The Laryngoscope

C 2013 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Neutrophil-to-Lymphocyte Ratio as a Novel-Potential

Marker for Predicting Prognosis of Bell Palsy

Abdulkadir Bucak; Sahin Ulu; Serdar Oruc; Fatih Yucedag, PhD;

Mustafa Said Tekin, MD; Fatma Karakaya, MD; Abdullah Aycicek

Objectives/Hypothesis: Bell palsy can be defined as an idiopathic, acute, facial nerve palsy. Although the pathogenesis
of Bell palsy is not fully understood, inflammation seems to play important role. Neutrophil-to-lymphocyte (NLR) ratio was
defined as a novel potential marker to determine inflammation and it is routinely measured in peripheral blood. Our goal
was to investigate the relationship between Bell palsy and inflammation by using NLR.
Study Design: Retrospective study.
Methods: The 54 patients who were followed up for Bell palsy for a period of 1 to 3 years, along with 45 age- and sex-
matched controls, were included in the study. An automated blood cell counter was used for NLR measurements. All patients
were treated with prednisone, 1 mg/kg per day with a progressive dose reduction. Patients were classified according to the
House-Brackmann grading system at posttreatment period. Those with House-Brackmann grade I and grade II were regarded
as satisfactory recovery; and those with House-Brackmann grade III to grade VI were regarded as nonsatisfactory recovery.
Results: The mean NLR and neutrophil values in patients with Bell palsy were significantly higher than in the control
group (P 5 0.001 and P < 0.001, respectively). In addition, NLR levels were higher in nonsatisfactory recovered patients com-
pared with satisfactory recovered ones (P < 0.001).
Conclusion: This is the first study investigating the relationship between NLR levels and Bell palsy and its prognosis.
Our result suggest that while evaluating Bell palsy patients, NLR might be taken into account as a novel potential marker to
predict the patients prognosis.
Key Words: Facial nerve, Bell palsy, prognosis, inflammatory marker, neutrophil, neutrophil-to-lymphocyte ratio.
Level of Evidence: 3b.
Laryngoscope, 124:16781681, 2014

INTRODUCTION
The pathogenesis of Bell palsy is not fully under-
stood; however, inflammation and viral infections seem
to play an important role.1,2 Inflammatory reaction com-
presses the facial nerve in the fallopian canal, particu-
larly in the labyrinthine segment.3
Because it is difficult to predict a prognosis in the
early stage of the disease, a variety of clinical tests have
been introduced. Electrophysiological tests are in use as
the main prognostic test for facial nerve paralysis. These
tests include electroneuronography (ENoG), nerve excit-
ability test, electromyography (EMG), blink reflex, and
the stapedial muscle reflex. Among these, ENoG and
EMG usefulness for predicting the prognosis has been
proven.46 However, most of these tests must take place
during a specific time period; thus, they are not suitable
for practical use.
White blood cell (WBC) count and its subtypes are
known as classic inflammatory markers, especially in cardi-
ovascular diseases.7 Neutrophil-to-lymphocyte ratio (NLR)
has been defined as a novel potential marker to determine
inflammation and can be measured routinely in peripheral
blood without any cost. Also, in recent studies NLR has
been introduced as a potential marker to determine inflam-
mation in cardiac and noncardiac disorders.812
To our knowledge, NLR values in Bell palsy and role
in the prognosis of this disease have not been investigated.
Based on this background, we aimed to investigate the rela-
tionship between Bell palsy and inflammation by using
NLR, which is a new method that is measured routinely in
complete blood count (CBC) tests without any cost.

From the Department of Otolaryngology (A.B., S.U., F.Y., M.S.T., A.A.);
and Department of Neurology (S.O., F.K.), Afyon Kocatepe University,
Faculty of Medicine, Afyonkarahisar, Turkey.
Editors Note: This Manuscript was accepted for publication
November 26, 2013.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Abdulkadir Bucak, Assist. Professor,
Department of Otolaryngology, Afyon Kocatepe University, Faculty of
Medicine, Ali Cetinkaya Kampusu Tp Fakultesi Izmir Karayolu 8.km
03200, Afyonkarahisar, Turkey. E-mail: abdulkadirbucak@yahoo.com
DOI: 10.1002/lary.24551
MATERIALS AND METHODS
The present study was conducted in the Otorhinolaryngol-
ogy and Neurology Clinics of Afyon Kocatepe University Faculty
of Medicine Hospital between January 2010 and March 2013.
The study protocol was approved by the ethics committee of
Afyon Kocatepe University Faculty of Medicine and was con-
ducted in accordance with the ethical principles described by
the Declaration of Helsinki. A uniform consent was obtained
from all the groups. The patient files were scanned; 54 patients
who were followed up due to Bell palsy for a period of 1 to 3
years by otorhinolaryngology and neurology clinics and 45

