Bell's palsy; cranial nerve 7 palsy; facial nerve palsy
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Etiology
- postinfectious
- especially upper respiratory tract infection
- secondary to nerve compression from edema
- viral
- bacterial
- sarcoidosis
- demyelinating disorders
- diabetes
- predisposing factor
- 4-fold higher incidence in patients with diabetes
- hypertension
- possibly predisposing factor
- recovery rate is lower in hypertensive patients
- pregnancy
- higher incidence
- especially 3rd trimester
- preeclampsia further increases incidence
- migraine 2-fold increase risk[9]
- idiopathic
Epidemiology
- 23 per 100,000 persons/year
- 1 in 60-70 persons/lifetime[16]
Pathology
- palsy of the facial nerve (cranial nerve 7)
Clinical manifestations
- sudden lower motor neuron weakness involving upper & lower facial muscles
- generally unilateral (ipsilateral to lesion)
- bilateral involvement with:
- corneal reflex may be compromised
- postauricular or facial pain, especially postinfectious
- ipsilateral lacrimation
- hyperacusis with involvement of stapedial nerve
- ipsilateral dysgeusia
- facial numbness (subjective)
- objectively sensation is intact
- extraocular muscles intact (EOMI)
- normal reflexes
- vesicular lesions on tympanic membrane & external auditory canal in Herpes zoster-associated Bell's palsy
- severe cases may be associated with dyarthria[12]
Laboratory
- complete blood count (CBC): normal
- erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
- serum chemistries: normal
- serologic tests for syphilis
- serology for HIV1
- serology for Lyme disease
- serum angiotensin-converting enzyme
- sarcoidosis
- may be falsely elevated in smoker
- cerebrospinal fluid (CSF) examination
- protein
- glucose
- cell count
- VDRL
- IgG index
- oligoclonal banding (also send serum for comparison)
- routine laboratory testing may not be necessary[4]
Diagnostic procedures
- routine special laboratory testing not indicated[7]
- nerve conduction studies
- 5-7 days post onset
- abnormal conduction latency
- abnormal stimulation threshold
- serial studies for evaluation of surgical options
- electromyography (EMG): denervation changes after 14-21 days
Radiology
- routine diagnostic imaging not indicated
- magnetic resonance imaging (MRI) with gadolinium contrast
- indications: incomplete recovery after 3 months
- evaluation for edema, mass lesions, demyelination
- evidence of multiple cranial nerves involved, (masseter: CN5-3; abducens: CN6)
Differential diagnosis
- trauma
- Herpes zoster infection
- neurosyphilis
- sarcoidosis
- Borrelia burgdorferi (Lyme disease)
- HIV infection
- neoplasm: cerebellopontine angle
- primary
- metastatic
- demyelinating disease
- diabetes-related disorder
- hypertension-related disorder
- pregnancy-related disorder
- stroke
- facial droop with dysarthria may suggest stroke[12]
- paralysis of the forehead muscles suggests Bell's palsy
- most strokes that cause facial weakness have other neurologic signs, such as ipsilateral arm numbness or muscle weakness[12]
Management
- supportive care
- artificial tears
- ocular lubricant at night to protect the cornea
- consider taping eyelids
- pharmacologic agents
- glucocorticoid to improve recovery of facial function[5]
- beneficial within 72 hours of onset[3][4]
- prednisone 1 mg/kg/day for 3-5 days, 10 days[18]
- rapid taper with total course of 10 days
- probably benificial if started within 1 week
- number needed to treat for full recovery of facial function = 6-8[5], 11[10]
- antiviral agent
- analgesics for pain
- glucocorticoid to improve recovery of facial function[5]
- ophthalmology consult for:
- persistent ocular pain
- corneal abrasion or ulceration
- neurology or otolaryngology consult for
- progessive symptoms
- hearing loss or other otologic symptoms
- abnormalities other than facial muscle weakness
- recurrent weakness
- magnetic resonance imaging (MRI) anomalies
- cerebrospinal fluid (CSF) anomalies
- plastic surgery
- consider if nerve conduction response amplitude <10% of unaffected side on serial testing
- recovery with decompression is 90% vs 50% with medical therapy
- a gracilis muscle flap can be designed as a compound flap with multiple paddles for multivector reanimation after facial paralysis, improving all components of a smile[13]
- prognosis
- 70% chance of complete recovery (within few weeks)
- symptoms should resolve within 3 months[2][4]
- recurrence rate of 10%
- weakness may recur contralaterally
- patient education
- attention to eye protection
- report ocular pain, drainage, discharge
- Bell's palsy is NOT contagious
