Bell's Palsy

General Overview

• Sudden onset (usually over hours) of unilateral facial paralysis peaking within first week and then gradually resolve over three weeks to three months (may be due to HSV)
  • With or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands.
• DDx
  • Herpes zoster infection
  • Otitis media
  • Lyme disease
  • Guillain-Barré syndrome
  • HIV infection
  • Sarcoidosis
  • Sjögren syndrome
  • Tumor
  • Stroke
  • Melkersson-Rosenthal syndrome

Physical Exam

• Facial movement
  • Closing the eyes, elevating the brow, frowning, showing the teeth, puckering the lips, and tensing the soft tissues of the neck to observe for platysma activation.
  • Sparing of the forehead muscles on the affected side of the face is suggestive of a central (upper motor neuron) lesion because of bilateral innervation to this area.
  • Sensation
• Skin
  • Particular attention is directed at the external ear to look for vesicles or scabbing (which indicates zoster) and for mass lesions within the parotid gland.

Investigations

• Consider CT C+ or MRI (with Gadolinium) imaging of the brain, temporal bone, and parotid gland if the physical signs are atypical, there is slow progression beyond three weeks, or if there is no improvement at four months
• Consider Lyme serologies if endemic area

Management

• Eye care if poor eye lid closure and reduced tearing
  • Artificial tears during the day, ointment at night
  • Protective goggles/glasses
• If onset <72h, Prednisone (60 to 80 mg/day) x 1 week
  • If severe, consider addition of Valacyclovir 1g TID x 1 week
• For persistent symptoms, consider imaging and ENT referral