed equally
Open AccessPublished:November 14, 2022DOI:https://doi.org/10.1016/j.pediatrneurol.2022.11.007

      Abstract

      In the Division of Pediatric Neurology at the University Medical Center Göttingen we observed that many patients with Bell`s palsy are overweight or obese. To evaluate whether overweight and obesity are associated with increased risk of Bell´s palsy in children we conducted this single-centered retrospective study by performing a database search for ICD-10 primary and secondary diagnosis of G51.0 (facial nerve palsy) between January 1, 2010, and December 31, 2020. For risk assessment, patients body mass indices (BMI) were compared with BMI data of controls from a nationwide child health survey.
      In total, 202 patients with peripheral facial nerve palsies (pFP) were included, of which nearly half were classified as Bell´s palsies. 38 % and 24 % of the patients with Bell´s palsy and pFP had a BMI above the 90th percentile. High BMI was associated with statistically increased odds of Bell´s palsy in the group of overweight and obese patients (BMI > 90th percentile; OR, 2.42; 95 % CI, 1.6-3.8; P < 0.001) and solely obese patients (BMI > 97th percentile; OR 2.43; 95 % CI, 1.4-4.3; P = 0.003). In conclusion, we could confirm our observation that overweight and obesity are associated with increased risk of Bell´s palsy in children.

