Bell's palsy: Difference between revisions
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==Background==
==Background==
*Dysfunction of peripheral CN VII of unknown cause due to Inflammation at geniculate ganglion <ref>Greco A. et al. Bell's palsy and autoimmunity. Autoimmun Rev. 2012;12 622-627</ref>
*Dysfunction of peripheral [[cranial nerve]] VII of unknown cause due to Inflammation at geniculate ganglion <ref>Greco A. et al. Bell's palsy and autoimmunity. Autoimmun Rev. 2012;12 622-627</ref>
*Maximal clinical weakness around 3wks; at least partial recovery by 6 months
*Maximal clinical weakness around 3 weeks; at least partial recovery by 6 months
*Always test CN VI function (should be normal) to rule-out [[CVA]]
*Always test CN VI function (should be normal) to rule-out [[CVA]]
==Differential Diagnosis==
#Amyloidosis
#Anesthesia nerve blocks
##Cerebral Aneurysms (vertebral, basilar, or carotid)
#[[Botulism]]
#[[CVA]]
#[[Guillain-Barré Syndrome]]
#[[HIV - AIDS (Main)|HIV]]
#[[Intracranial Hemorrhage]]
#[[Lyme Disease]]
#[[Malignant Otitis Externa]]
#[[Meningitis]]
#Neurosyphilis
#[[Otitis Media]] (acute or chronic)
#[[Parotitis]]
#Ramsay Hunt syndrome
#Sarcoidosis
#Tumor
##Acoustic neuroma or other cerebellopontine angle lesions
##Meningioma
##Cerebellar pontine angle
##Facial nerve schwannomaa
##Parotid
##Sarcoma
==Work Up==
*Clinicians should NOT obtain routine laboratory testing or diagnostic imaging in patients with new-onset Bell's palsy ([[EBQ:Evidence Levels|Level C]])<ref name="bells guidelines">Baugh RF, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg. 2013 Nov;149(3 Suppl):S1-S27.</ref>


==Clinical Features==
==Clinical Features==
*Acute onset (over hours) of unilateral facial paralysis
[[File:Bell's palsy.png|thumb|Right-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.]]
*Acute onset (over hours) of unilateral [[facial paralysis]]
**No forehead sparing
**No forehead sparing
*Inability to raise eyebrows
*Inability to raise eyebrows
**Drooping of angle of the mout
*Drooping of angle of the mouth
*Incomplete closure of the eyelids on the affected side
*Incomplete closure of the eyelids on the affected side
**Can lead to corneal exposure keratitis
**Can lead to corneal exposure keratitis


===Associated Symptoms===
===Associated Symptoms===
#Alterations in Taste
*Alterations in taste
#Hyperacusis
*Hyperacusis
#Inability to produce tears
*Inability to produce tears
#Subjective feeling of facial numbness although no demonstrable numbness
*Subjective feeling of facial numbness without objective findings
 
==Differential Diagnosis==
{{Facial paralysis}}
 
===Others===
*Amyloidosis
*[[Botulism]]
*[[Guillain-Barré Syndrome]]
*[[HIV - AIDS (Main)|HIV]]
*[[Intracranial Hemorrhage]]
*[[Malignant Otitis Externa]]
*[[Meningitis]]
*Neurosyphilis
*[[Otitis Media]] (acute or chronic)
*[[Parotitis]]
*[[Sarcoidosis]]
*[[Sjögren Syndrome]]
*[[Eclampsia]]
 
==Evaluation==
*Clinical diagnosis
*Clinicians should NOT obtain routine laboratory testing or diagnostic imaging in patients with new-onset Bell's palsy ([[EBQ:Evidence Levels|Level C]])<ref name="bells guidelines">Baugh RF, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg. 2013 Nov;149(3 Suppl):S1-S27.</ref>


==Treatment==
==Management==
#Cornea eye protection (Level X)<ref name="bells guidelines"></ref>
{{Bell's palsy Treatment}}
##Artificial tears qhr while pt is awake AND
##Ophthalmic ointment at night
##Protective glasses or goggles
===Steroids<ref name="bells guidelines"></ref>===
*Level B evidence
#Prednisone 60-80mg qday x1wk<ref name="UpToDate Bells">UpToDate. Bell's Palsy Prognosis and Treatment. March, 2014</ref>
===Antivirals===
*for patients <72 hours of symptom onset
#Valacyclovir 1000mg TID x1wk<ref name="UpToDate Bells"></ref> OR
#Acyclovir 400mg 5x per day x 1wk


