Bell's Palsy


History/Symptoms

  • Sudden onset of unilateral paralysis of upper & lower face muscles
    • Starts out gradual, may take several hours before clinically significant Sx
    • No other CNS/ear or posterior fossa dz
    • May follow URI or other viral dz
  • Decr lacrimation
  • Otalgia
  • Poor eyelid motor function
  • Ear ache
  • Tingling/numbness of mouth/buccal region
  • Eye pain/blurry vision
  • Often assoc w/ polyneuritis
    • Periauricular pain (CN V)
    • Hyperacusis (CN VIII)
    • Decr taste on anterior 2/3 of tongue (CN IX)
       

Physical Exam/Signs

  • Face
    • Paralysis must include forehead & lower face
    • Inability to smile on affected side
    • Drooling on affected side
    • Central lesions DO NOT affect forehead musculature
    • Peripheral lesions DO affect forehead musculature
  • Eyes
    • Inability to close eyelid
    • Paralytic ectropion of lower lid, corneal exposure/injury
    • Decr lacrimation/tear distribution
    • Autonomic synkinesis
    • Loss of nasolabial fold
  • Ears
    • Posterior auricular pain (ipsilateral)
    • Tympanic membranes intact & normal
    • Hyperacusis (ipsilateral)
  • Taste
    • Ipsilateral decr in taste sense
  • Rest of body may be normal

Etiology

  • Likely viral or postviral syndrome
    • HSV
    • Lyme dz
    • EBV
    • CMV
    • HIV
    • Herpes zoster
  • Likely non-viral causes
    • DM
    • HTN
    • Inflammatory dz
    • Autoimmune dz
 

DDx

Condition Comments/Test
Stroke S/S of other neurologic dysfunction.
Forehead movement is spared
Tests:
 
CT/MRI brain.
Otitis media Fever, pain, ear discharge, underlying immune compromise.
Test:
 Ear exam, +/- CT
HSV PCR DNA.
Lyme disease +/- tick bite or erythema migrans
Fever, headache, fatigue, arthritis, Skin rash,
Tests:
 ELISA or indirect fluorescent Antibody titers to Borrella burgdorferi are elevated
 Confirm w/ Western bolt assay
Ramsay Hunt Syndrome Blisters are present on auricular concha of the pinna.
Tests:
 Wound scrapings for Tzank smear
 Serology
HIV  
Facial Nerve injury Hx of trauma or surgery
Test:
 CT of temporal bone detects temporal bone Fx or facial nerve lesion.
Tumor There may be progressive facial paralysis, a parotid mass, local pain, primary cancer elsewhere in the body, tinnitus, or ipsilateral 8th nerve-type hearing loss.
Tests:
 MRI
Rosenthal-Melkersson Syndrome There are recurrently swollen lips or face & fissured/geographic tongue.
Tests:
 None
Heerfordt Syndrome Fever, anterior uveitis,  & parotid gland enlargement.
Tests:
 CXR suggests sarcoidosis.
 Opthalmologic exam confirmes uveitis.
 There may be non-caseating granulomas in the parotid.

Diagnosis

  • Clinical
    • Sudden, recent onset, unilateral, idiopathic facial paralysis
       
  • Labs/Tests
    • CBC, RPR or VDRL, ELISA or Western Blot or HIV screen, ESR, cANCA, HSV titers (r/o bloodborne/viral dz)
    • Thyroid function studies (r/o thyroid dz)
    • Serum glucose, HbA1C (determine DM status)
    • CSF analysis (r/o CNS dz)
       
  • Imaging
    • MRI brain/face (facial nerve pathway)
    • CT
       
  • Other tests
    • House-Brackman Facial Paralysis Scale
      • Grade I: normal
      • Grade II: mild
      • Grade III: Moderate, complete eye closure w/ effort, good forehead mvmt
      • Grade IV: Mod-Severe, incomplete eye closure, moderate forehead mvmt
      • Grade V: Severe, some mvmt
      • Grade VI: Total paralysis, no mvmt
    • Electromyography of facial muscles
    • Conduction tests of facial nerve function (electroneurography)
    • Audiometry, Brain-stem audiotry evoked Response
    • Blepharokymography
    • Salivary flow
       

Treatment

  • Prednisone x 10 days
    • Adult: 10 mg, 6 tabs (60 mg) po qd x 5 days, then 5t po x1 day, then 4t po x1 day, then 3t po x1 day, then 2t po x1 day, then 1t po x1 day, then stop. # 45
    • Pediatric: 1 mg/kg/day x7 days
  • Antiviral:
    • Adult: Valacyclovir 1g po tid x 7 days. #21
    • Pediatric: Acyclovir
      • >2 yo: 80 mg/kg/day divided 5 times daily, up to 400 mg PO 5 times per day
      • <2 yo: not recommended
      • Some recommend:
        • >2 yo: 1000 mg QID x10 days
        • <2 yo: not recommended
  • Eye protection (eye patch):
    • The eye must not become irritated or infected. if there is any doubt, refer pt to Optho.
    • To protect the cornea from drying & abrasion, a transparent eye patch can be worn during the day, and artificial tears should be used every hour during the day and ophthalmic lubricants at night time.
    • Overnight the lid can be taped closed using nonirritant tape.
  •  

Follow up

Prognosis:

  • Under stringent criteria defining normal, only 24% of all Bell palsy patients recover to normal, as they were prior to paralysis.
  • Looser criteria suggest that 71% of all Bell palsy patients recover to normal or near normal: 94% for those presenting with incomplete paralysis and 61% for those presenting with complete paralysis.
  • All patients must recover to some degree within 6 months; otherwise, the diagnosis of Bell palsy cannot be applied.

Monitoring

  • Patients with Bell palsy should be seen within 1 to 2 weeks after initial visit, to monitor treatment safety and the condition of the eye. After that, follow-up can be monthly or at 3 months and 6 months.
  • There is some suggestion that pregnancy decreases satisfactory outcomes in comparison with the usual Bell palsy patients and that pregnant women developing Bell palsy should be closely monitored for development of hypertensive disorder of pregnancy

Patient instruction

  • The patient should not rub the eye.
  • The eye should be kept moist with drops and/or ophthalmic ointment.
  • A clear eye protective shield should be worn when awake.
  • The patient should call the doctor if there is irritation in the eye.

 

Disposition

  1. Prognosis good in most cases
  2. Admit if severe w/ complications
  3. Peripheral nerve lesions
    • Discharge w/ neuro follow up in 1-2 days