      Keywords

      Introduction

      Obesity is an increasing and major health problem not only in adulthood but also in childhood and adolescence worldwide [
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      Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the global burden of disease study.
      ]. It is implicated in the development of chronic diseases associated with the metabolic syndrome such as hypertension, type 2 diabetes and cardiovascular disease [
      • Lee E.Y.
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      • Weihrauch-Blüher S.
      • Schwarz P.
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      ]. Recently, several studies gave critical evidence of overweight and obesity also playing a role in inflammatory and autoimmune diseases in adults [
      • Versini M.
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      Obesity in autoimmune diseases: Not a passive bystander.
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      Obesity and diabetes- Not only a simple link between two epidemics.
      ,
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      • et al.
      Overweight, obesity, and the likelihood of achieving sustained remission in early rheumatoid arthritis: Results from a multicenter prospective cohort study.
      ,
      • Munger K.L.
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      Body size and risk of MS in two cohorts of US women.
      ] and children [
      • Umano G.R.
      • et al.
      Pediatric Obesity and the Immune System.
      ,
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      • Soheili S.
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      Association of childhood obesity and the immune system: A systematic review of reviews.
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      • Huppke B.
      • et al.
      Association of obesity with Multiple Sclerosis risk and response to First-line disease modifying drugs in children.
      ,
      • Rasul T.
      • Frederiksen J.L.
      Link between overweight/obese in children and youngsters and occurrence of multiple sclerosis.
      ].
      Bell´s palsy, defined as an acute peripheral facial nerve palsy (pFP) of unknown cause, is the most common cranial nerve palsy with an incidence of more than 20 per 100,000 person-years in adults and a lower incidence of approximately 6 per 100,000 person-years in children [
      • Morales D.R.
      • Donnan P.T.
      • Daly F.
      • Van Staa T.
      • Sullivan F.M.
      Impact of clinical trial findings on Bell’s palsy management in general practice in the UK 2001–2012: interrupted time series regression analysis.
      ,
      • Rowlands S.
      • Hooper R.
      • Hughes R.
      • Burney P.
      The epidemiology and treatment of Bell’s palsy in the UK.
      ,
      • Jackson C.G.
      • Von Doersten P.G.
      The facial nerve.
      ,
      • Katusic S.K.
      • Beard C.M.
      • Wiederholt W.C.
      • Bergstralh E.J.
      • Kurland L.T.
      Incidence, clinical features, and prognosis in Bell’s palsy, Rochester, Minnesota.
      ]. Depending on the geographical region, Bell´s palsy accounts for up to one half of all pFP in children [
      • Papan C.
      • et al.
      Infectious causes of peripheral facial nerve palsy in children-a retrospective cohort study with long-term follow-up.
      ,
      • Jenke A.C.
      • Stoek L.M.
      • Zilbauer M.
      • Wirth S.
      • Borusiak P.
      Facial palsy: Etiology, outcome and management in children.
      ]. Whereas the causes of non-idiopathic pFP are numerous, including infectious, neoplastic, traumatic or congenital diseases, the etiology of Bell´s palsy is not fully understood yet. Earlier studies suggested a correlation with the reactivation of a herpes simplex virus 1 (HSV 1)- infection in neural ganglia [
      • Baringer J.R.
      Herpes simplex virus and Bell palsy.
      ,
      • Schirm J.
      • Mulkens P.S.
      Bell’s palsy and herpes simplex virus.
      ,
      • Adour K.K.
      • Bell D.N.
      • Hilsinger Jr., R.L.
      Herpes simplex virus in idiopathic facial paralysis (Bell palsy).
      ], though this is discussed controversially in recent studies [
      • Linder T.
      • Bossart W.
      • Bodmer D.
      Bell’s palsy and herpes simplex virus: Fact or mystery?.
      ,
      • Kennedy P.G.
      Herpes simplex virus type 1 and Bell's palsy-a current assessment of the controversy.
      ]. Another hypothesis is that Bell´s palsy occurs due to a cell-mediated autoimmune reaction, which may be prompted by a viral infection beforehand and is described as a mononeuritic variant of Guillain-Barré syndrome, respectively [
      • Aviel A.
      • Ostfeld E.
      • Burstein R.
      • Marshak G.
      • Bentwich Z.
      Peripheral blood T and B lymphocyte subpopulations in Bell’s palsy.
      ,
      • Charous D.I.
      • Saxe B.I.
      The Landry–Guillain–Barré syndrome.
      ,
      • Abramsky O.
      • Webb C.
      • Teitelbaum D.
      • Arnon R.
      Cellular immune response to peripheral nerve basic protein in idiopathic facial paralysis (Bell’s palsy).
      ]. A few studies addressed possible risk factors for Bell´s palsy apart from the well-known risk in pregnancy [
      • Hilsinger R.L.
      • Adour K.K.
      • Doty H.E.
      Idiopathic facial paralysis, pregnancy, and the menstrual cycle.
      ] and found diabetes and hypertension to be related [
      • Riga M.
      • Kefalidis G.
      • Danielides V.
      The role of diabetes mellitus in the clinical presentation and prognosis of Bell palsy.
      ,
      • Adour K.K.
      • Wingerd J.
      • Doty H.E.
      Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis (Bell’s palsy).
      ,
      • Savadi-Oskouei D.
      • Abedi A.
      • Sadeghi-Bazargani H.
      Independent role of hypertension in Bell`s palsy: A case-control study.
      ]. Recently So Young Kim et al. found a proportionally positive association of BMI and occurrence of Bell´s palsy in a retrospective study screening the ≥ 40-year-old population of the Korean National Health Insurance cohort and postulated that obesity is a risk factor for Bell´s palsy [
      • Kim S.Y.
      • Oh D.J.
      • Park B.
      • Choi H.G.
      Bell’s palsy and obesity, alcohol consumption and smoking: A nested case-control study using a national health screening cohort.
      ].
      To the best of our knowledge there are no studies investigating the association of overweight and obesity with Bell´s palsy in a pediatric setting. In the Division of Pediatric Neurology at the University Medical Center Göttingen we observed that many patients with Bell`s palsy are overweight or obese. This study was conducted to evaluate whether overweight and obesity are associated with increased risk of Bell´s palsy in children.

