Bell Palsy


Article Author:
Matthew Warner
Julia Hutchison


Article Editor:
Matthew Varacallo


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/30/2019 5:16:54 PM

Introduction

Bell palsy is the most common peripheral paralysis of the seventh cranial nerve with an onset that is rapid and unilateral. The diagnosis is one of exclusion and most often made on physical exam. The facial nerve has both an intracranial, intratemporal, and extratemporal course as its branches. The facial nerve has a motor and parasympathetic function as well as taste to the anterior two-thirds of the tongue. It also controls salivary and lacrimal glands. The motor function of the peripheral facial nerve controls the upper and lower facial muscles. As a result, the diagnosis of Bell's palsy requires special attention to forehead muscle strength. If forehead strength is preserved, a central cause of weakness should be considered. Although the utility of antivirals has been called into question, treatment is medical with most sources recommending a combination of corticosteroids and antiviral medication.[1][2][3]

Bell palsy is the most common cause of unilateral facial paralysis. It is more common in diabetics and in pregnant females.

Etiology

Bell's Palsy (BP) is by definition idiopathic in nature.  Increasing evidence in the literature demonstrates multiple potential clinical conditions and pathologies known to manifest, at least in part, with a period of unilateral facial paralysis.  The literature has highlighted several viral illnesses such as herpes simplex virus, varicella-zoster virus, and Epstein-Barr virus.  Providers may ambiguously (and incorrectly) refer to a diagnosis of Bell's palsy in the setting of a potentially known etiologic mechanism.  This can occur, for example, in the setting of known associations (e.g. Ramsay-Hunt syndrome and Lyme disease).[4]

While there are many potential causes, including idiopathic, traumatic, neoplastic, congenital, and autoimmune, about 70% of facial nerve palsies wind up with a diagnosis of BP.  

Epidemiology

The annual incidence is 15 to 20 per 100,000 with 40,000 new cases each year and the lifetime risk is 1 in 60. There is an 8% to 12% recurrence rate. Even without treatment, 70% of patients will have complete resolution. There is no gender or racial preference, and palsy can occur at any age, but more cases are seen in mid and late life with the median age of onset at 40 years. Risk factors include diabetes, pregnancy, preeclampsia, obesity, and hypertension.[5]

Pathophysiology

Bell's palsy is thought to result from compression of the seventh cranial nerve at the geniculate ganglion. The first portion of the facial canal, the labyrinthine segment is the narrowest and it is here that most cases of compression occur. Due to the narrow opening of the facial canal, inflammation causes compression and ischemia of the nerve. The most common finding is a unilateral facial weakness that includes the muscles of the forehead.

History and Physical

Patients present with rapid and progressive symptoms over the course of a day to a week often reaching a peak in severity on 72 hours. Weakness will be partial or complete to one-half of the face, resulting in weakness of the eyebrows, forehead, and angle of the mouth. Patients may present with an inability to close the affected eyelid or lip on the affected side.

The key physical exam finding is a partial or complete weakness of the forehead. If forehead strength is preserved, a central cause should be investigated. Patients may also complain of a difference in taste, sensitivity to sound, otalgia, and changes to tearing and salivation.

Ocular features include

  • Corneal exposure
  • Lagophthalmos
  • Brow droop
  • Paralytic ectropion of the lower lid
  • Upper eyelid retraction
  • Decreased tear output
  • Loss of nasolabial fold

Evaluation

History and physical examination guide the evaluation. The House-Brackmann Facial Nerve Grading System can be used to describe the degree of facial nerve weakness. This grading system goes from a grade of I (no weakness) to VI (complete weakness). If the presentation is consistent with Bell's palsy, there are no required lab or radiographic tests. If there are atypical features, patients may need to be evaluated for a central cause of their symptoms. Likewise, Lyme disease testing is based on a history of possible tick-borne illness. The routine testing for Lyme disease is not recommended without other findings of the disease such as a history of a tick bite, skin rash or arthritis. Diabetic testing should not be performed as facial nerve palsy is not considered diabetic neuropathy. There is no consensus on the optimal timing of imaging for Lyme disease, but most sources recommend after 2 months of no improvement of the facial palsy. MRI is the imaging modality of choice. MRI can detect facial nerve inflammation as well as ruling out other conditions such as schwannoma, hemangioma or a space-occupying lesion.[6]

Nerve conduction studies and EMG may help determine outcomes in patients with severe Bell palsy.