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1678
 TABLE I.
The Characteristics and the Laboratory Data of the Groups.
Mean Value
Variables Patient Group Control Group P Value

Age 43.11 6 18.12 48.33 6 5.65 NS

Gender (%) male 27 (50) 18 (40) NS
female 27 (50) 27 (60)
Neutrophil 5.86 6 2.38 3.94 6 1.12 <0.001
Lymphocyte 2.51 6 1.38 2.27 6 0.56 NS
NLR 2.69 6 1.48 1.82 6 0.79 0.001
Monocyte 0.62 6 0.29 0.64 6 0.62 NS
White blood cell 8.94 6 2.86 6.96 6 1.31 < 0.001

NLR 5 neutrophil-to-lymphocyte; NS 5 not significant.

age-matched and sex-matched controls were included in the

study. The patients were classified according to the House-
Brackmann grading system at pretreatment and posttreatment
period. At posttreatment period, the patients with House-
Brackmann grade I and II were regarded as satisfactory recov-
ery, and House-Brackmann grade III to grade VI were regarded
as nonsatisfactory recovery. The 13 patients with nonsatisfac-
tory recovery, despite minimum follow-up at 1 year, were
invited to the hospital and an EMG test was carried out. The
routine pretreatment CBC test of patients were recorded.
Those patients who had any acute inflammation or infec-
tion, pneumonia, acute or chronic renal failure, chronic liver
disease, chronic obstructive pulmonary disease, obstructive
sleep apnea, connective tissue disease, inflammatory bowel dis-
ease, current smoking, or active otologic disease were excluded
from the study. The patients were evaluated with gadolinium-
enhanced MRI or CT with the intention to rule out additional
otologic diseases. All the patients were treated with corticoste-
roids (at an initial dose of prednisone of 1 mg/kg/day), with a
gradual dose reduction maintained for at least 2 weeks.
Hematologic Analyses
NLR was calculated as a simple ratio between the abso-
lute neutrophil and the absolute lymphocyte counts. An auto-
mated blood cell counter was used for CBC measurements
(Sysmex XT 2000i, Kobe, Japan). All samples were run in dupli-
cate, and the mean values were used for statistical analysis.
Fig. 1. The mean NLR values of the patients with Bell palsy and the
control group. NLR 5 neutrophil-to-lymphocyte. [Color figure can be
viewed in the online issue, which is available at www.laryngoscope.
com.]
Bell palsy was 27:27, whereas it was 18:27 for the con-
trol group. Age and sex distributions of the groups were
both similar. All of the characteristics of the groups and
the laboratory data are outlined in Table I.
The mean neutrophil values of Bell palsy patients
were 5.86 6 2.38 and 3.94 6 1.12 in the control group.
The mean neutrophil values in patients with Bell palsy
were significantly higher than in the control group
(P <0.001). The mean lymphocyte values of Bell palsy
patients were 2.51 6 1.38 and 2.27 6 0.56 in the control
group. The difference was not statistically significant
(P > 0.05).
The mean NLR values were 2.69 6 1.48 in Bell palsy
patients and 1.82 6 0.79 in the control group. The mean
NLR values in patients with Bell palsy were significantly
higher than in the control group (P 5 0.001) (Fig. 1).

Statistical Analysis
Continuous variables were presented as mean 6 SD, and
categorical variables were expressed as percentage. Kolmogorov-
Smirnov test was used to evaluate the distribution of variables;
students t test was used for continuous variables for those with
normal distribution; Mann-Whitney U test was used for contin-
uous variables for those without normal distribution; and Chi-
square test was used for categorical variables. Pearson correla-
tion analysis was used to assess the relationships. P < 0.05
value was accepted as significant level. For statistical calcula-
tions, SPSS statistical software (SPSS for Windows, version
17.0; SPSS Inc., Chicago, IL) was used.