      Methods

      This single-center retrospective study of facial nerve palsies (FP) in children was carried out at the Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen. The study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University Medical Center in Göttingen (internal reference number: 5/12/17). All data were derived from database and medical record review and were deidentified; thus, informed consent was waived by the University Medical Center Göttingen.
      We performed a database search for ICD-10 primary and secondary diagnosis of G51.0 (facial nerve palsy) between January 1, 2010, and December 31, 2020. After precise analysis of the past and present medical history and clinical, laboratory and radiological findings, we excluded adult patients ≥ 18 years old, patients with central FP, insufficient documentation and those who received the ICD-10 code G51.0 but did not present a FP by definition.
      We recorded age, sex, time from manifestation to presentation at the hospital, the degree of pFP via House-Brackmann (HB) score at presentation, the presence of associated diseases including overweight and obesity, the etiology of pFP and documented controls if conducted. We evaluated the HB score retrospectively based on the clinical examination in the medical record. Documentation of solely “incomplete peripheral facial nerve palsy” was rated as HB score 3.
      Bell´s palsy was diagnosed in case of proven absence of any other causes, including infectious, neoplastic, iatrogenic (postoperative), traumatic or inflammatory (Multiple sclerosis, Guillain-Barré syndrome) diseases.
      Overweight and obesity was diagnosed using the Body-Mass-Index (BMI) category recommended by the European Childhood Obesity Group with overweight being defined as BMI above the 90th to 97th percentile and obesity as BMI above the 97th percentile [
      • Poskitt E.M.
      Defining childhood obesity: the relative body mass index (BMI).
      ]. We did not subdivide in obese and extremely obese patients, meaning that a BMI percentile above 97 was classified as obese. BMI percentiles were standardized for age and sex using the Kromeyer-Hauschild references recommended for German children [
      • Kromeyer-Hauschild K.
      • et al.
      Perzentile für den Body-mass-Index für das Kindes- und Jugendalter unter Heranziehung verschiedener deutscher Stichproben.
      ]. For risk assessment, patients BMI percentiles were compared with the BMI data of 3.561 children aged 3 to 17 years who participated in a nationwide study surveying the general health status of children and adolescents in Germany conducted by the Robert-Koch-Institute (RKI) from 2014-2017 named “KiGGS Welle 2” [
      • Schienkiewitz A.
      • Brettschneider A.K.
      • Damerow S.
      • Schaffrath Rosario A.
      Overweight and obesity among children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends.
      ]. BMI percentiles in KiGGS Welle 2 were equally standardized according to the Kromeyer-Hauschild reference values. No further increase in prevalence of overweight and obesity in comparison to the first KiGGS survey conducted from 2003-2006 was observed in the second survey [
      • Schienkiewitz A.
      • Brettschneider A.K.
      • Damerow S.
      • Schaffrath Rosario A.
      Overweight and obesity among children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends.
      ].

      Statistical Analysis

      We reported mean, standard deviation, median and range for continuous and ordinal data.
      For statistical analysis we used IBM SPSS Statistics 27 (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). Frequencies, including 95 % Clopper-Pearson CIs, were reported for overweight and obese patients (BMI > 90th Percentiles) and solely obese patients (BMI > 97th Percentiles) with Bell´s palsy and pFP in general, including Bell´s palsies, respectively. Comparisons between our cohort and the control cohort from the RKI were performed using the Fisher exact test to determine statistical relevance with two-sided P < 0.05 considered statistically significant. For risk assessment we calculated OR with 95% CIs.

      Data Availability

      The dataset generated and analyzed during the current study is available from the corresponding author on reasonable request. The dataset of the control cohort from the Robert-Koch-Institut (RKI) is available in the RKI repository (https://www.rki.de/EN/Content/Health_Monitoring/JoHM_en/2018/JoHM_en_Inhalt_18_01.html).

