Bells Palsy

January 20,2010

History
- Sir Charles Bell,
Scottish Surgeon
- First described in
early 1800s based
on trauma to facial
nerves
- Definition of Bells
Palsy: Acute
peripheral CN VII
(facial nerve) palsy
of unknown cause

Anatomy

1) Motor to facial muscles

2) Parasympathetic innervation to lacrimal, submandibular, sublingual salivary glands
3) Afferent fibers for taste on anterior 2/3 tongue
4) Somatic afferents to external auditory canal & pinna

Epidemiology
of all facial palsys qualify as Bells Palsy
Annual Incidence 10-40/100,000
Lifetime incidence 1:60
Risk is 3xs greater in pregnancy, especially 3 rd
trimester
Increased risk with diabetes

Cause
Widely accepted cause is HSV-1,
however not proven
HSV mediates inflammatory/immune
response which leads to myelin
sheath degeneration, & edema which
causes compression and further
damage of CN VII

Clinical Features
Sudden onset symptoms,
usually hours w/ maximal
weakness w/in 48 hrs
Unilateral
Eyebrow sagging
Inability to close eye
Loss of nasolabial fold
Decreased tearing
Hyperacusis
Loss of taste to anterior
2/3 tongue
Mouth droop

Differential Diagnosis
Infection
External otitis Otitis media
Mastoiditis
Chickenpox
Herpes zoster (Ramsey Hunt syndrome)
Encephalitis Poliomyelitis (type I)
Mumps
Mononucleosis
Leprosy
Influenza
Coxsackievirus
Malaria
Syphilis
Tuberculosis
Botulism
Lyme disease
Tumor, central or local

Metabolic
DM
Hyperthyroidism
Vitamin A deficiency
Toxic
Iatrogenic
Idiopathic
Bell's
Melkersson-Rosenthal syndrome
(recurrent alternating facial palsy,
furrowed tongue)
Amyloidosis
Landry-Guillain-Barre syndrome
Multiple sclerosis
Myasthenia gravis
Sarcoidosis
Birth
Trauma

Ramsey Hunt Syndrome

AKA Herpes Zoster Oticus: Reactivation of
VZV within geniculate ganglia
Lifetime incidence VZV 10-20%; if live to
be 85, 50%
Risk Factors: Age, Malignancy,
Immunosuppressed
Pathophysiology:
1) Age related immunosenescence
2) Disease associated
immunocompromise
3) Iatrogenic immunosuppression
Clinical Features
Acute Vertigo
Hearing loss
Ipsilateral facial paralysis
Ear Pain
Vesicular rash
Rx: Steroids, acyclovir

Evaluation & Diagnosis

Bells Palsy is a clinical
diagnosis based on
typical presentation
absence of other
explanation or other
underlying disease
absence of cutaneous
lesions
otherwise normal neuro
exam

Possible Labs to check:

ESR, RPR, Lyme titer,
glucose, PCR if vesicular
lesions

Proceed with imaging

(MRI) if
Atypical Presentation
Slowly progressive over
2-3 weeks
If no improvement in
symptoms in 6 wks

Electrophysiology
(CMAP) performed if
complete facial
paralysis remains after
1 week of treatment

Treatment
Manual closing of eye such as with tape
while sleeping, lubricating eye drops
Steroids 60-80 mg daily x 5 days then
tapered over next 5 days or 1 mg/kg
daily x 7 days
+/-Acyclovir 400 mg 5xs daily x 10
days vs Valacyclovir 1 g BID x 7 days
Surgical Decompression no good
evidence to support

Prognosis
80% recover within weeks to months
If motor nerve conduction studies
show evidence of denervation after
10 days indicates prolonged recovery
of ~ 3 months & possible incomplete
recovery