!1.12 Bell's Palsy (Idiopathic Facial Paralysis)
This condition creates a very frightening facial disfigurement. An adult
complains of sudden onset of "numbness," a feeling of fullness or swelling,
pain or some other change in sensation on one side of the face; a crooked
smile, mouth "drawing" or some other asymmetrical weakness of facial muscles;
an irritated, dry or tearing eye; drooling out of the corner of the mouth; or
changes in hearing or taste. Often there will have been a viral illness one to
three weeks before. Upon initial observation of the patient, it is immediately
apparent that he is alert and oriented, with a unilateral facial paralysis
that includes one side of the forehead.
What to do:
* Perform a thorough neurological examination of cranial and upper cervical
nerves, and limb strength, noting which are involved, and whether
unilaterally or bilaterally. Ask the patient to wrinkle the forehead, close
the eyes forcefully, smile, puff the cheeks and whistle, observing closely
for facial assymetry. Central or cerebral lesions result in relative
sparing of the forehead. Check tearing, ability to close the eye and
protect the cornea, corneal dessication, hearing, and, when practical,
taste. Examine the ear canals for herpetic vesicles and the tympanic
membrane for signs of otitis media or cholesteatoma. Patients presenting
with facial paralysis accompanied by acute otitis media, chronic
suppurative middle ear disease, otorrhea or otitis externa require
* If the cornea is dry or injured from the patient's inability to make tears
and blink, protect it by patching. If patching is not necessary, then
recommend wearing eyeglasses and applying methylcellulose artificial tears
regularly during the day and using a protective bland ointment at night.
* If there is a history of head trauma, obtain a CT scan of the head
(including the skull base) to rule out a temporal bone fracture.
* If the diagnosis is clearly an early idiopathic cranial nerve palsy not
caused or complicated by trauma, infection, or diabetes, try to ameliorate
symptons with a short course of corticosteroids (e.g., prednisone 60mg qd,
tapering after 5 days.)
* Send a serum specimen for acute phase Lyme disease titers, if available,
because this is another treatable disorder which can present as a facial
neuropathy. In areas where Lyme disease is endemic, a 10 day course of
tetracycline or doxycycline may be indicated.
* If the etiology appears to be zoster-varicella (e.g., grouped vesicles on
the tongue) prescribe acyclovir or famcyclovir as for shingles.
* Reassure the patient that 70-80% of cases of Bell's palsy recover
completely in a few weeks, but provide for definite followup and
* Provide appropriate specialty referral when there is a mass in the head or
neck or a history of any malignancy.
What not to do:
* Do not forget alternate causes of facial palsy which require different
treatment, such as cerebrovascular accidents and cerebellopontine angle
tumors (which usually produce weakness in limbs or defects of adjacent
cranial nerves), multiple sclerosis (which is usually not painful, spares
taste, and often produces intranuclear ophthalmoplegia), Ramsay Hunt
syndrome (or herpes zoster of the geniculate ganglion, which causes
decreased hearing, pain, and vesicles in the ear canal), and polio (which
presents as fever, headache, neck stiffness, and palsies).
* Do not order a CT unless there is a history of trauma or the symptoms are
atypical and include such findings as vertigo. central neurological signs,
or severe headache.
* Do not make the diagnosis of Bell's palsy in patients who report gradual
onset of facial paralysis over several weeks or facial paralysis that has
persisted 3 months or more. These patients need further evaluation by a
neurologist or otolaryngologist.
Idiopathic nerve paralysis is a common malady. It affects 20 per 100,000
people a year. Although Bell's palsy was described classically as a pure
facial nerve lesion, and physicians have tried to identify the exact level at
which the nerve is compressed, the most common presenting complaints are
related to trigeminal nerve involvement. The mechanism is probably a spotty
demyelination of several nerves at several sites, caused by a viral infection.
Diabetics and pregnant women have increased incidence of Bell's palsy.
* Austin JR, Peskind SP, Austin SG, et al: Idiopathic facial nerve paralysis:
a randomized double blind controlled study of placebo versus prednisone.
* Stankiewicz JA: A review of the published data on steroids and idiopathic
facial paralysis. Otolaryngol Head Neck Surg 1987;97:481-486.
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