      Results

      Database search for primary and secondary ICD-10 diagnosis G51.0 (facial nerve palsy) yielded 265 cases, of which we excluded 63 patients (Fig. 1). Of the 202 pFP included, nearly half
      Figure thumbnail gr1
      Figure 1Patient Selection and Etiology of Peripheral Facial Nerve Palsies (pFP).
      (49 %, n=99) were diagnosed with Bell´s palsy and the other half (51%, n=103) were classified as non-idiopathic pFP. The latter included 56 patients (28 % of all pFP) with confirmed neuroborreliosis via cerebral spinal fluid (CSF) analysis, 13 patients with postoperative pFP mostly after tumor resections, 8 patients suffering from an otitis-associated pFP and 8 patients with pathologic CSF constellation (2 patients with zoster oticus, 4 patients with an isolated CSF pleocytosis, 2 patients were positively tested for herpes simplex virus (HSV)-DNA/elevated HSV-antibody indices in CSF).
      In comparison to patients with pFP in general, patients with Bell´s palsy were on average two years older at diagnosis with mean (SD) age in patients with Bell`s palsy of 11.6 (4.3) years and mean (SD) age in patients with pFP, including patients with Bell´s palsy of 9.7 (4.7) years (Table 1). There was no sexual preference in either Bell´s palsy or all pFP patients, and the House-Brackmann (HB) score at presentation did not differ between the groups with a mean (SD) score of 3.9 (0.4).
      Table 1Characteristics of the cohort (Peripheral facial nerve palsy versus Bell´s palsy)
      Peripheral facial nerve palsy including Bell´s palsy
      VariableTotal cohortFemaleMale
      No./Total No. (%)20297/202 (48)105/202 (52)
      Age in y, Mean (SD)9.7 (4.7)9.6 (4.6)9.8 (4.8)
      Median (range)10 (1 mo.-17)10 (9 mo.-17)10 (1 mo.-17)
      HB a, Mean (SD)3.9 (0.4)3.8 (0.4)3.9 (0.3)
      Median (range)4 (2-5)4 (2-5)4 (3-5)
      BMI > 90th Percentile
      No./Total No. (%)48/202 (24)16/97 (16)32/105 (30)
      Age in y, Mean (SD)12.2 (3.7)12.2 (3.1)12.2 (4.0)
      Median (range)13 (1-17)12.5 (7-17)14 (1-17)
      HB, Mean (SD)3.8 (0.4)3.8 (0.4)3.9 (0.4)
      Median (range)4 (3-4)4 (3-4)4 (3-4)
      Bell`s palsy
      VariableTotal cohortFemaleMale
      No./Total No. (%)9951/99 (52)48/99 (48)
      Age in y, Mean (SD)11.6 (4.3)11.5 (4.1)11.8 (4.5)
      Median (range)13 (9 mo.-17)12 (9 mo.-17)14 (1-17)
      HB, Mean (SD)3.9 (0.4)3.9 (0.4)3.9 (0.3)
      Median (range)4 (3-5)4 (3-5)4 (3-4)
      BMI > 90th Percentile
      No./Total No. (%)38/99 (38)14/51 (27)24/48 (50)
      Age in y, Mean (SD)12.2 (4.0)12.6 (3.1)12.0 (4.5)
      Median (range)13.5 (1-17)12.5 (8-17)14 (1-17)
      HB, Mean (SD)3.8 (0.4)3.7 (0.5)3.9 (0.3)
      Median (range)4 (3-4)4 (3-4)4 (3-4)
      Abbreviations: pFP, peripheral facial nerve palsy HB, House-Brackmann score; BMI, body mass index, kg/m2; SD, standard deviation. a HB score was evaluated retrospectively based on the clinical examination in the medical record. In 34 and 11 cases the degree of facial nerve palsy of patients with pFP and Bell´s palsies were not sufficiently described and were taken out of the HB cohort. Documentation of “incomplete peripheral facial nerve palsy” was rated as HB score 3.
      38 % (38/99) and 24 % (48/202) of the patients with Bell´s palsy and pFP had a BMI above the 90th percentile, with boys having a larger proportion in both groups (24 % boys vs. 14 % girls of patients with Bell`s palsy and 16 % boys vs. 8 % girls of patients with pFP in general). The mean age of diagnosis of overweight and obese patients was 12.2 years in both groups, with no major differences between the sexes (Table 1). Interestingly only one-fifth of the patients with pFP and overweight or obesity were under the age of 10 years (10/48 in total numbers). Overweight and obese patients had a similar degree of facial nerve palsy as non-overweight or obese patients with a mean HB (SD) score at presentation of 3.8 (0.4).
      Of the patients with non-idiopathic pFP (103/202) only 10 were overweight or obese, which is why we included the patients with Bell´s palsy in the group of patients with pFP in general. Figure 2 shows the distribution of age, sex and BMI including BMI-percentiles of patients with Bell´s palsy and non-idiopathic pFP.
      Figure thumbnail gr2
      Figure 2Distribution of age, sex and BMI of patients with Bell´s palsy (BP) and non-idiopathic pFP (n-iFP).
      To evaluate statistical significance, we compared our groups with the age groups from the RKI with the highest prevalence of overweight and obesity (20,5 % of the 11-13 years old) and obesity only (8,5 % of the 14-17 years old) (Table 2). High BMI was associated with statistically increased odds of Bell´s palsy in the overweight (BMI > 90th percentile; OR, 2.42; 95 % CI, 1.6-3.8; P < 0.001) and obese group (BMI > 97th percentile; OR 2.43; 95 % CI, 1.4-4.3; P = 0.003). The statistical significance was not equally achieved for boys and girls due to a significantly higher overweight and obesity rate in boys (BMI > 90th percentile) and a comparable obesity rate (BMI > 97th percentile) in boys and girls. Boys with a BMI > 90th percentile had an OR of 3.82 (95 % CI, 2.1-7.1; P < 0.001) and a lower OR of 2.00 (95 % CI, 0.9-4.6; P = 0.120) in the obese group only. In contrast, the odds for Bell´s palsy in the female cohort were statistically significant in the obese but not the overweight and obese group (BMI > 97th percentile; OR, 2.89; 95 % CI, 1.3-6.2; P = 0.009 vs. BMI > 90th percentile; OR, 1.52; 95 % CI, 0.8-2.9; P = 0.206). The proportion of overweight or obese patients in the pFP cohort in general was not statistically significant in either girls or boys, nor in the overall cohort (Table 2).
      Table 2Odds of pediatric risk for Bell´s palsy and Peripheral Facial Nerve Palsy
      Controls with BMI