==Disposition==
==Disposition==
*Discharge with ophtho f/u for monitoring of the affected cornea
*Discharge with ophtho follow up for monitoring of the affected cornea
*Refer to a facial nerve specialist for:<ref name="bells guidelines"></ref>
*Refer to a facial nerve specialist for:<ref name="bells guidelines" />
**New or worsening neurologic findings at any point
**New or worsening neurologic findings at any point
**Ocular symptoms developing at any point
**Ocular symptoms developing at any point
**Incomplete facial recovery 3 months after initial symptom onset.
**Incomplete facial recovery 3 months after initial symptom onset
 
==Prognosis==
*Most patients recover completely, although some have permament disfiguring facial weakness<ref>Peitersen E. The natrual history of Bell's palsy. Am J Otol 1982;4:107-111.</ref>
**71% of untreated patients recover completely
**An additional 13% of untreated patients achieve near-normal function (a total of 84% achieve normal or near-normal function even without treatment)
 
===Poor Prognostic Indicators===
''Any one of the following''<ref>Gilden. Bell's Palsy. N Engl J Med 2004; 351:1323-1331</ref>
*Older age
*Hypertension
*Impairment of taste
*Pain other than in the ear
*Complete facial weakness


==See Also==
==See Also==
*[[CVA]]
*[[CVA]]
 
*[[Facial paralysis]]
==Source==
*Tintinalli


==References==
==References==
<references/>  
<references/>  


[[Category:Neuro]]
[[Category:Neurology]]
[[Category:Ophtho]]
[[Category:Ophthalmology]]

Revision as of 23:38, 1 October 2019

Background

  • Dysfunction of peripheral cranial nerve VII of unknown cause due to Inflammation at geniculate ganglion [1]
  • Maximal clinical weakness around 3 weeks; at least partial recovery by 6 months
  • Always test CN VI function (should be normal) to rule-out CVA

Clinical Features

Right-sided peripheral facial nerve palsy with inability to wrinkle the forehead and nose, unequal lid fissures, and inability to lift the corner of the mouth.
  • Acute onset (over hours) of unilateral facial paralysis
    • No forehead sparing
  • Inability to raise eyebrows
  • Drooping of angle of the mouth
  • Incomplete closure of the eyelids on the affected side
    • Can lead to corneal exposure keratitis

Associated Symptoms

  • Alterations in taste
  • Hyperacusis
  • Inability to produce tears
  • Subjective feeling of facial numbness without objective findings

Differential Diagnosis

Facial paralysis

Others

Evaluation

  • Clinical diagnosis
  • Clinicians should NOT obtain routine laboratory testing or diagnostic imaging in patients with new-onset Bell's palsy (Level C)[2]

Management

Eye Protection

  • Cornea eye protection (Level X)[2]
    • Artificial tears qhr while patient is awake
    • Ophthalmic ointment at night
    • Eye should be taped shut at night
    • Protective glasses or goggles

Steroids

Should be started within 72hrs of symptom onset[3]

Antivirals

Most likely no added benefit when combined with steroids.[6] However also little harm associated with antivirals especially in patients with normal renal function[5]

Antibiotics

  • Consider empiric doxycycline if high index of suspicion for Lyme based on clinical presentation or lab data

Disposition

  • Discharge with ophtho follow up for monitoring of the affected cornea
  • Refer to a facial nerve specialist for:[2]
    • New or worsening neurologic findings at any point
    • Ocular symptoms developing at any point
    • Incomplete facial recovery 3 months after initial symptom onset

Prognosis

  • Most patients recover completely, although some have permament disfiguring facial weakness[7]
    • 71% of untreated patients recover completely
    • An additional 13% of untreated patients achieve near-normal function (a total of 84% achieve normal or near-normal function even without treatment)

Poor Prognostic Indicators

Any one of the following[8]

  • Older age
  • Hypertension
  • Impairment of taste
  • Pain other than in the ear
  • Complete facial weakness

See Also

References

  1. ↑ Greco A. et al. Bell's palsy and autoimmunity. Autoimmun Rev. 2012;12 622-627
  2. ↑ 2.0 2.1 2.2 Baugh RF, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg. 2013 Nov;149(3 Suppl):S1-S27.
  3. ↑ Vargish L. For Bell’s palsy, start steroids early; no need for an antiviral. J Fam Pract. Jan 2008; 57(1): 22–25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183838/pdf/JFP-57-22.pdf
  4. ↑ 4.0 4.1 UpToDate. Bell's Palsy Prognosis and Treatment. March, 2014
  5. ↑ 5.0 5.1 Gronseth GS, Paduga R. Evidence-based guideline update: Steroids and antivirals for Bell palsy: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012Full Text
  6. ↑ Lockhart et al. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869.
  7. ↑ Peitersen E. The natrual history of Bell's palsy. Am J Otol 1982;4:107-111.
  8. ↑ Gilden. Bell's Palsy. N Engl J Med 2004; 351:1323-1331
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