- Sudden onset of
unilateral paralysis of upper & lower face
- 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
- Poor eyelid
- Ear ache
- Tingling/numbness of mouth/buccal region
- Eye pain/blurry
- Often assoc w/
- Periauricular pain (CN V)
- Decr taste
on anterior 2/3 of tongue (CN IX)
- Paralysis must
include forehead & lower face
- Inability to
smile on affected side
- Drooling on
lesions DO NOT affect forehead musculature
lesions DO affect forehead musculature
- Inability to
ectropion of lower lid, corneal
- Loss of
auricular pain (ipsilateral)
membranes intact & normal
decr in taste sense
- Rest of body may
- Likely viral or
- Lyme dz
- Likely non-viral
||S/S of other neurologic dysfunction.
movement is spared
||Fever, pain, ear discharge, underlying immune compromise.
Ear exam, +/- CT
||+/- tick bite or erythema migrans
Fever, headache, fatigue, arthritis, Skin rash,
ELISA or indirect fluorescent Antibody titers to Borrella burgdorferi are
Confirm w/ Western bolt assay
|Ramsay Hunt Syndrome
||Blisters are present on auricular concha of the pinna.
Wound scrapings for Tzank smear
|Facial Nerve injury
||Hx of trauma or surgery
CT of temporal bone detects temporal bone Fx or facial nerve lesion.
||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.
||There are recurrently swollen lips or face & fissured/geographic
||Fever, anterior uveitis, & parotid gland enlargement.
CXR suggests sarcoidosis.
Opthalmologic exam confirmes uveitis.
There may be non-caseating granulomas in the parotid.
- Sudden, recent onset, unilateral, idiopathic facial paralysis
- 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)
- MRI brain/face
(facial nerve pathway)
- Other tests
Facial Paralysis Scale
- Grade I:
- Grade II:
- Grade III:
Moderate, complete eye closure w/ effort,
good forehead mvmt
- Grade IV:
Mod-Severe, incomplete eye closure, moderate
- Grade V:
Severe, some mvmt
- Grade VI:
Total paralysis, no mvmt
of facial muscles
- Conduction tests
of facial nerve function (electroneurography)
Brain-stem audiotry evoked Response
- Salivary flow
- 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
1 mg/kg/day x7 days
- Adult: Valacyclovir 1g po tid x 7 days. #21
- >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
- 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
- All patients must recover to some degree within 6 months;
otherwise, the diagnosis of Bell palsy cannot be applied.
- 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
- The patient should not rub the eye.
- The eye should be kept moist with drops and/or ophthalmic
- A clear eye protective shield should be worn when awake.
- The patient should call the doctor if there is irritation in the
- Prognosis good in
- Admit if severe w/
- Peripheral nerve
- Discharge w/
neuro follow up in 1-2 days