      > 90th Percentile (11-13 y)
      For the control group we used data from the “KiGGS Welle 2” study from the Robert-Koch-Institute (RKI). We compared our data with the age groups from the RKI with the highest prevalences of overweight and obesity (BMI > 90th Percentile, 11-13 y, 167/816 in total numbers) and obesity (BMI > 97th Percentile, 14-17 y, 81/955 in total numbers) [34].
      Patients with Bell´s palsy with BMI > 90th PercentilePatients with Peripheral facial nerve palsy with BMI > 90th Percentile
      Variable%, (95% CI)% (95% CI)No./Total NoOR (95% CI)P Value% (95% CI)No./Total NoOR (95% CI)P Value
      Female20.0 (15-26.2)27.5 (15.7-41.1)14/511.52 (0.8-2.9)0.20616.5 (9.3-23.7)16/970.79 (0.4-1.4)0.478
      Male21.1 (15.5-28.1)50.0 (35.4-64.6)24/483.82 (2.1-7.1)<0.001
      Fisher exact test; significant at P < 0.05.
      30.5 (21.9-39.0)32/1051.65 (1.0-2.7)0.050
      Total20.5 (17.6-23.2)38.4 (28.3-47.5)38/992.42 (1.6-3.8)< 0.001
      Fisher exact test; significant at P < 0.05.
      23.8 (18.3-29.7)48/2021.21 (0.8-1.7)0.336