Electroneurgraphyuses EMG to monitor the difference in potentials generated by the facial muscles on both sides.

If hearing loss is suspected than auditory evoked potentials and audiography should be performed.

There is a grading system for clinical evaluation of Bell palsy. The grading system ranges from mild to severe dysfunction.

Other tests include testing for saliva flow, tear function, and nerve excitability.

Treatment / Management

It is important to know that spontaneous recovery does occur and hence the role of treatment remains questionable.

Corticosteroids are the main treatment with a common regimen consisting of 60 mg to 80 mg a day for approximately 1 week. There is also some evidence stating corticosteroids and antivirals combined improved the outcome of Bell's palsy compared with corticosteroids alone. A meta-analysis in 2009 found that steroids alone were the treatment of Bell's palsy and the addition of antivirals did not meet statistical significance.

For patients with severe facial nerve palsy (House-Brackmann IV or greater) can be offered combination therapy with steroids and antivirals. There was no significant increase in adverse reactions from antivirals compared with either placebo or corticosteroids. Patients should be instructed to use eye lubrication and patch the affected eye at bedtime to reduce the likelihood of a corneal abrasion.

Surgical options can be considered when there is no improvement in symptoms after weeks or months. Techniques to present eye desiccation range from eyelid weights to muscle transfers. Facial nerve decompression has not been found to be a recommended treatment option and is considered on a case by case basis. Prior studies evaluating facial nerve compression have been of poor quality. It is recommended to refer to a specialist (plastic surgery, neurology, otolaryngology) sooner rather than later if no improvement has been seen in 4 weeks to explore more aggressive treatments.[7][8][9]

Differential Diagnosis

Causes of peripheral seventh nerve palsy such as Lyme disease and Ramsey Hunt syndrome should be excluded. Other less common causes of facial palsy include tuberculosis, HIV, trauma, sarcoidosis, vasculitis, and neoplasm. There is a reported 10.8% misdiagnosis rate from specialty referral centers. Also, if there are episodes of recurrence, clinicians should consider Melkersson-Rosenthal syndrome. This is a rare neurocutaneous syndrome with a recurrence of facial palsy, orofacial edema, and a fissured tongue. Melkersson-Rosenthal is more commonly diagnosed in females.

Prognosis

In 71% of untreated cases, Bell's Palsy resolves completely without treatment. Treatment with corticosteroids has been found to increase the likelihood of improved nerve recovery.  Recurrence does occur, and one study found a recurrence rate of 12%.[8]  Another study reported up to 10% of patients afflicted with BP will experience symptomatic recurrence after a mean latency of 10 years [10].

Risk factors associated with poor outcome include 1) complete paralysis 2) age more than 60 and 3) decreased salivation or taste on the ipsilateral side. The longer the recovery, the more likely that residual sequelae may develop.

A recurrence rate of 5-15% has been reported.

Complications

  • Corneal dryness leading to visual loss
  • Permanent damage to the facial nerve
  • Abnormal growth of nerve fibers

Postoperative and Rehabilitation Care

Continued monitoring of patients with Bell Palsy is required to ensure that recovery is taking place. If the EMG studies show that less than 25% of muscles are involved, then supportive care is recommended. But if the paralysis is severe, the patient will need counseling.

Consultations

  • Ophthalmologist
  • Neurologist
  • ENT surgeon

Pearls and Other Issues

As stated, the misdiagnosis rate can be up to 10.8%, so careful history, and physical exam is essential. The focus on the physical exam is the forehead muscles. Since Bell's palsy is a peripheral facial nerve palsy, there needs to be involvement of the forehead muscles. The history and physical guide testing for causes of facial nerve weakness. It is not recommended that all patients be tested for Lyme disease, only those that have a history of tick bite or manifestations of rash and arthritis. Patients may be treated at home medically with close follow up to assure improvement of symptoms. There should be a consideration for timely specialty referral if there has been little improvement in the first few weeks of disease. There are no known preventative measures, and 8% to 12% of patients will have a recurrence.

