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Page 1 of 5
Practice
PRACTICE
PRACTICE POINTER
Liam Masterson specialty registrar, ear, nose, and throat surgery , Martin Vallis general practitioner
2
3
principal , Ros Quinlivan consultant, neuromuscular disease , Peter Prinsley consultant, ear, nose,
4
and throat surgeon
Ear, Nose, and Throat Department, Cambridge University Hospitals NHS Trust, Cambridge CB2 0QQ, UK; 2Rosedale Surgery, NHS Great Yarmouth
and Waveney Clinical Commissioning Group, Lowestoft, UK; 3MRC Centre for Neuromuscular Disease, National Hospital for Neurology and
Neurosurgery, London, UK; 4Ear, Nose, and Throat Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
1
How is it assessed?
Patients may have risk factors for stroke, which include older
age (>60 years), hypertension, previous stroke or transient
ischaemic attack, diabetes, high cholesterol, smoking, and atrial
fibrillation.6 Corroborative evidence may also be found by
examining for abnormalities in other cranial nerves and the
peripheral nervous systemincreased tone, limb weakness,
hyper-reflexia, upgoing plantars, and sensory loss.4
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Page 2 of 5
PRACTICE
How is it managed?
Management is influenced strongly by the initial clinical review
and provisional working diagnosis. With an LMN lesion, the
main priority is to treat the underlying cause, to improve
symptoms, and to reduce associated morbidity, such as
contracture of the facial muscles, synkinesis (involuntary
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Page 3 of 5
PRACTICE
Antivirals
Coulson SE, ODwyer NJ, Adams RD, et al. Expression of emotion and quality of life after
facial nerve paralysis. Otol Neurotol 2004;25:1014-9.
Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bells palsy executive
summary. Otolaryngol Head Neck Surg 2013;149:656-63.
Peitersen E. Bells palsy: the spontaneous course of 2500 peripheral facial nerve palsies
of different etiologies. Acta Otolaryngol Suppl 2002;549:4-30.
May M, Schaitkin B, Shapiro A. The facial nerve. Thieme, 2001.
Holland NJ, Bernstein JM. Bells palsy. BMJ Clin Evid 2014;2014. pii:1204.
Donnan GA, Fisher M, Macleod M, et al. Stroke. Lancet Neurol 2008;371:1612-23.
De Diego-Sastre JI, Prim-Espada MP, Fernndez-Garca F. The epidemiology of Bells
palsy. Rev Neurol 2005;41:287-90.
Kosins AM, Hurvitz KA, Evans GR, et al. Facial paralysis for the plastic surgeon. Can J
Plast Surg 2007;15:77-82.
Kamerer DB, Thompson SW. Middle ear and temporal bone trauma. In: Bailey BJ, ed.
Head and neck surgeryotolaryngology. 3rd ed. Lippincott Williams & Wilkins,
2001:1108-14.
Pretto Flores L, De Almeida CS, Casulari LA. Positive predictive values of selected clinical
signs associated with skull base fractures. J Neurosurg Sci 2000;44:77-82.
Sharp MC, MacfArlane R, Hardy DG et al. Team working to improve outcome in vestibular
schwannoma surgery. Br J Neurosurg 2005;19:122-7.
Hobson CE, Moy JD, Byers KE, et al. Malignant otitis externa: evolving pathogens and
implications for diagnosis and treatment. Otolaryngol Head Neck Surg 2014;151:112-6.
Smith RP, Schoen RT, Rahn DW, et al. Clinical characteristics and treatment outcome
of early Lyme disease in patients with microbiologically confirmed erythema migrans. Ann
Intern Med 2002;136:421-8.
Buchanan M, Lyons M. Clinical review: Bells palsy GPonline 2010. www.gponline.com/
clinical-review-bells-palsy/neurology/article/1000464.
Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bells palsy (idiopathic facial
paralysis). Cochrane Database Syst Rev 2011;12:CD006283.
Salinas RA, Alvarez G, Daly F, et al. Corticosteroids for Bells palsy (idiopathic facial
paralysis). Cochrane Database Syst Rev 2010:CD001942.
Taverner D. Cortisone treatment of Bells palsy. Lancet Neurol 1954;267:1052-4.
Engstrm M, Berg T, Stjernquist-Desatnik A. Prednisolone and valaciclovir in Bells palsy:
a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol
2008;7:993-1000.
Sullivan FM, Swan IR, Donnan PT. Early treatment with prednisolone or acyclovir in Bells
palsy. N Engl J Med 2007;357:1598-607.