      Controls with BMI

      > 97th Percentile (14-17 y)
      For the control group we used data from the “KiGGS Welle 2” study from the Robert-Koch-Institute (RKI). We compared our data with the age groups from the RKI with the highest prevalences of overweight and obesity (BMI > 90th Percentile, 11-13 y, 167/816 in total numbers) and obesity (BMI > 97th Percentile, 14-17 y, 81/955 in total numbers) [34].
      Patients with Bell´s palsy with BMI > 97th PercentilePatients with Peripheral facial nerve palsy with BMI > 97th Percentile
      Variable%, (95% CI)% (95% CI)No./Total NoOR (95% CI)P Value% (95% CI)No./Total NoOR (95% CI)P Value
      Female7.7 (5.2-11.4)19.6 (9.8-31.4)10/512.89 (1.3-6.2)0.009
      Fisher exact test; significant at P < 0.05.
      11.3 (5.2-18.6)11/971.51 (0.7-3.1)0.235
      Male9.2 (6.2-13.4)16.7 (8.3-27.1)8/482.00 (0.9-4.6)0.12010.5 (4.8-16.2)11/1051.17 (0.6-2.4)0.708
      Total8.5 (6.7-10.3)18.2 (11.1-26.3)18/99 32.43 (1.4-4.3)0.003
      Fisher exact test; significant at P < 0.05.
      10.9 (6.4-15.3)22/2021.34 (0.8-2.2)0.274
      Abbreviations: pFP, peripheral facial nerve palsy; BMI, body mass index, kg/m2; OR, odds ratio.
      Fisher exact test; significant at P < 0.05.
      a For the control group we used data from the “KiGGS Welle 2” study from the Robert-Koch-Institute (RKI). We compared our data with the age groups from the RKI with the highest prevalences of overweight and obesity (BMI > 90th Percentile, 11-13 y, 167/816 in total numbers) and obesity (BMI > 97th Percentile, 14-17 y, 81/955 in total numbers) [
      • Schienkiewitz A.
      • Brettschneider A.K.
      • Damerow S.
      • Schaffrath Rosario A.
      Overweight and obesity among children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends.
      ].
      To see whether there were other possibly associated pre-existing conditions in patients with Bell´s palsy we checked our files regarding past and present medical history. 6 of the patients with Bell´s palsy had documented recurrent facial nerve palsies, 4 of them had a BMI > 90th percentile. 5 patients had autoimmune-related conditions such as neurodermitis, bronchial asthma and psoriasis of which 3 patients had a BMI > the 90th percentile. Two patients had an euthyroid goiter, two a hypothyreoidism, in each case one patient was obese. Three patients had arterial hypertension, only one patient was obese. Interestingly, there was a positive family history of pFP in 5 patients with Bell´s palsy. Family history was not documented on a regular basis.
      Of the 202 patients with pFP, 68 patients had a documented clinical follow-up in our department and about half (54 %, n = 37) were patients with Bell´s palsy. For standardization we compared patients who had a clinical follow-up < 120 days after manifestation and were not treated with prednisolone (n = 41 patients with pFP) (Table 3). Of these patients 63 % (n = 26) had a HB score of 1-2, 37 % (n = 15) had a HB score of 3-4. The distribution was comparable to the group of patients with Bell´s palsy only. 23 patients with pFP and a BMI > 90th percentile had a clinical follow-up, 13 within 120 days after manifestation and without treatment with prednisolone. Of these, 77 % (n 10) had a HB score of 1-2. The distribution was again comparable to the group of patients with Bell´s palsy only. Of the 34 patients treated with prednisolone, only 12 patients had a documented clinical follow-up within 120 days, with 75 % (9) presenting a HB score of 1-2.
      Table 3Outcome of Patients with pFP and Bell´s palsy (Clinical follow-up < 120 days after manifestation)
      Patients (n)
      For standardization none of these patients were treated with prednisolone.
      HB score 1-2, n (%)
      Documentation of “incomplete peripheral facial nerve palsy” was rated as HB score 3.
      HB score 3-4, n (%)
      pFP: 4126 (63)15 (37)
      Bell´s palsy: 2617 (65)9 (35)
      BMI > 90th percentile
      pFP: 1310 (77)3 (23)
      Bell´s palsy: 107 (70)3 (30)
      Abbreviations: pFP, peripheral facial nerve palsy; BMI, body mass index, kg/m2; HB, House-Brackmann score.
      a For standardization none of these patients were treated with prednisolone.
      b Documentation of “incomplete peripheral facial nerve palsy” was rated as HB score 3.

