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Bell's palsy
From WikEM
Contents
Background
- Dysfunction of peripheral cranial nerve VII of unknown cause due to Inflammation at geniculate ganglion [1]
- Maximal clinical weakness around 3wks; at least partial recovery by 6 months
- Always test CN VI function (should be normal) to rule-out CVA
Clinical Features
- 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 although no demonstrable numbness
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
- HIV
- Intracranial Hemorrhage
- Malignant Otitis Externa
- Meningitis
- Neurosyphilis
- Otitis Media (acute or chronic)
- Parotitis
- Sarcoidosis
Evaluation
- Clinicians should NOT obtain routine laboratory testing or diagnostic imaging in patients with new-onset Bell's palsy (Level C)[2]
Management
- Cornea eye protection (Level X)[2]
- Artificial tears qhr while patient is awake AND
- Ophthalmic ointment at night
- Protective glasses or goggles
Steroids
- Prednisone 60-80mg qday x1wk[3] (Level B Evidence)[4]
- Steroids should be started within 72hrs of symptoms[5]
Antivirals
- Most likely no added benefit when combined with steroids. However also little harm associated with antivirals especially in patients with normal renal function[4]
- Valacyclovir 1000mg TID x1wk[3] OR
- Acyclovir 400mg 5x per day x 1wk
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.
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.
- ↑ 3.0 3.1 UpToDate. Bell's Palsy Prognosis and Treatment. March, 2014
- ↑ 4.0 4.1 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
- ↑ Vargish L. For Bell’s palsy, start steroids early; no need for an antiviral. J Fam Pract. Jan 2008; 57(1): 22–25../docss/JFP-57-22.pdf
