Bell's palsy: Difference between revisions
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==Background== | ==Background== | ||
[[File:Cranial nerve VII.png|thumb|Bilateral course of facial nerve. Note that the forehead muscles receive innervation from both hemispheres of the brain, which is why there is forehead sparing for [[stroke]] but not Bell's palsy (or other peripheral facial nerve injury).]] | |||
*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> | *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 | **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]] | *Always test CN VI function (should be normal) to rule-out [[CVA]] | ||
*Bilateral Bell's palsy associated with [[Lyme disease]] | |||
==Clinical Features== | ==Clinical Features== | ||
[[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.]] | [[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 | [[File:Bellspalsy.jpg|thumb|A person attempting to show his teeth and raise his eyebrows with Bell's palsy on his right side; notice how the forehead is NOT spared).]] | ||
*Acute onset (over hours) of unilateral [[facial paralysis]] | |||
**No forehead sparing | **No forehead sparing | ||
*Inability to raise | *Inability to raise eyebrow on affected side | ||
*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 | |||
*Hyperacusis | |||
*Inability to produce tears | |||
*Subjective feeling of facial numbness without objective findings | |||
*Retroauricular pain | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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===Others=== | ===Others=== | ||
*Amyloidosis | *[[Amyloidosis]] | ||
*[[Botulism]] | *[[Botulism]] | ||
*[[Guillain-Barré Syndrome]] (bilateral palsy) | |||
*[[Guillain-Barré Syndrome]] | |||
*[[HIV - AIDS (Main)|HIV]] | *[[HIV - AIDS (Main)|HIV]] | ||
*[[Intracranial Hemorrhage]] | *[[Intracranial Hemorrhage]] | ||
*[[Malignant Otitis Externa]] | *[[Malignant Otitis Externa]] | ||
*[[Meningitis]] | *[[Meningitis]] | ||
*Neurosyphilis | *[[Neurosyphilis]] | ||
*[[Otitis Media]] (acute or chronic) | *[[Otitis Media]] (acute or chronic) | ||
*[[Parotitis]] | *[[Parotitis]] | ||
*[[Sarcoidosis]] | *[[Sarcoidosis]] | ||
*[[ | *[[Sjögren Syndrome]] | ||
* | *[[Eclampsia]] | ||
==Evaluation== | ==Evaluation== | ||
===Workup=== | |||
*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> | *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> | ||
===Diagnosis=== | |||
*Clinical diagnosis | |||
**Must performed detail ear exam to rule out [[otitis media|ear infection]] and [[Herpes zoster oticus|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== | ==Management== | ||
{{Bell's palsy Treatment}} | {{Bell's palsy Treatment}} | ||
==Disposition== | ==Disposition== | ||
*Discharge with ophtho follow up 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" | *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) | |||
*Up to 10% of patients have a recurrence on the ipsilateral or controlateral side | |||
===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]] | |||
*[[Cranial nerve abnormalities]] | |||
*[[Lyme disease]] | |||
==References== | ==References== |
Latest revision as of 08:23, 14 May 2022
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