Follow-up:
- serial examinations to document course of disease
- serial nerve conduction studies for evaluation of surgical options
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1041-42
- ↑ 2.0 2.1 Prescriber's Letter 10(6):34 2003
- ↑ 3.0 3.1 3.2 de Almeida JR et al Combined corticosteroid and antiviral treatment for Bell palsy: A systematic review and meta-analysis. JAMA 2009 Sep 2; 302:985. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19724046
Steiner JF Treatment of Bell palsy: Translating uncertainty into practice. JAMA 2009 Sep 2; 302:1003. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19724051 - ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 5.0 5.1 5.2 5.3 Gronseth GS and 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. November 7, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23136264 <Internet> http://www.neurology.org/content/early/2012/11/07/WNL.0b013e318275978c.abstract
- ↑ 6.0 6.1 Thaera GM, Wellik KE, Barrs DM et al Are corticosteroid and antiviral treatments effective for bell palsy? A critically appraised topic. Neurologist. 2010 Mar;16(2):138-40 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20220455
- ↑ 7.0 7.1 Baugh R et al Clinical Practice Guideline Summary: Bell's Pasy. American Academy of Otolaryngology/ Head and Neck Surgery Foundation. http://www.entnet.org/guide_lines/upload/Bulletin_BellsExecSummary_Final_102313.pdf
- ↑ Peng KP et al Increased risk of Bell palsy in patients with migraine. A nationwide cohort study. Neurology. Dec 17, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25520313 <Internet> http://www.neurology.org/content/early/2014/12/17/WNL.0000000000001124
Silberstein SD, Silvestrini M Does migraine produce facial palsy? For whom the Bell tolls. Neurology. Dec 17, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25520314 <Internet> http://www.neurology.org/content/early/2014/12/17/WNL.0000000000001136 - ↑ 9.0 9.1 9.2 The NNT: Antiviral (Anti-Herpes virus) Medications for Bell's Palsy. http://www.thennt.com/nnt/antivirals-for-bells-palsy/
Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19821283 - ↑ 10.0 10.1 The NNT: Systemic Corticosteroids for Bell's Palsy http://www.thennt.com/nnt/steroids-for-bells-palsy/
Salinas RA, Alvarez G, Daly F, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2010 Mar 17;(3):CD001942 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20238317 - ↑ Baugh RF, Basura GJ, Ishii LE et al Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg. 2013 Nov;149(3 Suppl):S1-27 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24189771
- ↑ 12.0 12.1 12.2 12.3 Wilner AN Diagnostic Error in Patients With Neurologic Symptoms. Medscape. Oct 31, 2016 http://www.medscape.com/features/slideshow/diagnostic-errors/neurologic
- ↑ 13.0 13.1 Boahene KO, Owusu J, Ishii L et al The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation. JAMA Facial Plast Surg. Published online March 22, 2018. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29566121 https://jamanetwork.com/journals/jamafacialplasticsurgery/fullarticle/2675433
- ↑ Glass GE, Tzafetta K. Bell's palsy: a summary of current evidence and referral algorithm. Fam Pract. 2014 Dec;31(6):631-42. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25208543
- ↑ 15.0 15.1 Pacheco A et al. Positive tests for Lyme disease and emergency department visits for Bell's palsy patients. J Emerg Med 2020 Sep 22; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32978030 https://www.jem-journal.com/article/S0736-4679(20)30725-3/fulltext
- ↑ 16.0 16.1 Marson AG, Salinas R Bell's Palsy. West J Med. 2000 Oct;173(4):266-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11017995 PMCID: PMC1071111 Free PMC article
- ↑ 17.0 17.1 George E, Richie MB, Glastonbury CM. Facial nerve palsy: clinical practice and cognitive errors. Am J Med. 2020;133:1039-1044. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32445717
- ↑ 18.0 18.1 18.2 NEJM Knowledge+
Madhok VB, Gagyor I, Daly F et al Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016 Jul 18;7(7):CD001942. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27428352 PMCID: PMC6457861 Free PMC article. Review.
Sullivan F, Daly F, Gagyor I. Antiviral Agents Added to Corticosteroids for Early Treatment of Adults With Acute Idiopathic Facial Nerve Paralysis (Bell Palsy). JAMA. 2016 Aug 23-30;316(8):874-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27552621 https://jamanetwork.com/journals/jama/fullarticle/2545664 - ↑ NINDS Bell's Palsy Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Bells-Palsy-Information-Page