De Almeida JR, Al Khabori M, Guyatt GH. Combined corticosteroid and antiviral treatment
for bell palsy: a systematic review and meta analysis. JAMA 2009;302:985-93.
Rafii B, Sridharan S, Taliercio S. Glucocorticoids in laryngology: a review. Laryngoscope
2014;124:1668-73.
Kenny T, Tidy C. Bells palsy. Cox J, series ed. 2013. www.patient.co.uk/health/bellspalsy.
Walker D, Hallam M, Ni Mhurchadha S, et al. Our experience: the psychosocial impact
of facial palsy. Clin Otolaryngol 2012;37:474-7.
Browning GG. Bells palsy: a review of three systematic reviews of steroid and anti-viral
therapy. Clin Otolaryngol 2010;35:56-8.
Lockhart P, Daly F, Pitkethly M, et al. Antiviral treatment for Bells palsy (idiopathic facial
paralysis). Cochrane Database Syst Rev 2009;4:CD001869.
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Page 4 of 5
PRACTICE
How is it managed?
Steroid tablets (usually prednisolone) help to reduce inflammation and are normally taken for 10 days.18 19 This short course of drugs is
unlikely to have notable side effects if you have no history of high blood sugar levels (diabetes), hypertension, gastric ulcer, or glaucoma.22
To ensure maximum benefit, the steroid tablets should be started within three days of the facial weakness appearing.5
If the eyelid cannot shut completely, the surface of the eye may dry up and be harmed. In addition, the tear ducts may not function temporarily,
which could dry the eye further.22 Treatment is needed to keep the eye moist. This normally involves frequent lubricating eye drops during
the day. At night, eye ointment can be applied before closing the eye shut with tape.
Table
Table 1| Clinical signs to check in lower motor neurone facial nerve palsy
Are the ears clear on otoscopy?
Assess the tympanic membrane and ear canal; acute or chronic otitis media (cholesteatoma) and malignant otitis
externa can all cause lower motor neurone facial palsy and will require further urgent assessment in secondary care
(ear, nose, and throat)
Perform Webers and Rinnes tuning fork tests; although Ramsay Hunt syndrome will be associated with sensorineural
hearing loss (SNHL), it is important to exclude a cerebellopontine angle lesion (normally presents with gradual onset
unilateral SNHL); acute otitis media or cholesteatoma may be associated with conductive hearing loss, whereas patients
with Bells palsy normally have abnormal sensitivity to loud sounds
Is there a rash?
Small vesicular eruptions that affect the tympanic membrane, ear canal, external pinna, or oral cavity may indicate
Ramsay Hunt syndrome; Lyme disease is restricted to heavily forested regions and presents with a characteristic
erythematous bullseye lesion on the limbs or trunk (70% of cases), arthralgia, and facial swelling; it is caused by a bite
from a tick carrying Borrelia burgdorferi (US) or B afzalii/garinii (Europe), and an antibody test may help confirm the
diagnosis13
Are there any bruises or scars in the head The palsy may be secondary to a skull base fracture (common associated signs include periorbital or mastoid bruising,
and neck region?
blood in the ear canal, and haemotympanum9) or recent mastoid, parotid, or submandibular gland surgery
Is the corneal reflex intact on both sides In addition to facial muscle weakness, a cerebellopontine angle lesion (such as an acoustic neuroma) may cause a
reduced or absent corneal reflex on the affected side aural fullness (owing to trigeminal nerve deficit)
Is the mastoid region tender or swollen? A tender swelling of the mastoid with associated middle ear inflammation or pinna lateralisation (or both) may suggest
acute mastoiditis
Is the parotid gland enlarged?
Palpation of a parotid lump may suggest cancer (particularly if associated with a history of regional skin cancer, delayed
onset facial palsy, or pain); if cancer is suspected, thoroughly examine the rest of the head and neck and refer urgently
(for example, through the two week wait suspected head and neck cancer pathway in the UK)
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Page 5 of 5
PRACTICE
Figure
Differential diagnosis of a unilateral facial palsy. Percentages are based on combined epidemiological data from 6024
patients with lower motor neurone facial palsy (rarer conditions including mumps, syphilis, HIV, Guillain-Barr syndrome,
otitic barotrauma, myasthenia gravis, systemic lupus erythematosus, sarcoidosis, and multiple sclerosis have been
excluded).3 4 *Endemic in forested regions; misdiagnosed cerebrovascular disease evident in about 1.5% of all patients3
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