Enhancing Healthcare Team Outcomes

Bell palsy is the commonest cause of unilateral facial paralysis. While benign, the condition does have moderate morbidity and can lead to loss of vision. Thus, the disorder is best managed by an interprofessional team.

The cause of Bell palsy remains unknown, and its treatment remains controversial. While steroids and/or antiviral medications are often prescribed, there are no randomized clinical trials to determine which is better or effective. The problem is compounded by the fact that the majority of cases resolve spontaneously. However, in individuals with long-standing facial paralysis accompanied by poor speech, incomplete eyelid closure or poor aesthetics, treatment needs to be addressed by an interprofessional team. Because the disorder affects different organ systems, an interprofessional team of clinicians, nurses, and technologists have proven effective. The most important feature of the treatment is to be patient-focused rather than symptom focus.

In any case, all clinicians including the pharmacist and nurse practitioner must educate the patient on eye protection and lubrication. Eye dryness should be prevented at all costs using tears and other liquid preparations. If there is evidence of non-compliance or evidence that the eye is becoming dry and irritated, the nurse or pharmacist should report back to the clinical team leader.

The neurology nurse must educate the patient on facial exercises that can help improve muscle strength and facial coordination. These exercises can reduce poor aesthetics and improve the functionality of the facial muscles. If the patient is non-compliant, the nurse should report to the clinical team leader and assist with further education of the patient.

The availability of botulinum toxin has helped reduce the long-term burden of this disorder. Surgery is the last resort treatment and may be required in chronic cases. The facial muscles do remain viable for several years, and in these cases, complex reconstructions are available. However, rather than subject the patient to complex surgery with no guarantee of improvement, early recognition, and initiation of steroidal therapy is recommended.[11] (Level lll) Close follow up with the interprofessional team is necessary to ensure that no complications occur.

Outcomes

Evidence-based medicine is lacking when it comes to treatment and outcomes for Bell palsy. The problem is made more difficult because many cases resolve spontaneously. The majority of outcomes have been from case reports or small case series. While recovery does occur in most patients, it often takes months or even years for a full recovery. Because there are several types of treatments available besides medications, an interprofessional team should be involved in the management since not everyone responds to the same treatment. [12](Level V)


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Bell Palsy - Questions

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A 65-year-old male with a past medical history of polymyalgia rheumatica presents to his primary care provider for follow up. He was seen in urgent care and diagnosed with Bell's palsy last week. He has been taking prednisone 60 mg daily for the past week but has not noticed any improvement in his symptoms. Which of the following physical exam findings would warrant further workup for an alternative diagnosis?



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A 65-year-old male presents to his healthcare provider with post-auricular pain, facial weakness, and excessive tearing, which started 24 hours previously. Past medical history is significant for cold sores and asthma. The patient is not currently taking any medications and has no allergies. He denies ever experiencing symptoms like this previously. On the physical exam, the patient has complete weakness of the left side of his face. He has a normal sensory exam on both sides of his face. What is the next step in management?



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A middle-aged patient presents with acute lower motor nerve facial paralysis of the left side of the face that developed over 24 hours. The patient was administered steroids and famciclovir by her primary care doctor when the paralysis occurred. This was over 1 year ago, and she has recovered no facial function. What is her most likely diagnosis?



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A patient presents with acute lower motor nerve facial paralysis of the left side of the face that developed over 24 hours. The patient was administered steroids and famciclovir by her primary care doctor when the paralysis occurred. This was over 1 year ago, and she has recovered no facial function. What is the test that is most likely able to exclude a facial nerve tumor?



