Bell's palsy

Background

• Dysfunction of peripheral CN VII of unknown cause
• Maximal clinical weakness around 3wks; at least partial recovery by 6 months
• Always test CN VI function (should be normal) to rule-out CVA

Differential Diagnosis

1. Amyloidosis
2. Anesthesia nerve blocks
   1. Cerebral Aneurysms (vertebral, basilar, or carotid)
3. Botulism
4. CVA
5. Guillain-Barré Syndrome
6. HIV
7. Intracranial Hemorrhage
8. Lyme Disease
9. Malignant Otitis Externa
10. Meningitis
11. Neurosyphilis
12. Otitis Media (acute or chronic)
13. Parotidtitis
14. Ramsay Hunt syndrome
15. Sarcoidosis
16. Tumor
    1. Acoustic neuroma or other cerebellopontine angle lesions
    2. Meningioma
    3. Cerebellar pontine angle
    4. Facial nerve schwannomaa
    5. Parotid
    6. Sarcoma

Work Up

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

Clinical Features

• Acute onset (over hours) of unilateral facial paralysis
  • No forehead sparing
  • Mouth drawn to the non-affected side
• Incomplete closure of the eyelids on the affected side
  • Can lead to corneal exposure keratitis

Treatment

1. Cornea eye protection (Level X)
   1. Artificial tears qhr while pt is awake AND
   2. Ophthalmic ointment at night
   3. Protective glasses or goggles
2. Steroids + antiviral therapy for patients <72 hours of symptom onset (Level B)
   1. Corticosteroids
      1. Prednisone 60-80mg qday x1wk
   2. Antivirals
      1. Valacyclovir 1000mg TID x1wk
         1. Or, Acyclovir 400mg 5x per day x 1wk

Disposition

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

See Also

• CVA

Source

• Tintinalli