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<H2>1.12 Bell's Palsy (Idiopathic Facial Paralysis)</H2>
<HR>

<H4>Presentation</H4><IMG src=3D"http://www.ncemi.org/cse/cse0112.gif"=20
align=3Dright> This condition creates a very frightening facial =
disfigurement. An=20
adult complains of sudden onset of "numbness," a feeling of fullness or=20
swelling, pain or some other change in sensation on one side of the =
face; a=20
crooked smile, mouth "drawing" or some other asymmetrical weakness of =
facial=20
muscles; an irritated, dry or tearing eye; drooling out of the corner of =
the=20
mouth; or changes in hearing or taste. Often there will have been a =
viral=20
illness one to three weeks before. Upon initial observation of the =
patient, it=20
is immediately apparent that he is alert and oriented, with a unilateral =
facial=20
paralysis that includes one side of the forehead.=20
<H4>What to do:</H4>
<UL>
  <LI>Perform a thorough neurological examination of cranial and upper =
cervical=20
  nerves, and limb strength, noting which are involved, and whether =
unilaterally=20
  or bilaterally. Ask the patient to wrinkle the forehead, close the =
eyes=20
  forcefully, smile, puff the cheeks and whistle, observing closely for =
facial=20
  assymetry. Central or cerebral lesions result in relative sparing of =
the=20
  forehead. Check tearing, ability to close the eye and protect the =
cornea,=20
  corneal dessication, hearing, and, when practical, taste. Examine the =
ear=20
  canals for herpetic vesicles and the tympanic membrane for signs of =
otitis=20
  media or cholesteatoma. Patients presenting with facial paralysis =
accompanied=20
  by acute otitis media, chronic suppurative middle ear disease, =
otorrhea or=20
  otitis externa require otolaryngologic consultation.=20
  <LI>If the cornea is dry or injured from the patient's inability to =
make tears=20
  and blink, protect it by <A=20
  href=3D"http://www.ncemi.org/cse/cse0206.htm">patching</A>. If =
patching is not=20
  necessary, then recommend wearing eyeglasses and applying =
methylcellulose=20
  artificial tears regularly during the day and using a protective bland =

  ointment at night.=20
  <LI>If there is a history of head trauma, obtain a CT scan of the head =

  (including the skull base) to rule out a temporal bone fracture.=20
  <LI>If the diagnosis is clearly an early idiopathic cranial nerve =
palsy not=20
  caused or complicated by trauma, infection, or diabetes, try to =
ameliorate=20
  symptons with a short course of corticosteroids (e.g., prednisone 60mg =
qd,=20
  tapering after 5 days.)=20
  <LI>Send a serum specimen for acute phase Lyme disease titers, if =
available,=20
  because this is another treatable disorder which can present as a =
facial=20
  neuropathy. In areas where Lyme disease is endemic, a 10 day course of =

  tetracycline or doxycycline may be indicated.=20
  <LI>If the etiology appears to be zoster-varicella (e.g., grouped =
vesicles on=20
  the tongue) prescribe acyclovir or famcyclovir as for <A=20
  href=3D"http://www.ncemi.org/cse/cse1118.htm">shingles</A>.=20
  <LI>Reassure the patient that 70-80% of cases of Bell's palsy recover=20
  completely in a few weeks, but provide for definite followup and =
reevaluation.=20

  <LI>Provide appropriate specialty referral when there is a mass in the =
head or=20
  neck or a history of any malignancy.</LI></UL>
<H4>What not to do:</H4>
<UL>
  <LI>Do not forget alternate causes of facial palsy which require =
different=20
  treatment, such as cerebrovascular accidents and cerebellopontine =
angle tumors=20
  (which usually produce weakness in limbs or defects of adjacent =
cranial=20
  nerves), multiple sclerosis (which is usually not painful, spares =
taste, and=20
  often produces intranuclear ophthalmoplegia), Ramsay Hunt syndrome (or =
herpes=20
  zoster of the geniculate ganglion, which causes decreased hearing, =
pain, and=20
  vesicles in the ear canal), and polio (which presents as fever, =
headache, neck=20
  stiffness, and palsies).=20
  <LI>Do not order a CT unless there is a history of trauma or the =
symptoms are=20
  atypical and include such findings as vertigo. central neurological =
signs, or=20
  severe headache.=20
  <LI>Do not make the diagnosis of Bell's palsy in patients who report =
gradual=20
  onset of facial paralysis over several weeks or facial paralysis that =
has=20
  persisted 3 months or more. These patients need further evaluation by =
a=20
  neurologist or otolaryngologist.</LI></UL>
<H4>Discussion</H4>Idiopathic nerve paralysis is a common malady. It =
affects 20=20
per 100,000 people a year. Although Bell's palsy was described =
classically as a=20
pure facial nerve lesion, and physicians have tried to identify the =
exact level=20
at which the nerve is compressed, the most common presenting complaints =
are=20
related to trigeminal nerve involvement. The mechanism is probably a =
spotty=20
demyelination of several nerves at several sites, caused by a viral =
infection.=20
Diabetics and pregnant women have increased incidence of Bell's palsy.=20
<H4>References:</H4>
<UL>
  <LI>Austin JR, Peskind SP, Austin SG, et al: Idiopathic facial nerve=20
  paralysis: a randomized double blind controlled study of placebo =
versus=20
  prednisone. Laryngoscope 1993;103:1326-1333.=20
  <LI>Stankiewicz JA: A review of the published data on steroids and =
idiopathic=20
  facial paralysis. Otolaryngol Head Neck Surg =
1987;97:481-486.</LI></UL>
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