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A 32-year-old female with a history of dysmenorrhea presents for evaluation of excessive tearing from her left eye and left facial weakness. She reports her symptoms started gradually 72 hours ago. She states that last week, she was sick with cold symptoms of a runny nose and sore throat, but those symptoms have since then resolved. Vital signs include a heart rate of 75/min, a temperature of 98.5 F, blood pressure of 120/60 mmHg, respiratory rate of 14 breaths per minute, and pulse oxygenation of 99% on room air. Further, head and neck examination reveals incomplete closure and tearing of the left eye with weakness of the entire side of the left face. Which of the following organisms has been associated with the most likely diagnosis?



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A 30-year-old man attends the outpatient department with the complaint of difficulty in closing his right eye for the past two days following a long outdoor journey. He has a history of type 2 diabetes mellitus. On examination, there is a deviation of angle of mouth to the left side, and half of his cornea is exposed while he attempts closure of his right eye. On examining the response to sound, he says that even small sounds are becoming unbearable when heard from the right side. What is the site of the insertion of the muscle involved?



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A 17-year-old previously healthy female presents to urgent care for evaluation of right-sided facial weakness, which started two days ago. She reports difficulty closing her right eye and change in taste on the right side of her tongue. Physical exam reveals a weakness of the right side of the face involving the upper and lower facial muscles. Which cranial nerve is most likely affected in this patient's condition?



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A patient has been diagnosed with Bell palsy. They may develop a corneal ulcer for which of the following reasons?



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A 40-year-old male with a past medical history of bipolar disorder presents to the emergency department for evaluation of left-sided facial weakness, which started two days ago. His vital signs show a heart rate of 76 beats per minute, blood pressure of 125/79 mmHg, temperature of 99 F, respiratory rate of 16 breaths per minute, and pulse oxygenation of 99% on room air. Further neurological examination shows a paralysis of the left side of his face. No sensory deficits are noted. Based on the most likely diagnosis, what motor task will the patient have difficulty completing?



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A 13-year-old girl was diagnosed with a right-sided facial palsy 12 weeks ago. After her symptoms of facial weakness started 12 weeks, she was taken to her clinician who diagnosed her. She then completed a 7-day course of prednisone and acyclovir. She now presents to the clinic complaining that there is involuntary twitching of the right corner of her mouth each time she blinks her right eye. What is the most likely etiology of her symptoms?



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A 43-year-old female presents with acute onset of unilateral facial weakness. She states that she was getting ready in front of the mirror when she noticed the dropping of her mouth. She also complains of altered taste sensation on half of her tongue, and inability to tolerate loud noises. Her past medical history is remarkable for irritable bowel syndrome and fibromyalgia. She is not currently taking any medications. Her vital signs include a heart rate of 60 bpm, a temperature of 98.5 F, blood pressure of 130/70 mmHg, respiratory rate of 15 breaths per minute, with pulse oxygenation of 100% on room air. On examnation of her face, it is noted that she has weakness of the right side of her face, which does not spare the forehead. What muscle is most likely to be affected by this condition?



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A 41-year-old female with a past medical history of diabetes presents for evaluation of right-sided facial weakness, which started two days ago. She reports difficulty closing her right eye, tinnitus, and a change in taste. Vital signs include a heart rate of 75 bpm, a temperature of 98.5 F, blood pressure of 140/70 mmHg, respiratory rate of 20 breaths per minute, and pulse oxygenation of 97% on room air. Physical exam reveals paralysis of the right facial muscles. There is depression of the right nasolabial fold with facial droop and loss of brow wrinkles on the right forehead. What is the most appropriate next step in management?



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A 50-year-old man attends the outpatient department with the complaint of difficulty in closing his right eye and increased tearing from it for the past two days following a long outdoor journey. He has a history of hypertension and type 2 diabetes mellitus, for which he takes lisinopril and metformin, respectively. On examination, his heart rate is 70 bpm, his blood pressure is 160/90 mmHg, he is afebrile, O2 saturation is 100% on room air, and the respiratory rate is 14 breaths/min. The facial exam reveals that there is a deviation of angle of mouth to the left side, and half of his cornea is exposed while he attempts closure of his right eye. Schirmers test is negative, but hyperacusis is positive on the right side. He undergoes a magnetic resonance imaging (MRI) of the head. In MRI, where should be looked mainly to diagnose the lesion?