      Discussion

      This retrospective single-center database research from 2010 to 2020 yielded a large cohort of 202 individually selected patients with pFP after comprehensive medical data analysis. Nearly 50 % of the patients were diagnosed with Bell´s palsy after exclusion of any other causes. The other half was classified as non-idiopathic pFP and was associated with an infectious disease in 70 % of the cases, mainly neuroborreliosis. The distribution is comparable to other studies focussing on the etiology of pFP in children in Germany [
      • Papan C.
      • et al.
      Infectious causes of peripheral facial nerve palsy in children-a retrospective cohort study with long-term follow-up.
      ,
      • Jenke A.C.
      • Stoek L.M.
      • Zilbauer M.
      • Wirth S.
      • Borusiak P.
      Facial palsy: Etiology, outcome and management in children.
      ]. Girls and boys were equally affected and mean age of patients with pFP of 9.7 years was again comparable to the results in the literature [
      • Papan C.
      • et al.
      Infectious causes of peripheral facial nerve palsy in children-a retrospective cohort study with long-term follow-up.
      ,
      • Jenke A.C.
      • Stoek L.M.
      • Zilbauer M.
      • Wirth S.
      • Borusiak P.
      Facial palsy: Etiology, outcome and management in children.
      ,
      • Hanci F.
      • Türay S.
      • Bayraktar Z.
      • Kabakuş N.
      Childhood facial palsy: Etiologic factors and clinical findings, an observational retrospective study.
      ,
      • Lee Y.
      • SooYoon H.
      • Yeo S.G.
      • Lee E.H.
      Factors associated with fast recovery of Bell palsy in children.
      ,
      • Karatoprak E.
      • Yilmaz S.
      Prognostic factors associated with recovery in children with Bell’s palsy.
      ], which confirms the representative character of our cohort.
      The pathophysiology of Bell´s palsy remains unknown, but several predisposing factors have been investigated in adults such as pregnancy, hypertension and diabetes [
      • Hilsinger R.L.
      • Adour K.K.
      • Doty H.E.
      Idiopathic facial paralysis, pregnancy, and the menstrual cycle.
      ,
      • Riga M.
      • Kefalidis G.
      • Danielides V.
      The role of diabetes mellitus in the clinical presentation and prognosis of Bell palsy.
      ,
      • Adour K.K.
      • Wingerd J.
      • Doty H.E.
      Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis (Bell’s palsy).
      ,
      • Savadi-Oskouei D.
      • Abedi A.
      • Sadeghi-Bazargani H.
      Independent role of hypertension in Bell`s palsy: A case-control study.
      ] as well as obesity [
      • Kim S.Y.
      • Oh D.J.
      • Park B.
      • Choi H.G.
      Bell’s palsy and obesity, alcohol consumption and smoking: A nested case-control study using a national health screening cohort.
      ]. No study to date has investigated the association of overweight and obesity with Bell´s palsy in children. We found that the rate of patients with Bell's palsy who were overweight and/or obese was significantly higher than that of healthy controls. Thereby, the risk of developing Bell's palsy is increased more than twofold with overweight and/or obesity. A limitation to the study is the comparison of our cohort with an external control cohort from the RKI. The prevalence of overweight and obesity (BMI > 90th percentile) in the control cohort, maintaining 3.561 children aged 3 to 17 years, was 15.4 % and of obesity alone (BMI > 97th percentile) 5.9 %, each rising with age and no relevant gender imbalances [
      • Schienkiewitz A.
      • Brettschneider A.K.
      • Damerow S.
      • Schaffrath Rosario A.
      Overweight and obesity among children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends.
