Bell's palsy
(Redirected from Bell's Palsy)
Background
- Dysfunction of peripheral cranial nerve VII of unknown cause due to Inflammation at geniculate ganglion [1]
- Thought that may be associated with herpes simplex virus
- 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
- Bilateral Bell's palsy associated with Lyme disease
Clinical Features
- Acute onset (over hours) of unilateral facial paralysis
- No forehead sparing
- Inability to raise eyebrow on affected side
- 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
- Retroauricular pain
Differential Diagnosis
Facial paralysis
- Bell's palsy
- CVA
- Trigeminal neuralgia
- Tick paralysis
- Herpes zoster oticus (Ramsay Hunt syndrome)
- CNS tumor
- Acoustic neuroma or other cerebellopontine angle lesions
- Meningioma
- Cerebellar pontine angle
- Facial nerve schwannoma
- Parotid
- Sarcoma
- Anesthesia nerve blocks
- Cerebral Aneurysms (vertebral, basilar, or carotid)
Others
- Amyloidosis
- Botulism
- Guillain-Barré Syndrome (bilateral palsy)
- HIV
- Intracranial Hemorrhage
- Malignant Otitis Externa
- Meningitis
- Neurosyphilis
- Otitis Media (acute or chronic)
- Parotitis
- Sarcoidosis
- Sjögren Syndrome
- Eclampsia
Evaluation
Workup
- Clinicians should NOT obtain routine laboratory testing or diagnostic imaging in patients with new-onset Bell's palsy (Level C)[2]
Diagnosis
- Clinical diagnosis
- Must performed detail ear exam to rule out ear infection and Ramsay Hunt Syndrome
- Facial weakness progressing to paralysis over weeks to months, progressive twitching or facial spasm suggests a neoplasm affecting the facial nerve
- If facial paralysis + pulsatile tinnitus and hearing loss, suspect a glomus tumor or cerebellar pontine angle tumor
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]
- Prednisone 60-80mg qday x1wk[4] (Level B Evidence)[5]
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]
- Valacyclovir 1000mg TID x1 week[4] OR
- Acyclovir 400mg 5x per day x1 week
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)
- Up to 10% of patients have a recurrence on the ipsilateral or controlateral side
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
- ↑ Greco A. et al. Bell's palsy and autoimmunity. Autoimmun Rev. 2012;12 622-627
- ↑ 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.
- ↑ 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
- ↑ 4.0 4.1 UpToDate. Bell's Palsy Prognosis and Treatment. March, 2014
- ↑ 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
- ↑ Lockhart et al. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869.
- ↑ Peitersen E. The natrual history of Bell's palsy. Am J Otol 1982;4:107-111.
- ↑ Gilden. Bell's Palsy. N Engl J Med 2004; 351:1323-1331