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A 36-year-old male has had left-sided facial weakness associated with hyperacusis and left eye-watering for the past 3 weeks. He completed a 7-day course of prednisone and valacyclovir and feels like his symptoms are gradually improving. He has been taping his eye at night and denies ay vision changes. On examination, he has a left-sided facial paresis involving the upper and lower face. Fluorescein staining shows no uptake to the left eye. Which type of neuron is most likely affected in the condition causing his facial weakness?



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A 65-year-old male with a history of diabetes, transient ischemic attack, and hypertension presents to the emergency department for right-sided facial weakness, which started 3 hours before arrival. The patient reports that he was washing his hands and noticed in the mirror that his smile looked crooked. He takes lisinopril and metformin. On physical examination, his heart rate is 80 bpm, his blood pressure is 160/70 mmHg, the temperature is 98.7F, pulse oxygenation is 100% on room air, and the respiratory rate is 16 breaths per minute. Fingerstick glucose reveals blood glucose levels of .80 mg/dl. An electrocardiogram (EKG) is obtained, which shows normal sinus rhythm. On examination, the patient has significant drooping of the right corner of his mouth. What would be the best next step to determine the etiology of the patient’s symptoms?



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A patient has bilateral bell palsy. Which of the following would also be an expected finding?



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In which medical disorder would one expect sagging of the orbicularis oris?



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With Bell palsy, one expects to see all of the following except which of the following?



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A 17 year old patient diagnosed with Bell palsy 2 weeks ago complains of eye irritation, dryness, and foreign body sensation. On examination, best corrected visual acuity is 20/20. Examination of his cornea shows few scattered punctate epithelial erosions. Schirmer test with anaesthesia is 10 mm. Corneal sensation is intact and the patient has an upgoing Bell phenomenon. Which is the best treatment for this patient?



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A nurse is working in triage when a patient arrives with facial drooping as shown in the image below. Which of the following is true regarding the condition that is suspected? Select all that apply.

(Move Mouse on Image to Enlarge)
  • Image 6695 Not availableImage 6695 Not available
    Contributed by Centers for Disease Control and Prevention (NIH), PD US HHS CDC
Attributed To: Contributed by Centers for Disease Control and Prevention (NIH), PD US HHS CDC



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A 16-year-old patient comes in with symptoms of Bell palsy. Which muscle is least likely to be affected?



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A 65-year-old male with a history of hypertension, diabetes, and tobacco use presents to the emergency department for evaluation of left-sided facial weakness, which started two hours ago. The patient reports that he woke up around 5 am to get some water, and his face felt normal. He went back to sleep, and when he woke up again at 7 am, he noticed weakness on the right side of his face. He reports he was drooling from the right corner of his mouth when he woke up. He says last week he was sick with a cold and had a cold sore, but those symptoms have resolved. His vital signs show a heart rate of 75/min, a temperature of 98.5 F, blood pressure of 175/90 mmHg, respiratory rate of 20 breaths per minute, with pulse oxygenation of 99% on room air. On examination, the patient has drooping of the right corner of his mouth. When asked to smile the left side of his mouth moves upward, and the right stays depressed. His forehead reveals symmetric forehead creasing with eyebrow elevation. Reflexes are 2+ throughout. Strength and sensation in the upper and lower extremities are normal. What is the next appropriate step in management?



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Bell Palsy - References

References

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Somasundara D,Sullivan F, Management of Bell's palsy. Australian prescriber. 2017 Jun     [PubMed]
Reich SG, Bell's Palsy. Continuum (Minneapolis, Minn.). 2017 Apr     [PubMed]
Spencer CR,Irving RM, Causes and management of facial nerve palsy. British journal of hospital medicine (London, England : 2005). 2016 Dec 2     [PubMed]
Zhao H,Zhang X,Tang YD,Zhu J,Wang XH,Li ST, Bell's Palsy: Clinical Analysis of 372 Cases and Review of Related Literature. European neurology. 2017     [PubMed]
Mower S, Bell's palsy: excluding serious illness in urgent and emergency care settings. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association. 2017 Apr 13     [PubMed]
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