      ]. Overweight and obese patients with Bell´s palsy in our cohorts had a mean age of 12.2 years with a standard deviation of 4. We compared our cohorts with the age groups from the RKI with the highest prevalence of overweight and obesity (20,5 % of the 11-13 years old) and obesity (8,5 % of the 14-17 years old). Interestingly, the rate of boys with Bell´s palsy and a BMI > 90th percentile almost doubled the rate of overweight and obese girls with Bell`s palsy (50% vs. 27,5%), while there were no statistically significant gender differences in the prevalence of overweight and obesity in the control cohort. In contrast, the proportion of obese girls and boys with a BMI above the 97th percentile was comparable, with the rate of obese girls even being slightly higher (19.6 % vs. 16.7 %). Taking that distribution into account, the statistical significance differed between the sexes and led to the conclusion that the threshold for developing Bell´s palsy associated with a higher BMI appears to be lower in boys than in girls.
      The rates of overweight and obese patients as well as exclusively obese patients generally did not reach statistical significance in the cohorts of patients with pFP, which implies the significance of a high BMI only in connection with Bell's palsy. Due to the fact that overweight and obesity are related to metabolic disorders such as hypertension and diabetes not only in adults but also in children [
      • Pulgaron E.R.
      • Delamater A.M.
      Obesity and type 2 diabetes in children: Epidemiology and treatment.
      ,
      • Wühl E.
      Hypertension in childhood obesity.
      ,
      • Polsky S.
      • Ellis S.L.
      Obesity, insulin resistance, and type 1 diabetes mellitus.
      ] and that these comorbidities were associated with Bell´s palsies in adults [
      • Chobot A.
      • Górowska-Kowolik K.
      • Sokołowska M.
      • Jarosz-Chobot P.
      Obesity and diabetes- Not only a simple link between two epidemics.
      ,
      • Riga M.
      • Kefalidis G.
      • Danielides V.
      The role of diabetes mellitus in the clinical presentation and prognosis of Bell palsy.
      ,
      • Adour K.K.
      • Wingerd J.
      • Doty H.E.
      Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis (Bell’s palsy).
      ,
      • Savadi-Oskouei D.
      • Abedi A.
      • Sadeghi-Bazargani H.
      Independent role of hypertension in Bell`s palsy: A case-control study.
      ], we reviewed our files regarding pre-existing conditions in the cohort of patients with Bell´s palsy. We found three patients with documented arterial hypertension of which only one patient was obese. There was no patient with concomitant diabetes mellitus. Due to the retrospective nature of the study, we were only able to assess documented and already diagnosed diseases and were not able to measure glycated hemoglobin (HbA1c) or long-term blood pressure in order to diagnose or uncover any preliminary stages of diabetes or hypertension. Apart from that, 5 patients were diagnosed with autoimmune diseases such as neurodermitis, bronchial asthma and psoriasis, of which 3 patients had a BMI > the 90th percentile. It is also noteworthy that 6 of the patients with Bell´s palsy had documented recurrent facial nerve palsies, of which 4 had a BMI > 90th percentile, which accounted for 11 % of all overweight or obese patients with Bell´s palsy. This may lead to the conclusion that overweight or obese patients are at greater risk for recurrent Bell´s palsies although more studies are needed.
      Choi et al. investigated the association of obesity and recovery from Bell´s palsy and found no differences between weight categories and initial degree of facial nerve palsy, but found that obesity and underweight reduce the ultimate recovery rate of patients with Bell´s palsy in a cohort of adults and children in Korea [
      • Choi S.A.
      • et al.
      Association between recovery from Bell’s palsy and body mass index.
      ]. In line with the first observation, the initial degree of facial nerve palsy in overweight or obese patients did not differ from the rest of the cohort in our study. Of the very limited comparable data from controls in our clinic, no major differences in recovery rates for overweight or obese patients compared to non-overweight or obese patients were detectable, but this association clearly requires more reliable data for investigation.
      This study confirmed that overweight or obesity increased the odds for Bell´s palsy not only in adult patients but also in obese girls and overweight and obese boys.

      Uncited reference

      • Greco A.
      • et al.
      Bell’s palsy and autoimmunity.
      .

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