RESULTS
Mean age of the patients with Bell palsy and the Fig. 2. The mean NLR values according to the recovery.
control group was 43.11 6 18.12 and 48.33 6 5.65 years, NLR 5 neutrophil-to-lymphocyte. [Color figure can be viewed in
respectively. Male-to-female ratio of the patients with the online issue, which is available at www.laryngoscope.com.]

Laryngoscope 124: July 2014 Bucak et al.: Neutrophil-to-Lymphocyte for Prognosis of Bell Palsy
1679
 Patients were evaluated according to the response
to the treatment and were divided into two groups: satis-
factory recovery and nonsatisfactory recovery. The mean
NLR values were 3.41 6 1.76 in the nonsatisfactory
recovered group and 2.46 6 1.32 in the satisfactory
recovered group. NLR levels were higher in the nonsa-
tisfactory recovered group compared with the satisfac-
tory recovered group (P < 0.05) (Fig. 2).
DISCUSSION
Bell palsy is defined as a sudden paralysis/paresis
of all muscles on one side of the face; dry eye; pain
around the ear; altered sense of taste; hypersensitivity
to sounds; or decreased tearing that is not associated
with any other cranial neuropathy, ear, cerebellopontine,
or brainstem disease.13 Approximately one in 65 people
may experience such a condition in their lifespan. How-
ever, the exact etiopathogenesis of the Bell palsy is still
unclear. Microcirculatory failure and infectious, genetic,
immunologic, and inflammatory causes have been
hypothesized.2,14 The studies proposed that cell-mediated
immunologic responses may be of importance in the
pathogenesis of this disease. The measuring of the serum
samples of the patients with Bell palsy shows that the
IL-6, IL-8, and TNF-a levels were significantly higher in
the Bell palsy than in the control.2,13
In another study, the patients with Bell palsy had a
significantly lower percentage of B cells and T helper/
inducer subsets levels than did the controls. Patients
were evaluated according to clinical presentation and
divided into two groups. The patients with severe
impairment had significantly lower percentages of both
B cells and T helper/inducer subsets, whereas the
patients with mild to moderate impairment had only
decreased percentages of B cells subsets.1
WBC and its subtypes were found as inflammatory
markers in cardiovascular diseases. NLR was defined as
a novel-potential marker to determine inflammation in
cardiac and noncardiac disorders.811,15 NLR can be eas-
ily calculated as the neutrophils-to-lymphocytes ratio in
the peripheral blood. NLR is practical, inexpensive, and
also valuable as high-cost inflammatory markers includ-
ing IL-6, IL-1b, IL-8, and TNF-a.12 NLR has been found
to be an important index for predicting adverse clinical out-
comes and a reliable marker in oncology1619; cardiology
(acute coronary syndromes, heart failure, and coronary
revascularization procedures)8,9,2022; end-stage renal dis-
ease; and inflammatory diseases such as Alzheimer, ulcera-
tive colitis and appendicitis.12,2325
In our study, NLR levels were significantly higher
in patients with Bell palsy than the in control group,
indicating the presence of inflammation. In addition,
neutrophil and values were higher than in the control
group. Also, when the patients were compared according
to the recovery, NLR levels were higher in patients with
nonsatisfactory recovery, which may be explained by the
higher inflammatory situation in the nonsatisfactory
recovered patients. This result may help clinicians as a
practical and reliable indicator for Bell palsy patients in
terms of treating and predicting the prognosis.
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1680
Limitations of Our Study
Because this was a single-center study in one local-
ity, our study group was small.
CONCLUSION
To our knowledge, this is the first study investigat-
ing the relationship between NLR levels and Bell palsy
and its prognosis. Our results suggest that while evalu-
ating Bell palsy patients, NLR might be taken into
account as a novel potential marker to predict the
patients prognosis. Also, because this area of research is
a novel field, more prospective multicenter controlled
studies with larger series are needed to demonstrate
the possibility of a future test that could be used as an
estimator for prognosis.
Acknowledgement
The authors would like to thank Dr. Mehmet Yaman and
Dr. M. Sena Ulu for their contribution to this project.
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